Part V. Qualified — Internal Revenue Bulletin 2016-29

Complete only if QI is acting as a QDD and only for accounts for which QI is acting in its QDD capacity. See section 2.01 of the QI Agreement for the definition of “account” with respect to QI acting as a QDD. If QI is acting as a QDD and is a foreign branch of a U.S. financial institution, it is not required to complete questions in this Part relating to the QDD tax liability (Parts A.3, A.5, and D).

A. General Information-Check to Confirm

QI has established procedures to ensure that it is acting as a QDD for all payments received by QI with respect to potential section 871(m) transactions and underlying securities when acting as a principal and for all payments made by QI with respect to potential section 871(m) transactions when acting as a principal, except payments specifically excluded from QDD activities in the QI Agreement, and that it is not acting as a QDD for any other payments.
QI has established procedures to determine whether a payment is a dividend equivalent payment and the amount of the dividend equivalent, including taking into account information received pursuant to Treas. Reg. § 1.871–15(p), where appropriate.
QI has established procedures to determine its QDD tax liability, including whether a transaction is a dealer or non-dealer transaction.
QI has properly filed Form 1042 (including all information required to be reported by a QDD).
QI has satisfied its QDD tax liability.
Did QI use a statistical sampling method in conducting the review of its accounts for which QI acted as a QDD? Y/N/NA a. If yes, was it the safe harbor method under Appendix II to the QI Agreement? b. If no, describe the method used.
Total number of accounts for which QI acted as a QDD.
Total number of accounts for which QI acted as a QDD reviewed as part of the periodic review.

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B. Documentation

Total accounts reviewed with valid documentation.
Total accounts reviewed with invalid documentation or no documentation.
Total accounts reviewed with invalid documentation or no documentation for which valid documentation or additional valid documentation was obtained after the initial review.
Total accounts reviewed for which treaty benefits were claimed.
Total accounts reviewed for which treaty benefits were claimed where QI did not obtain sufficient documentation to establish the payee’s entitlement to treaty benefits (including, where applicable, the treaty statement and limitation on benefits information required by section 5.03(B) of the QI Agreement).
Total accounts reviewed held by U.S. non-exempt recipient account holders.
Total accounts held by U.S. non-exempt recipient account holders reviewed for which QI has obtained a valid Form W–9.

C. Withholding

The aggregate amount reported as withheld under chapter 3 by QI on Forms 1042–S for payments with respect to potential section 871(m) transactions it made when acting as a QDD.
Number of accounts for which amounts were withheld under chapter 3 for payments with respect to potential section 871(m) transactions it made when acting as a QDD.
The aggregate amount reported as withheld under chapter 4 by QI on Forms 1042–S for payments with respect to potential section 871(m) transactions it made when acting as a QDD.
Number of accounts for which amounts were withheld under chapter 4 for payments with respect to potential section 871(m) transactions it made when acting as a QDD.
Aggregate amount reported as withheld on Forms 1099 for payments with respect to potential section 871(m) transactions made to U.S. persons.
Number of accounts for which amounts were backup withheld under section 3406 for payments with respect to potential section 871(m) transaction made to U.S. persons.
Additional withholding required under chapter 4 based on results of periodic review.
Additional withholding required under chapter 3 based on results of periodic review.
Additional backup withholding required based on results of periodic review.
The aggregate amount of deposits made in accordance with section 3.08 of the QI Agreement with respect to payments made when acting as a QDD.

D. Reconciliation of QDD Tax Liability

Total amount of dividend and dividend equivalent payments received in a dealer capacity.
Total amount of dividend equivalent payments made by QI acting as a QDD in its dealer capacity.
Total amount of qualifying dividend equivalent offsetting payments made by QI acting as a QDD in its dealer capacity.
Total amount of dividend equivalent payments or qualifying dividend equivalent offsetting payments made or contractually obligated to be made by QI acting as a QDD in its dealer capacity.
Total amount of dividend and dividend equivalent payments received by QI acting as a QDD in its non-dealer capacity.
Total amount of dividend equivalent payments made by QI acting as a QDD in its non-dealer capacity.
Total section 871(m) amount (difference between line 1 and the sum of lines 2–4).
Total amount of payments with respect to potential 871(m) transactions and underlying securities received as a principal.
Total amount of other payments received with respect to potential section 871(m) transactions and underlying securities as a principal that are not dividend or dividend equivalent payments received in a dealer capacity (difference between line 8 and line 1)

E. Reporting

Total amount of dividend equivalent payments reported on Form 1042–S.
Total amount of payments that are not dividend equivalent payments reported on Form 1042–S.
Total amount of payments of qualifying dividend equivalent offsetting payments made to U.S. persons, as described in section 2.70(A)(1) of the QI Agreement, reported in a pool on Form 1042–S.
Total amount of payments of qualifying dividend equivalent offsetting payments that are effectively connected with the conduct of a trade or business in the United States, as described in section 2.70(A)(2) of the QI Agreement, reported in a pool on Form 1042–S.

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Total amount of payments of amounts that otherwise would be qualifying dividend equivalent offsetting payments but for the limitation in section 2.70(B) of the QI Agreement.
Total amount of payments reported on Form 1099.
Aggregate amount of any claims for credit or refund made by QI acting as a QDD with respect to payments with respect to potential section 871(m) transactions.