PART III. WAIVER — Internal Revenue Bulletin 2017-3

For Parts B.1 through 6, while the curing of inadequate documentation is permissible, the information reported in this section of the Appendix must not reflect any remediation or curing. Note: In order to be eligible for a waiver, QI must be able to confirm all of the eligibility requirements in Part A are met. For purposes of this Part, “account” means, unless otherwise specified, any account for which QI acts as a QI.

A. Eligibility for Waiver (check each statement to confirm)

QI is an FFI that is not also acting as a QDD.
QI is not part of a consolidated compliance program.
For each calendar year covered by the certification period, the reportable amounts received by QI do not exceed $5 million.
QI timely filed its Forms 1042, 1042-S, 945, 1099, and 8966 (as required for chapter 4 purposes or the reporting required under an applicable IGA), as applicable, for all calendar years covered by the certification period.

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QI made all periodic certifications and reviews required by sections 10.02 and 10.03 of the QI Agreement as well as all certifications required pursuant to QI’s FATCA requirements as a participating FFI or registered deemed-compliant FFI.
QI made the certification of internal controls in Part II.A.

B. Information required (provided for the most recent calendar year within the certification period)

The total number of accounts a. Total number of direct account holders

i. Foreign persons ii. U.S. exempt recipients iii. U.S. non-exempt recipients iv. Intermediaries and flow-through entities b. Total number of indirect account holders

i. Foreign persons ii. U.S. exempt recipients iii. U.S. non-exempt recipients iv. Intermediaries and flow-through entities 2. The total number of U.S. account holders that received reportable payments. 3. The total number of non-U.S. account holders that received reportable amounts. 4. The total number of such accounts that have valid documentation. 5. The total number of accounts that have no documentation or invalid documentation. 6. The total number of Forms 1042-S filed by QI. 7. Total of reportable amounts received for non-U.S. accounts. 8. Total of reportable payments received for U.S. accounts. 9. The aggregate amount of tax withheld under chapter 3 and chapter 4 (by QI or QI’s withholding agent(s)). 10. The total number of Forms 1099 filed by QI. 11. The aggregate amount of backup withholding under section 3406 by QI or QI’s payor(s).

PART IV. PERIODIC REVIEW: QI FACTUAL INFORMATION—To be Completed by All QIs that have not Applied for or Obtained a Waiver. If QI acts solely as a QDD and has no other QI activities, QI is not required to complete Part IV.B through F.

A. General Information

Did QI use an external reviewer to conduct any portion of its periodic review? Y/N a. If yes, provide name(s) of reviewer(s).
Did QI use an internal reviewer to conduct any portion of its periodic review? Y/N a. If yes, provide a brief description of the internal reviewer, such as their department and other roles and responsibilities with

respect to the QI’s QI activities. 3. Calendar year reviewed for periodic review.

Caution: On the due date for reporting the factual information relating to the periodic review (provided in section 10.04 of the QI Agreement), there must be 15 or more months available on the statutory period for assessment for taxes reportable on Form 1042 of the calendar year for which the review was conducted or the QI must submit, upon request by the IRS, a Form 872, Consent to Extend the Time to Assess Tax , that will satisfy the 15-month requirement. The Form 872 must be submitted to the IRS at the address provided in section 12.06 of the QI Agreement.

B. General Information on Accounts and Review of Accounts

For Parts B through F, while the curing of inadequate documentation is permissible, unless otherwise indicated, the information reported shall be based on the review and not results obtained after curing. For purposes of this Part, “account” means, unless otherwise specified, any account for which QI acts as a QI. However, do not include accounts for which QI is acting as a QDD or accounts receiving substitute interest payments for which QI has assumed primary withholding responsibility.

Did QI assume primary chapters 3 and 4 withholding responsibility for any accounts for the calendar year provided in Question 3 in Part A, above? Y/N
Did QI assume primary Form 1099 reporting and backup withholding responsibility for any accounts for the calendar year provided in Question 3 in Part A, above? Y/N
Total accounts reviewed for periodic review.
Did QI use a statistical sampling method in conducting the review of its accounts? 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 accounts reviewed that received reportable amounts.
Total accounts reviewed that received withholdable payments that are not reportable amounts.

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C. Documentation

Total accounts reviewed held by direct account holders.
Total accounts reviewed held by indirect account holders.
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 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.
If QI has not assumed primary Form 1099 reporting and backup withholding responsibility, total accounts held by U.S. non-exempt recipient account holders reviewed for which QI has transmitted Forms W-9 to a withholding agent.
Total accounts reviewed assigned to chapter 3 or chapter 4 withholding rate pools.
Total accounts reviewed assigned to chapter 3 or chapter 4 withholding rate pools where QI did not correctly report withholding rate pool information to a withholding agent.
Total accounts reviewed that are U.S. accounts (or U.S. reportable accounts under an applicable IGA) (if applicable).
Total accounts reviewed that are U.S. accounts (or U.S. reportable accounts under an applicable IGA) (if applicable) for which QI has obtained a valid Form W-9 or, if applicable, self-certification.

D. Withholding

The aggregate amount reported as withheld under chapter 3 by QI on Forms 1042-S.
Number of accounts for which amounts were withheld under chapter 3.
The aggregate amount reported as withheld under chapter 4 by QI on Forms 1042-S.
Number of accounts for which amounts were withheld under chapter 4.
The aggregate amount reported as withheld by QI on Forms 1099.
Number of accounts for which amounts were backup withheld under section 3406.
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 under section 3406 based on results of periodic review.
The aggregate amount of deposits made in accordance with section 3.08 of the QI Agreement.
Number of partnerships or trusts to which the joint account treatment of section 4.05 of the QI Agreement was applied (if applicable). a. Total accounts to which joint account treatment applied for which appropriate documentation was obtained and the

appropriate rate of withholding was applied. b. Total accounts to which joint account treatment applied for which ppropriate documentation was obtained and the

appropriate rate of withholding was not applied. c. Total accounts to which joint account treatment applied for which appropriate documentation was not obtained and the

appropriate rate of withholding was not applied. d. Aggregate amount of underwithholding resulting from the appropriate rate of withholding not being applied with respect

to an account to which the joint account treatment applied.

E. Reconciliation of Reporting on Payments of Reportable Amounts

The aggregate amount reported paid to QI on all Forms 1042-S issued to QI.
The aggregate amount reported paid by QI on Forms 1042-S to QI’s chapter 4 reporting pools (other than the U.S. payee pool) (including a chapter 4 reporting pool of a PAI or a partnership or trust to which QI applies the agency option).
The aggregate amount reported paid by QI on Forms 1042-S to QI’s chapter 4 reporting pool- U.S. payee pool.
The aggregate amount reported paid by QI on Forms 1042-S to QI’s chapter 3 reporting pools (including chapter 3 reporting pools of a PAI or partnership or trust to which QI applies the joint account or agency option).
The aggregate amount reported paid by QI on Forms 1042-S to other QIs (excluding QIs that are acting as QDDs), QSLs, and WPs and WTs as a class.
The aggregate amount reported paid by QI on Forms 1042-S to QIs that are acting as QDDs.
The aggregate amount reported paid by QI on Forms 1042-S to participating FFIs, registered deemed-compliant FFIs, and registered deemed-compliant Model 1 IGA FFIs that are intermediaries or flow-through entities as a class and with respect to their chapter 4 reporting pools (excluding amounts referenced in Questions 5 and 6 directly above).
The aggregate amount reported paid by QI on Forms 1042-S to indirect account holders (not included in Question 2 or 7 above and including an account holder of an intermediary or flow through entity reported by QI as made to an unknown recipient on Form 1042-S).
The aggregate amount subject to reporting on Form 1042-S paid by QI to U.S. non-exempt recipients as a class not includable in a chapter 4 withholding rate pool of QI.

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The aggregate amount subject to reporting on Form 1042-S paid by QI to U.S. exempt recipients as a class not includable in a chapter 4 withholding rate pool of QI.
The aggregate amount paid by QI to its direct account holders (including account holders of any PAI or partner, beneficiary, or owner of a partnership or trust to which QI applies the joint account or agency option) that requested individual Form(s) 1042-S.
Total of questions 2 through 11.
The amount of any unreconciled variances (if Question 1 minus Question 12 is other than 0).

F. Reconciliation of Withholding on Reportable Amounts

The aggregate amount reported as withheld by another withholding agent on Forms 1042-S issued to QI.
The aggregate amount reported by QI as amounts it withheld on Forms 1042-S.
The aggregate amount reported by QI as amounts it backup withheld on Forms 1099.
If QI did not assume primary withholding responsibility and amounts are entered for questions 2 or 3, explain any underwithholding that occurred by the withholding agent.
If QI assumed primary withholding responsibility and an amount is entered for question 1, explain the amount withheld by others.
The aggregate amount of any collective claims for refund or credit made by QI.