PART I. GENERAL — Internal Revenue Bulletin 2017-6

A. Did WT make a pooled reporting elec tion? Y/N B. The number of partnerships or trusts to

which WT applied the agency option (if none enter 0).

Each partnership or trust to which WT applied the agency option has provided WT with a certification that it has maintained status as a certified deemed-compliant FFI, an owner-documented FFI with respect to WT, an NFFE, or an exempt beneficial owner as required under section 9.02(A)(2) of the WT Agreement. Y/N
Each partnership or trust to which WT applied the agency option has provided WT with either (1) its documentation and other information for inclusion in WT’s periodic review (as described in section 9.02(A)(6) of the WT Agreement) or (2) a certification described in sec

tion 8.03 of the WT Agreement and the results of the periodic review described in section 8.06 of the WT Agreement for the certification period. Y/N C. The number of partnerships or trusts to

which WT applied the joint account option (if none enter 0).

Each partnership or trust to which WT applies the joint account option has provided WT with a certification that it has maintained status as a certified deemed-compliant FFI, an owner-documented FFI with respect to WT, an exempt beneficial owner, or an NFFE as required under section 9.01(A)(1) of the WT Agreement. Y/N

PART II: CERTIFICATION OF INTERNAL CONTROLS BY RESPONSIBLE OFFICER AND GENERAL INFORMATION

Complete either Section A (Certification of Effective Internal Controls) or Section

February 6, 2017 856 Bulletin No. 2017–6

have been known) by the responsible officer, including the findings of any procedure, process, review, or certification undertaken in preparation for the responsible officer’s certification of internal controls, WT maintains effective internal controls over its documentation, withholding, and reporting obligations under the WT Agreement and according to its applicable FATCA requirements for beneficiaries or owners for which it acts as a WT. 3. Based on the information known (or information that reasonably should have been known) by the responsible officer, including the findings of any procedure, process, review, or certification undertaken in preparation for the responsible officer’s certification of internal controls, there are no material failures, as defined in section 8.03(B of the WT Agreement, or, if there are any material failures, they have been corrected as of the date of this certification, and such failures are identified as part of this certification as well as the actions taken to remediate them and to prevent their reoccurrence by the date of this certification. See Part II.D.2.a of this Appendix. 4. With respect to any failure to withhold, deposit, or report to the extent required under the WT Agreement, WT has corrected such failure by paying any taxes due (including interest and penalties) and filing the appropriate return (or amended return). 5. All partnerships and trusts to which WT applies the agency option have either (a) provided documentation and other necessary information for inclusion in the WT’s periodic review or (b) provided the responsible officer of WT with a certification of effective internal controls described in Part II.A of this Appendix and have represented to WT that there are no material failures, as defined in section 8.03(B) of the WT Agreement, or, if there are such failures, they have been corrected as of the time of this certification, and the partnerships or trusts have disclosed any such failures to WT together

with the actions taken by the partnership or trust to remediate such failures. 6. Unless WT has received a waiver, a periodic review was conducted for the certification period in accordance with section 8.04 of the WT Agreement, and the results of such review are reported to the extent required in section 8.06 of the WT Agreement.

B. Qualified Certification

If the responsible officer has identified (1) an event of default or (2) a material failure that WT has not corrected as of the date of this certification, check the applicable statements to confirm:

The responsible officer (or designee) has identified an event of default, as defined in section 10.05 of the WT Agreement, or has determined that, as of the date of the certification, there are one or more material failures as defined in section 8.03(B) of the WT Agreement with respect to WT’s compliance or the compliance of a partnership or trust to which WT applies the agency option and that appropriate actions will be taken to prevent such failures from reoccurring.
With respect to any failure to withhold, deposit, or report to the extent required under the WT Agreement, WT will correct such failure by paying any taxes due (including interest and penalties) and filing the appropriate return (or amended return).
The responsible officer (or an officer of the partnership or trust to which WT applies the agency option if the partnership or trust performs its own periodic review) will respond to any notice of default (if applicable) or will provide (either directly or through WT) to the IRS, to the extent requested, a description of each material failure and a written plan to correct each such failure.

C. Amended Form 1042

Did WT file an amended Form 1042 to report additional tax liability based on the results of the periodic review or the findings of any other procedure, process, or review under

taken by the responsible officer in preparation for the certification of internal controls? Y/N

D. Material Failures or Event of Default

Did the responsible officer determine that as of the date of the periodic review report (or the date of completion of any other procedure, process, or review), there are no material failures with respect to WT’s compliance with the WT Agreement? Y/N
Did the responsible officer determine that as of the date of the periodic review report (or the date of completion of any other procedure, process, or review), there are one or more material failures with respect to WT’s compliance with the WT Agreement and that appropriate actions have been or will be taken to prevent such failures from reoccurring? Y/N

a. If yes, check the following ma terial failures that were identified.

i. WT’s establishment of, for

financial statement purposes, a tax reserve or provision for a potential future tax liability related to WT’s failure to comply with the WT Agreement, including its FATCA requirements as a participating FFI, registered deemed-compliant FFI, or registered deemedcompliant Model 1 IGA FFI. ii. WT’s failure to establish

written policies, procedures, or systems sufficient for the relevant personnel of WT to take actions consistent with WT’s obligations under the WT Agreement. iii. A criminal or civil pen alty or sanction imposed on WT by a regulator or other governmental authority or agency with oversight over WT’s compliance with AML/ KYC procedures, if applicable, to which WT is

Bulletin No. 2017–6 857 February 6, 2017

subject and that is imposed due to WT’s failure to properly identify beneficiaries or owners under the requirements of those procedures. iv. A finding (including a

finding noted in the periodic review report described in section 8.06 of the WT Agreement) that, for one or more years covered by the WT Agreement, WT failed to:

Withhold an amount that WT was required to withhold under chapter 3 or 4 as required under section 3 of the WT Agreement;
Make deposits in the time and manner required by section 3.05 of the WT Agreement or make adequate deposits to satisfy its withholding obligations, taking into account the procedures under section 7 of the WT Agreement;
Report or report accurately on Forms 1042 or 1042–S as required under sections 6.01 and 6.02 of the WT Agreement;
Report or report accurately on Forms 8966 as required under section 6.05 of the WT Agreement; or
Report or report accurately on Form 3520–A and the Foreign Grantor Trust Owner Statements and Foreign Grantor Trust Beneficiary Statements as required under section 6.03 of the WT Agreement.

v. Other (include a detailed

explanation). 3. The material failure(s) identified in the review has been corrected by the time of this certification. Y/N/NA

a. If yes, describe the steps taken

to correct the material failure. b. If no, describe the proposed

steps to be taken to correct the material failure and the time frame for completing such steps. 4. Did any partnerships or trusts to which WT applies the agency option inform WT that it has had a material failure with respect to its obligations as described in the WT Agreement? Y/N/NA

a. If yes, provide the name of the

partnership or trust and, based on the information provided by the partnership or trust, describe the steps taken to correct the material failure or the proposed steps to be taken to correct the material failure and the timeframe for completing such steps. 5. An event of default as defined in section 10.05 of the WT Agreement has been identified. Y/N

b. If yes, identify the event of

default.

i. WT failed to implement

adequate procedures, accounting systems, and internal controls to ensure compliance with the WT Agreement; ii. WT underwithheld a ma terial amount of tax that WT was required to withhold under chapter 3 or 4 and failed to correct the underwithholding or to file an amended Form 1042 reporting, and paying, the appropriate tax; iii. WT made excessive re fund claims; iv. WT failed to file required

Forms 1040NR (if required), 1042, 1042–S, 8966, 3520–A and the Foreign Grantor Trust Owner Statements and Foreign Grantor Trust

Beneficiary Statements by the due date specified on such forms or filed forms that are materially incorrect or fraudulent; v. If WT is an FFI, WT

failed to materially comply with its FATCA requirements as a participating FFI, registered deemed-compliant FFI, or registered deemedcompliant Model 1 IGA FFI; vi. If WT is a sponsoring

entity of a sponsored FFI or a sponsored direct reporting NFFE, WT failed to materially comply with the due diligence, withholding, reporting, and compliance requirements of a sponsoring entity; vii. WT failed to perform a

periodic review when required or to document the findings of such review in a written report; viii. WT failed to inform the

IRS within 90 days of any significant change in its business practices to the extent that change affects WT’s obligations under the WT Agreement; ix. WT failed to cure a ma terial failure identified in the qualified certification described in Part II.B of this Appendix or identified by the IRS; x. WT made any fraudulent

statement or a misrepresentation of material fact with regard to the WT Agreement to the IRS, a withholding agent, or WT’s reviewer; xi. The IRS determined that

WT’s reviewer is not sufficiently independent, as described in the WT Agreement, to adequately perform its review function, and WT

February 6, 2017 858 Bulletin No. 2017–6

failed to arrange for a periodic review conducted by a reviewer approved by the IRS; xii. WT failed to make de posits in the time and manner required by section 3.05 of the WT Agreement or failed to make adequate deposits, taking into account the procedures of section 7.05 of the WT Agreement; xiii. If applicable, WT failed

to inform the IRS of any change in the applicable know-yourcustomer rules within 90 days of the change becoming effective when WT relied on documentary evidence as permitted in section 4.01(A) of the WT Agreement; xiv. A partnership or trust to

which WT applied the agency option was in default with the agency agreement and WT failed to terminate that agreement within the time period specified in section 9.02 of the WT Agreement; xv. WT failed to materially

comply with the requirements of a nonwithholding foreign trust under chapter 3 with respect to any beneficiary or owner for which WT does not act as a withholding foreign trust; xvi. WT is not in possession

of valid documentation described in sections 4.01 through 4.09 of the WT Agreement for each direct beneficiary or owner as of the due date of this certification; or xvii. Other (please describe).

E. Significant Change in Circumstances

Check the applicable statements to confirm.

For the most recent certification period, the periodic review (or any other procedure, process, or review) has not identified any significant change in circumstances, as described in section 10.04(C) or (D) of the WT Agreement.
For the most recent certification period, the periodic review has identified the following significant change(s) in circumstances:

a. A significant change in WT’s

business practices that affects WT’s ability to meet its obligations under the WT Agreement. b. If applicable, a material change in the applicable know-your-customer rules and procedures when WT relied on documentary evidence as permitted in section 4.01(A) of the WT Agreement. c. Other (please describe). 3. Describe any significant changes in circumstances identified in question 2.

F. Chapter 4 Status

Complete the applicable section (if any) and check the applicable statement to confirm.

a. If WT is a participating FFI:

For the most recent certification period under its WT Agreement, WT has obtained (or maintained) status as a participating FFI and has made the following certification of compliance with respect to its FFI agreement for the most recent certification period under the FFI agreement (check one). Note : You may check Not Applicable if, during the certification period under the WT Agreement, your chapter 4 status changed from one of the other applicable chapter 4 statuses to participating FFI or if your certification of compliance under the FFI agreement

is not yet due as of the date of this certification.

i. Certification of Effec tive Internal Controls ii. Qualified Certification iii. Not Applicable b. If WT is a registered

deemed-compliant FFI: For the most recent certification period under its WT Agreement, WT has certified as required under § 1.1471–5(f)(1)(ii)(B) or Annex II of an applicable Model 2 IGA that it has satisfied the requirements of the deemed-compliant status claimed. c. If WT is a registered deemed-compliant Model 1 IGA FFI: For the most recent certification period under its WT Agreement, WT has been resident in or organized under the laws of a jurisdiction that has in place a Model 1 IGA with the United States and has met the requirements under an applicable Model 1 IGA to be treated as a deemed-compliant FFI. d. If WT is a retirement fund: For the most recent certification period under the WT Agreement, WT has been a retirement fund or other fund that is an exempt beneficial owner described in § 1.1471–6(f) or a similar fund that qualifies as an exempt beneficial owner under an applicable Model 1 IGA or Model 2 IGA.