| Type of information | Specification |
| A. | Information regarding the person that is providing the information |
|
| Name of the certified financial intermediary or, where applicable, the withholding tax agent | |
| European unique identifier (EUID), legal entity identifier (LEI) or alternative | |
| Official address | |
| Other relevant data | Tax identification number (TIN) assigned by the source Member State, if available, and the TIN(s) assigned by the jurisdiction(s) of residence for tax purposes, TIN-issuing jurisdiction(s)
Email address and telephone number
|
| Indication if the information is provided pursuant to Article 10(3) | Identification of the financial intermediary that is not a certified financial intermediary (name and EUID, LEI or alternative) |
| B. | Information regarding the recipient of the dividend or interest payment |
|
Identification of the financial intermediary or final investor receiving the dividend or interest payment
When the reporting option of Article 10(4) is applicable: the withholding tax agent or the designated certified financial intermediary is required to report on the information about the final investor receiving the dividend or interest payment
| |
| Natural person | Name, TIN assigned by the source Member State, if available, and the TIN(s) assigned by the jurisdiction(s) of residence for tax purposes, TIN-issuing jurisdiction(s), date of birth, address |
| Entity | Name, TIN assigned by the source Member State, if available, and the TIN(s) assigned by the jurisdiction(s) of residence for tax purposes, TIN-issuing jurisdiction(s), address, LEI, where applicable, EUID, where applicable
In the absence of an identification number, legal form and date of incorporation
|
| Information about the tax residence (to be completed when the person in section A is the certified financial intermediary of the registered owner) | eTRC verification code or the information contained in Article 12(2), point (b), where applicable |
| Name of country of tax residence |
| Investment account number | Number of the account where the securities are held by the financial intermediary/investor receiving the payment |
| Type of account | The type of account according to Article 38 of Regulation (EU) No 909/2014 and other accounts:
A – Own account (maintained by a participant in the central securities depositary (CSD) of the original register of the securities)
B – Third-party general account (maintained by a participant in the CSD of the original register of the securities for the account of clients)
C – Third-party individual account (maintained by a participant in the CSD of the original register of the securities on behalf of a client)
D – Detail register account of a third-party general account (securities of a client included in a third-party general account maintained by a participant in the CSD of the original register of the securities)
E – Third-party global account other than B
F – Individual account of a securities holder other than D or C
G – Other type of account
|
| C. | Information regarding the payor of the dividend or interest payment |
|
Identification of the financial intermediary from which the reporter receives the dividend or interest payment
When the reporting option of Article 10(4) is applicable: section C contains information about each certified financial intermediary that is part of the security payment chain. This information relates to the sequential payment chain of financial intermediaries.
| |
| Legal person | Name, LEI, TIN assigned by the source Member State, if available, and the TIN(s) assigned by the jurisdiction(s) of residence for tax purposes, TIN-issuing jurisdiction(s), address, EUID, where applicable |
| Investment account number | Number of the account where the securities were held by the financial intermediary sending the payment |
| Type of account | The type of account according to Article 38 of Regulation (EU) No 909/2014 and other accounts:
| A – | Own account (maintained by a participant in the central securities depositary (CSD) of the original register of the securities) |
| B – | Third-party general account (maintained by a participant in the CSD of the original register of the securities for the account of clients) |
| C – | Third-party individual account (maintained by a participant in the CSD of the original register of the securities on behalf of a client) |
| D – | Detail register account of a third-party general account (securities of a client included in a third-party general account maintained by a participant in the CSD of the original register of the securities) |
| E – | Third-party global account other than B |
| F – | Individual account of a securities holder other than D or C |
|
| D. | Information regarding the dividend or interest payment |
|
| Issuer | Name, TIN or, in its absence, LEI or EUID, official address |
| CSD | Identification of the central securities depository of the original register of the securities |
| ISIN (International Securities Identifier Number) | Identification of the security |
| Security type | Type of share, underlying of a depository receipt, bond |
| Number of securities that give right to receive the payment | Number of securities settled |
| Number of securities pending settlement |
| Payment type | Cash
Shares (indication whether they derive from script dividend and the ISIN number)
|
| COAF (Official Corporate Action Event Identifier) or, if not available, detailed information on the distribution | Identification of the event (dividend/interest distribution) |
| Relevant dates | Ex-dividend date, record date, payment date |
| Amount of dividend or interest received/to be received and currency | Gross amount, net amount |
| Information about the withholding tax | Withholding tax rate applied or to be applied, amount withheld, the amount and the rate of a surcharge if applicable |
| The legal basis of the applicable withholding tax rate (to be completed when the person in section A is the certified financial intermediary of the registered owner) |
| Cash account IBAN | IBAN of the account to which the payment has been transferred |
| E. | Information regarding application of anti-abuse measures to be fulfilled by the certified financial intermediary requesting relief |
|
| Information about the holding period of underlying publicly traded shares | Two boxes:
| 1) | for underlying shares acquired more than five days before the ex-dividend date – number of shares |
| 2) | for underlying shares acquired within a period of five days before the ex-dividend date – number of shares
(‘First in, first out’ (FIFO) to be used in case of regular trading positions)
|
|
| Information about financial arrangement | Indicate evidence of any financial arrangement involving underlying publicly traded shares that has not been settled, expired or otherwise terminated at the ex-dividend date |
| For underlying shares linked to a financial arrangement – number of shares |
| For underlying shares not linked to a financial arrangement – number of shares |
| F. | Information regarding transactions that can be requested by the source Member State according to Article 10(2) |
|
| Information about the transactions of the underlying securities from 1 year before the record date up to and including 45 days after the record date | Trade dates |
| Contractual or agreed settlement dates |
| Actual settlement dates |
| The respective number of securities that are subject to the trade |
| Transaction type: purchase, sale, loan, transfer, other |
| G. | Information regarding depositary receipts that can be requested by the source Member State according to Article 10(2) |
|
| When it concerns a dividend payment arising from a depositary receipt | The name, the international securities identification number (e.g. ISIN) of the depositary receipts and of the underlying shares |
| The name of the bank in which the underlying shares are deposited |
| The ratio of the depositary receipts to the underlying shares |
| The number of depositary receipts held by the registered owner that give right to receive the dividend payment |
| The payment date of the dividend arising from a depositary receipt |
| The total number of issued depositary receipts at the record date |
| The total number of underlying shares for all issued depositary receipts at the record date |
