Fillable Beneficial Owner Declaration Of Status Form - Computershare (Page 3 of 3) in pdf

Reduced Rate

- Declaration & Undertaking to be made by the beneficial owner of a dividend

This part is to be completed by the person entitled to the benefit of the dividend attaching to a security(ies)

• This form is to be completed by the beneficial owner (of dividends, including dividends

in specie

) in order for the reduced rate of dividends tax,

referred to in sections 64FA, 64G or 64H of the Income Tax Act, 1962 (Act No 58 of 1962) (the Act) as well as the provisions of the Agreement for the

Avoidance of Double Taxation and Prevention of Fiscal Evasion (DTA) between the Republic of South Africa and the country of residence of the

beneficial owner, to apply.

•

In order to qualify for the reduced rate referred to above, this declaration and written undertaking should be submitted to the withholding agent,

Computershare, in order to ensure that any dividends declared and paid on or after such date, will be subject to a reduced rate of dividends tax where

appropriate - failure to do so will result in the full 15% dividends tax being withheld/payable.

•

Where the beneficial owner is a foreign resident but does not qualify for a reduced rate this section should NOT be completed.

Please provide the following details for all securities held in respect of which a reduced rate of tax is applicable. Only include

securities where you qualify for the reduced rate on this form.

No of

% of capital

% voting

Explanation of the reasons the beneficial owner meets

Registered company name

securities

held

rights

the requirements of the DTA

* (if more entries need to be made please complete another form or attach a schedule of your holdings).

DECLARATION in terms of sections 64FA(2)(a), 64G(3)(i) or 64H(3)(i) of the Act:

(full names in print please),

the undersigned hereby declare that all the relevant requirements in terms of Article **

of the Agreement for the Avoidance

of Double Taxation and Prevention of Fiscal Evasion (DTA) in force on the relevant date between the Republic of South Africa and the country of

residence of the beneficial owner specified above, as well as sections 64FA, 64G or 64H of the Act (whichever is applicable)

have been met and that dividends paid on the securities specified above are therefore subject to a reduced rate of **

** (Please refer to the SARS website for details of the DTA and the reduced rate that applies).

Signature_______________________________________ Date ___________________________________

(Duly authorised to do so)

Capacity of Signatory _____________________________________________________________________

UNDERTAKING in terms of section 64FA(2)(b), 64G(3)(ii) or 64H(3)(ii) of the Act:

(full names in print please),

the undersigned undertake to forthwith inform the Withholding Agent in writing should the circumstances of the beneficial owner

referred to in the declaration above change.

Signature_______________________________________ Date ___________________________________

(Duly authorised to do so)

Capacity of Signatory: _____________________________________________

NOTE: I am aware that it is the sole responsibility of the Beneficial Owner to ensure that this declaration and undertaking are filed timeously and that the

information provided in this declaration and undertaking is accurate and complete; I agree that the Regulated Intermediary will under no circumstances

be liable for any costs, expenses or damages including, but not limited to, any direct, indirect, special, consequential or incidental damages caused by or

arising from any late submission of declarations and/or omission to submit declarations and/or any incorrect or incomplete information provided by the

Beneficial Owner in the declarations; I agree that it remains at all times the sole responsibility of the Beneficial Owner to ensure that it complies with all

requirements and obligations in relation to Dividends Tax as set out in the Act from time to time.