U.S. TREAS Form treas-irs-3206-1999
OMB No. 1545-0153
1 Name and address of United Kingdom bank or institution 3a Name of corporation paying dividend 4a Payment date
5a Gross dividend
3b Name of corporation paying dividend 4b Payment date
5b Gross dividend
3c Name of corporation paying dividend 4c Payment date
5c Gross dividend
3d Name of corporation paying dividend 4d Payment date
5d Gross dividend
2 Name and address of dividend recipient (show country)
5e Total
We declare that we have received the above dividend(s) after deduction of U.S. tax of 15% at
source in the United States and that we have distributed it, without deducting further U.S. tax, to
the individual or entity shown in box 2 whose address is as shown in our records.
Signature
Form 3206 (Rev. Nov. 1999)
Department of the Treasury
Internal Revenue Service
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Date
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Information Statement by United Kingdom Withholding Agents Paying Dividends
From U.S. Corporations to Residents of the United States and Certain Treaty Countries
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 19367M
Copy A
For U.S. Internal Revenue Service