ZS-RE 1, CLAIM FOR REPAYMENT OF AUSTRIAN WITHHOLDING TAX

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Repayment of austrian withholding tax

Claim

under the tax treaties concluded by Austria

according to section 21 paragraph 1 subparagraph 1a Körperschaftsteuergesetz 1988

according to section 6 Körperschaftsteuergesetz 1988 (Exemption for foreign pension funds)

for the year (yyyy)

1. State

Please indicate here your State of residence

2. Information on the claimant

Tax Identification Number of the claimant´s residence state or, if not available, a similar identification number

Full name, date of birth (in case of individuals), Firm, trade register number or similar of the claimant´s residence state (in case of legal persons)

Legal form (in case of legal persons: for example stock corporation, association)

Address (post code, town, street, number) telephone or fax number, e-mail-address

Representative (if any) (name, address) telephone or fax number, e-mail-address

Mandate

mandate for cash receipts

mandate for postal deliveries

power of attorney

3. Computation of repayment amount

The following fields are to be filled in by the claimant (all amounts in Euro)

DIVIDENDS (according to Sheet A)

Repayment under tax treaties

Repayment according to section 21 paragraph 1 sub paragraph 1a Körperschaftsteuergesetz 1988

Repayment according to section 6 Körperschaftsteuergesetz 1988

ROYALTIES (according to Sheet B)

Royalties

OTHER INCOME (according to Sheet C)

Other Income

SUM

Repayment amount

4. Residence certificate of the foreign tax administration

For the purpose of obtaining tax relief in Austria the following is certified: Within the meaning of the Double Taxation Convention Austria has concluded with the State indicated in Section 1, the claimant was a resident of that State on the date or the dates when the income was received (Section 3) and the information on the claimant (Section 2) is in accordance with our knowledge.

Date (ddmmyyyy)