Microsoft Word - Foreign Resident Tax Form

1

InstructionsforRedeemingCertainIsraelBondsinIsrael

CertainseriesofIsraelbond

scanberedeemedinIsrael.(TheAppendixattheendofthisdocumentlists

thosebondsthatcanberedeemedinIsrael).TheStateofIsraelhasmadeprovisionsforredemption

withtheBankofIsraelinJerusalem.

Ifyouwouldprefertoredeemyourbond(s)outsideofIsrael,contactyourIsraelBondsrepresentative

ortheStateofIsrael’sFiscalAgent,Computershare,usingthecontactinformationnotedbelow:

YoucanredeemyourbondatanytimebysendingthecertificateforredemptiontoComputershare,

theStateofIsrael’sfiscalagent,atComputershare,150RoyallStreet,Canton,MA02021,telephone

+1(866)764‐3425(USbondholders)orCompu

tershare,1500Rob

ert‐BourassaBoulevard,Montreal,

QuebecH3A3S8(bondholdersoutsidetheUS).

RedemptionthroughtheBankofIsrael

Forbondsthathavenotyetreachedfinalmaturity,thereisalimitontheamountthatcanberedeemed

inIsrael–upto$1,000peryearforanIsraeliresident,andupto$2,500permonthforanonresident.

Thereisnolimitforbondsthathavereachedfinalmaturity.

Inacasewhereth

ebondholderisdeceasedorthebondwastransferredbytheoriginalbondholdertoa 

thirdparty,pleasecontactComputersharedirectlytoredeemthebond(s).

Redemption inIsrael:

OnlybondholderswhohaveabankaccountinIsraelorwhowishtoredeemthebondforcashpayment

atth

eofficesoftheBankofIsraelinJerusalem(atapre‐scheduledmeeting)mayredeemthebond

throughtheBankofIsrael.

Pleasenotethatsuchredemptionmaybesubjecttotaxwithholding,asfurtherexplainedbelow.

A. Theprocess

TheprocessforredeemingbondsthroughtheBankofIsraelisasfollows:

1. Mailtheoriginalbondcertificate,theRedemptionInformationFormfound attheendof

theseinstructions,andthesupportingdocumentstotheappropriateIsraelBondsoffice at

theaddress(es)below.WerequirethisinformationsothattheIsraelBondsorganizationand

theBankofIsraelcanverifythatyouortheentitytha

tyourepresentaretherightfulowner

ofthebondandfortaxreportingpurposes.Werecommendthatyouretainacopyofall

documentsforyourrecords,andthatyousendthecertificate(s)usingamethodthatallows

youtotrackthepackage.

UnitedStates

bondholders:

Canadianbondh

olders: Bondh

oldersoutside

theUSorCanada:

DirectorofOperations

Development

CorporationforIsrael

DirectorofOperations

Canada‐Israel

Securities,Limited

DirectorofOperations

DevelopmentCompany

forIsrael(Services)Ltd.

BinyaneiHauma

DEVELOPMENT CORPORATION FOR ISRAEL • Member FINRA • www.israelbonds.com | CANADA-ISRAEL SECURITIES, LIMITED • Registered as an Exempt Market Dealer • israelbonds.ca | DEVELOPMENT COMPANY FOR ISRAEL (INTERNATIONAL) LTD. Authorised and regulated by

the Financial Conduct Authority • israelbondsintl.com | DEVELOPMENT COMPANY FOR ISRAEL (EUROPE) GMBH • israelbondsintl.com | Competent supervisory authority: Bundesanstalt für Finanzdienstleistungsaufsicht www.bafin.de | Competent supervisory authority:

Bundesanstalt fuer Finanzdienstleistungsaufsicht www.bafin.de, and Autorité des Marchés Financiers www.amf-france.org

2

P O Box 5263

New York, NY

10150-5263

PO Box 434

North York RPO Steeles West

Toronto, ON M3J 0J3

AShazarStreet,7



Floor

Jerusalem,Israel

2. Decidewhetheryouwanttoreceivetheredemptionfundsbybanktransfertoabank

accountinIsraeloratthecashier'sdeskattheBankofIsraelinJerusalemincashandmark

therelevantboxontheform.

3. OnceyourredemptionrequestisreviewedbytheIsra elBonds office,ifthedocumentation

isinorder,IsraelBondswillprovideyouwithavoucherthatyoumustpresenttoredeem

thebondattheBankofIsraelcashier’sdeskforcashpayment.Ifyouelectpaymentbybank

transfer,youwillreceiveavoucherfromIsraelBondsthatyoumustsignandreturntoIsrael

BondsbutdonotneedtoscheduleameetinginIsrael.TheBankofIsraelistheonlyentity

thatwillacceptthevoucher.ThevoucherwillbevalidforredemptionONLYbytheperson(s)

orentitylistedonit,whomustprovidethegovernment‐issuedoriginalidentitydocument(s)

listedonthevouchertotheBankofIsrael,alongwiththeadditionaldocumentslistedinthe

chartbelow.Thevoucherwillspecifytheinterestamountontheprincipalamountofthe

bond.TheBankofIsraelwillwithholdtherequiredtaxfromtheinterestamount.

4. Pleasenotethatonceyourredemptionrequestisreviewedandyoureceiveavoucher,you

willnotreceiveyouroriginalcertificateback.Youwillbeabletoredeemthebondonlyin

Israelwiththevoucherprovidedifyouselectedcashpaymentorbybanktransfertothe

IsraelibankaccountyoulistedontheForm.Youwillhaveoneyearfromiss uanceofthe

vouchertoredeemitinIsraelby cash.

5. Ifthevoucherexpiredorithasbeenlost,contacttheIsraelBondsofficeforassistance.

MoreInformationaboutPaymentOp

tions:

a. Paymentviabank

transfertoanaccountinIsrael‐thesumtobetransferred,afterthe

requiredtaxdeduction,ifany,willbemadeinIsraelishekels(ILS).TheIsraelBondsofficew ill

sendyoursignedvoucherandtherelateddocumentstotheBankofIsraeltomakethebank

transferandwillsendacopyofthevouchertoyouforyourrecords,Notethatforabank

transfer,thetransferwillbemadeaftertherequiredtaxdeductio

n,ifany...Ifyoudonotpay

taxesinIsrael,completetheForeignResidentTaxForm(whichrequiresthatyoursignaturebe

notarized)andprovide thatdocumenttotheIsraelBondsoffice.

b. Paymentviacash‐YouwillreceiveyourpaymentinIsraelishekels(ILS)attherepresentative

exchangerateineffectonthedayyouarepaid.Youmustpresentthevoucherandallthe

requireddocumentsinpersonattheBankofIsraelat2KaplanStreet,Jerusalem,Israel.Do

notsignthevoucheruntilyouareatyourappointmentattheBankofIsrael.Youwillneedto

setupanin‐personmeetin

ginadvance,byemail,bycontacting[email protected]sothatyou

willbeadmittedtothebuildingwhenyouarrive.Theprocesscantakesometime,soplease

planaccordingly.ThereisnoguaranteeyouwillbeabletomeetwithanEnglish‐speaking

3

clerk.Thepaymentwillbemadeaftertherequiredtaxdeduction,ifany..Ifyoudonotpay

taxesinIsrael,completetheForeignResidentTaxForm(whichrequiresthatyoursignaturebe

notarized)wellinadvanceofyourtriptoIsraelandprovidethatdocumenttotheIsraelBonds

officeforforwardingtotheBankofIsrael.

B. TaxConsequencesforIsraeliResidentsandnon‐residents:

TheredemptionmaybesubjecttowithholdingtaxinIsrael.Aforeignresident willcompleteastatement

attachedtothisform,affirmingthattheyareaforeignresident.Thetaxwillbewithheld,ifsorequired,

bytheBankofIsrael.Therateofwithholdingtax,ifany,isasprovidedinthetablebelo

w,orwillbeset

inaccordancewithIsraelitaxlawthatwillapplyatthetimeofthewithholdin g.

C. Documentsrequiredforpayment‐

Pleaseprovidethebondcertificate,identityrelateddocumentationlistedontheFormbelowandthe

applicabletaxdocumentsrequiredbytheBankofIsraeltotheIsraelBondsoffice.IsraelBondswill

reviewandverifytheidentityofthebondholderand thestatusofthebond.TheBankofIsraelwill

reviewthetaxformsprovid

edandwillinformIsraelBondsifadditionaltaxinformationisneededfrom

thebondholder.Ifyouareanon‐residentofIsraelandhavequestionsaboutthetaxdocumentation, 

pleasecontactIsraelBondsandIsraelBondswillverifywithBankofIsraelwhatinformationisrequired

fromyou.Yo

urvoucherwillnotbeissuedun

tilIsraelBondshasverifiedyourid entityandthestatusof

yourbond.MaximumTaxwithholdingwillbemadeiftheBankofIsraeldeterminesthatthetax

documentationprovidedisnotsufficient.

4

DocumentsRequiredbytheBankofIsraelforTax‐ReportingPurposes

ResidentsofIsraelmustprovidetheauthorizationslistedbelowis suedbytheIsraeliTaxAuthority.Non‐

residentsmustcompletetheForeignResidentStatement

Documents

required from the

redeemer in order

to be paid

Maximum

current tax

withholding

rate without

tax

withholding

authorization

Documents required from the redeemer for reduced

tax withholding purposes or for tax exemption

(required by Bank of Israel for tax reporting

purposes)

Individual resident of

Israel—Bond Certificate

issuance date is before the

determining date of May

8, 2000.

1. Israeli ID card

2. Account

management

authorization

from the Bank

where the bank

account is

managed or

cancelled check

in Israel that

provides for the

relevant account

details.

3. Israel Bonds

voucher

%35 1. Israeli ID card

2. Authorization from Israeli Income Tax Authority

for tax reduction or exemption

Individual resident of

Israel—Bonds Certificate

issuance date is after the

determining date of May

8, 2000.

1. Israeli ID card

2. Account

management

authorization

from the Bank

where the bank

account is

managed or

cancelled check

in Israel that

provides for the

relevant account

details.

3. Israel Bonds

voucher

%25 1. Israeli ID card

2. Authorization from Israeli Income Tax Authority

for tax reduction or exemption

Israeli

company/NPO/Association

1. Incorporation

document

2. Account

management

authorization

from the Bank

where the bank

account is

managed or

cancelled check

in Israel that

provides for the

%23 1. Bookkeeping authorization (from Israel tax

Authority income tax

2. Authorization from Israel tax authority for tax

reduction or exemption

5

Documents

required from the

redeemer in order

to be paid

Maximum

current tax

withholding

rate without

tax

withholding

authorization

Documents required from the redeemer for reduced

tax withholding purposes or for tax exemption

(required by Bank of Israel for tax reporting

purposes)

relevant account

details.

3. Israel Bonds

voucher

Individual nonresident

1. Passport

2. Account

management

authorization

from the Bank

where the bank

account is

managed or

cancelled check

in Israel that

provides for the

relevant account

details

3. Israel Bonds

voucher

%0 Residency

4. A foreign resident statement

Without this document, BANK OF

ISRAEL will deduct the tax as an Israeli

resident.

Ifyouhaveanyquestionsregardingth

eredemptionprocess,pleasecontactyourlocalIsraelBonds

representativeorUSCustomerServiceat+1(888)519‐4111oremail[email protected]

(USbondholders);CanadaCustomerServiceat+1(866)543‐3351(Canadianbondholders); or+9722 500

1950extension609oremail[email protected](forbondholdersoutsidetheU.S.

orCanada).

6

Redemption InformationForm 

BondInformation

Bondcertificatenumber:__________________Issuedate:__________Maturitydate:__________

Bondtype:___________________________Bond purchaseamount:_________________

BondholderInformation–individual

Firstname:__________________Middlename:________________

Lastname:________________________________________________ 

Dateofbirth:_______________

Countryofresidencewhenthebondwaspurchased_____________

Nationality:________________

Passport/IDnumber:_____________________Enclose withthisformacopyofavalidgove

rnmen

tID.

YouwillneedtoshowthesameIDwhenredeemingthevoucherinperson.

Passporttype(countryofissuance):____________________________ 

Address:______________ ___________________ ____________________________________ ________

____________________________________________________ __________________ _______________

Emailaddress:________ _______________________

Telephonenumber:___________________TelephonenumberinIsrael:____________________

7

Bondhold

erinformation–institution

Companyname:________ ___________________ __________EINNumber(U.S.entities):____________

CompanyIDnumberinlocaljurisdiction(non‐U.S.entities):____________ _______________

Address:______________________________________________________________________________

____________________________________________________ __________________ _______________

Contactpersonnameandtitle:______________________ ____

Contactpersonemailaddress:___________________________

Contactpersonpassport/IDnumber:__________________Enclosewiththisformacopyofavalid

governmentID.Youwillneedtoshowth

esame

IDwhenredeemingthevoucherinperson.

Passporttype(countryofissuance):____________ _________

Contactpersontelephonenumber:____________________

ContactpersontelephonenumberinIsrael:____________________ 

____Attachacorporateresolutionorothercomparabledocumentsignedbyanattorneyoraccountant

statingthenamesofthebondholder’sauthorizedsignatories(mustincludethecontac

tpersonliste

d

above).

____Attachapowerofattorneyshowingthecontac tpersonlistedabovewhoisredeemingthebondon

behalfofthebondholder isauthorizedtoactontheinstitu tion’sbehalf.

PaymentInstructions–IndividualsandInstitutions(pleasecheckone) 

[]Paymentbydepositintoabankacco

unt.Noteth

attheaccountmustbeanIsraelishekelaccount.

Sendthebondcertificate,theidentitydocumentationandtaxformsrequiredbyBankofIsraeltoIsrael

Bondsasdetailedabove.

Bankaccounttype:_________________________ ___

Bankname:______________________________Branchnumber:_______________

Accountnumber:_________________

Nameofaccountholder: (mustbethei

ndividual'sortheinsti

tution'saccount)

_________________________________________________

Attachabankaccountconfirmationorvoidedcheck.

[]Paymentincash(Israelishekels,ILS)‐PleasenoteameetingmustbesetupinadvancewiththeBank

ofIsrael,viathecontactdetailsnotedabove.SendIsraelBondsthebondcertificate,ide ntity

8

documentationandtaxdocumentsrequiredbyBankofIsrael.Oncetheinformationiscompleteand

verified,youwillreceiveavoucherforredemption.Bringcopiesofallthedocumentationyouprovided

toIsraelBonds,copiesofyourtaxdocumentsandyouroriginalidentity documenttotheappointment

atBankofIsrael.

Bysigningbel

w,IaffirmthattheinformationaboveiscorrectandtruthfulandthatIamthe

rightfulownerofthebondoramanauthorizedrepresentativeoftherightfulin stitutionalowner

ofthebond.IfurtheraffirmthatIhavenottransferredorassignedthebondtoanyotherparty

andthatIpla

ntoredeemitthroughtheBankofIsraelbybanktransferorbycash.Iundersta nd 

thattheStateofIsrael,BankofIsraelandDevelopmentCorporationforIsrael/IsraelBonds,

Canada‐IsraelSecurities,LimitedandDevelopmentCompanyforIsrael(Services)Ltdcannot

providetaxadvicetomean

dImus

tcontactanaccountant orothertaxadvisorforinquiries

relatingtothetaxconsequencesofredeemingthebond(s).IfurtherunderstandthatIam

responsibleforalltaxreportingrequirementsrelatingtothebonds,waive,anddisclaimany

liabilityagainsttheStateofIsrael,BankofIsraelorth

eIsraelBondsenti

tieslistedaboverelating

tosuchtaxreporting.

Signature:__________ __________________ _____________________________________ __

PrintName:____________ _____________________________________________________

Ifactingonbehalfofanentity,nameofentity:________________________ _______________

Titleatentity:____________________________________ ______________

Date:________________________________________________________________________

____________________________________________________ __________________ __________

FORINTERNALUSEONLY

DateCertificateandSupportingDocumentsReceivedbyIsraelBonds:______________________

ReviewedBy:______________________________________Date__________________

9

Appendix‐ListofBondseriesthatcanberedeemedinIsrael

CODE_MILVE CAT_NAME

1700 6TH DEVELOPMENT SAVINGS REGISTERED "SB"

1799 6TH DEVELOPMENT CURRENT INCOME "RB"

1800 7TH DEVELOPMENT SAVINGS REGISTERED "7S"

1899 7TH DEVELOPMENT CURRENT INCOME "SD"

1999 7TH DEVELOPMENT CURRENT INCOME "7C"

2599 5TH DEVELOPMENT INVEST. CURRENT INCOME

5500 STATE OF ISRAEL CERTIFICATES $250

5501 STATE OF ISRAEL CERTIFICATES SERIES A $250

5502 STATE OF ISRAEL CERTIFICATES SERIES B $100

7101 DEV. INVEST. COUPONS 4.75% SERIES A

7102 DEV. INVEST. COUPONS 4.75% SERIES B

7103 DEV. INVEST. COUPONS 4.75% SERIES C

7201 2ND DEV. INVEST. 5.5% COUPONS SERIES A

7202 2ND DEV. INVEST. 5.5% COUPONS SERIES B

7203 2ND DEV. INVEST. 5.5% COUPONS SER. C

7301 3RD DEV. INVEST. 5.5% COUPONS SER. A

7302 3RD DEV. INVEST. 5.5% COUPONS SERIES B

7401 4TH DEV. INVEST. 5.5% COUPONS SERIES A

7402 4TH DEV. INVEST. 5.5% COUPONS SERIES B

7403 4TH DEV. INVEST. 5.5% COUPONS SERIES C

7404 4TH DEV. INVEST. 5.5% COUPONS SERIES D

7501 5TH DEV. INVEST. 5.5% COUPONS SERIES A

7502 5TH DEV. INVEST. 5.5% COUPONS SERIES B

7503 5TH DEV. INVEST. 5.5% COUPONS SERIES C

7504 5TH DEV. INVEST. 5.5% COUPONS SERIES D

7505 5TH DEV. INVEST. 5.5% COUPONS SERIES E

7506 5TH DEV. INVEST. 5.5% COUPONS SERIES F

7507 5TH DEV. INVEST. 5.5% COUPONS SERIES G

7508 5TH DEV. INVEST. 5.5% COUPONS SERIES H

7509 5TH DEV. INVEST. 5.5% COUPONS SERIES I

7510 5TH DEV. INVEST. 5.5% COUPONS SERIES j

8000 INDEPENDENCE ISSUE SAVINGS

8001 INDEPENDENCE ISSUE COUPONS

8100 DEV. ISSUE SAVINGS

8101 DEV. ISSUE COUPONS

8200 2ND DEV. ISSUE SAVINGS

8201 2ND DEV. ISSUE COUPONS SERIES A

8202 2ND DEV. ISSUE COUPONS SERIES B

8203 2ND DEV. ISSUE COUPONS SERIES C

8204 2ND DEV. ISSUE COUPONS SERIES D

8205 2ND DEV. ISSUE COUPONS SERIES E

8300 3RD DEV. ISSUE SAVINGS

8301 3RD DEV. ISSUE COUPONS SERIES A

8302 3RD DEV. ISSUE COUPONS SERIES B

8303 3RD DEV. ISSUE COUPONS SERIES C

8304 3RD DEV. ISSUE COUPONS SERIES D

8400 4TH DEV. ISSUE SAVINGS

10

8401 4TH DEV. ISSUE COUPONS SERIES A

8402 4TH DEV. ISSUE COUPONS SERIES B

8403 4TH DEV. ISSUE COUPONS SERIES C

8404 4TH DEV. ISSUE COUPONS SERIES D

8500 5TH DEV. ISSUE SAVINGS

8501 5TH DEV. ISSUE COUPONS SERIES A

8502 5TH DEV. ISSUE COUPONS SERIES B

8503 5TH DEV. ISSUE COUPONS SERIES C

8600 RECONSTRUCTION & DEV. SAVINGS

8601 RECONSTRUCTION & DEV. COUPONS SERIES A

8602 RECONSTRUCTION & DEV. COUPONS SERIES B

8603 RECONSTRUCTION & DEV. COUPONS SERIES C

8604 RECONSTRUCTION & DEV. COUPONS SERIES D

8605 RECONSTRUCTION & DEV. COUPONS SERIES E

8606 RECONSTRUCTION & DEV. COUPONS SERIES F

8700 6TH DEV. ISSUE SAVINGS

8701 6TH DEV. ISSUE COUPONS SERIES A

8702 6TH DEV. ISSUE COUPONS SERIES B

8703 6TH DEV. ISSUE COUPONS SERIES C

8704 6TH DEV. ISSUE COUPONS SERIES D

8800 6TH DEV. INTERNATIONAL SAVINGS

8804 6TH DEVELOPMENT INTERNATIONAL COUPONS SERIES D

8805 6TH DEVELOPMENT INTERNATIONAL COUPONS SERIES E

8806 6TH DEVELOPMENT INTERNATIONAL COUPONS SERIES F

8900 7TH DEVELOPMENT INTERNATIONAL SAVINGS "E"

8901 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES A

8902 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES B

8903 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES C

8904 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES D

8905 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES E

8906 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES F

8907 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES G

8908 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES H

8909 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES I

8910 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES J

8911 7TH DEVELOPMENT INTERNATIONAL COUPONS SERIES K

9000 7TH DEVELOPMENT INTERNATIONAL SAVINGS "7A"

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |milvo[email protected].i |לט :'2165521-02 |סקפ :4996669-02

דומע1 ךותמ7

Date /ךיראת :_____________

תרהצה בשות ץוח

Foreign Resident Statement

א. יטרפ ריהצמה Declarant details

גוס ריהצמה Declarant type

דיחי/ה Individual רבח ינב םדא Corporation

תונמא

Trust תופתוש לכש הירבח יבשות

ץוח A partnership whose members are all non-

residents

גוס קיזחמ תרגיאBondholder type/

תבותכ העובק )הנידמ ,ריע ,בוחר ,רפסמ תיב רפסמו הריד()#tate,city,street,apartmentsPermanentaddress(

ץחל ןאכ תנזהל טסקט.ץחל ןאכ תנזהל טסקט.

תבותכ חולשמל ראוד

MailingAddress

ןופלט דיינ/Mobilephoneתבותכ ראוד ינורטקלא/E‐mail

דיחיל/Individual:

ץחל ןאכ תנזהל טסקט.

תנידמ תובשות/

Stateorjurisdictionof

residence

תנידמ תוחרזא/

ofcitizenshipCountry

מהניד תקיפנמ ןוכרדה/

Countryissuing

Passport

ףקות ןוכרדה/

Passportexpirationdate

רבח ינב םדא/ Corporation/Entity

ץחל ןאכ תנזהל טסקט.

םש לעב תדועת סדנובה/

Nameofbondholder

סמ 'ןוכרדה/ Passport#

וא סמ 'םושיר /orRegistration#

ספוטה אלומי ב-2 םיקתעה /

Please complete 2 copies

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע2 ךותמ7

ץחל ןאכ תנזהל טסקט.

הנידמה הב דגאתה/

Stateorjurisdictionof

entity’sIncorporation

הנידמה הב םימייקתמ ההטילש

והלוהינ/

Stateorjurisdictionof

operationsentity’smain

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע3 ךותמ7

1. דיחיל/Individual:

ינא ריהצמ יכ ינא בשות ץוח ) ותרדגהכ ףיעסב 1 תדוקפל סמ הסנכה( ןיינעל תדוקפ סמ הסנכה יכו רומאה ןלהל ןוכנ

ייבגל )ןמס X תומוקמב םייטנבלרה:(

I declare that I am a foreign resident (as defined in Section 1 of the Income Tax Ordinance) for the purposes of

the Income Tax Ordinance and that the following details are correct (mark x in the relevant places):

תנידמ לארשי הניא םוקמ ירוגמ עובקה –

The State of Israel is not my permanent residence

תנידמ לארשי הניא םוקמ ירוגמ ירוגמו יתחפשמ-

The State of Israel is neither my permanent residence nor my family’s

permanent residence.

.sister, brother, Family is defined as father, mother, spouse,

daughter or son.

םוקמ יקוסיע ליגרה וא עובקה וניא יוצמ תנידמב לארשי –

My permanent place of employment is not in the State of Israel

יניא קסוע חלשמב די תנידמב לארשי -

I do not currently work in the State of Israel

ןיא יתולעבב קסע וא קלח קסעמ יוצמה תנידמב לארשי –

I do not own more than five percent of a business or part of a business in the

State of Israel

הנשה אל יתיהש יניאו ןווכתמ תוהשל תנידמב לארשי 183 םימי וא רתוי –

This calendar year I have not and do not intend to stay in the State of Israel for

183 days or longer

הנשה

אל יתיהש לארשיב, ףאו יניא ןווכתמ תוהשל הב, 30 םימי וא רתוי ךסו לכ יתייהש לארשיב, הנשה

םייתנשבו ומדקש הל, אל עיגי ל 425 םימי. –

This year I have not, nor intend to remain in the State of Israel for 30 days or

longer, and the total number of days I was in Israel over the past two years will

not exceed 425 days

יניא חטובמ דסומב חוטיבל ימואל תנידמב לארשי-

I am not insured and do not receive medical insurance from the National

Insurance Institute in the State of Israel

ןיא יתושרב ןוכרד ילארשי –

I do not have an Israeli passport

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע4 ךותמ7

יניא לעב/ת תוחרזא ילארשי

I do not have Israeli citizenship

דיחיל היהש בשות ץוח תעב תש

יכר תרגיא סדנובה ינא מצריה יכ הפוקתב יתשכרש תא תרגיאה

_____________ יתייה בשות ץוח

. שי ןמסל ףיעסב ב ליעל תא תואקספה תוסחייתמה תעל ךתויה בשות ץוח ןמזב תשיכר תרגיאה.

To an individual who was a foreign resident when purchasing the Bond and is a foreign resident today

(Date of purchase) and today I was and am a foreign resident.

_____________ I declare that when I purchased on

bond on

Please mark above your foreign residency country/countries at the time of purchasing the bond and/or today.

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיח

י יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע5 ךותמ7

םדא ינב רבח. 2

/ Corporation and other entities:

יננה ריהצמ/ה יכ רבח ינב םדאה וניה בשות ץוח ןויכ ש) :ןמס X תומוקמב םייטנבלרה(

I declare that the corporation is a foreign entity and that the following details are correct (mark x in the

relevant boxes):

אל םשרנ לצא םשר תורבחה לארשיב -

To the best of my knowledge, not registered with the Registrar of Companies in the

State of Israel

אל םשרנ לצא םשר תותומעה לארשיב –

To the best of my knowledge, not registered with the Registrar of Associations in the

State of Israel

אל םשרנ לצא םשר תויופתושה לארשיב –

To the best of my knowledge, not registered with the Registrar of Partnerships in the

State of Israel

לכ םיפתושה תופתושב םניא יבשות לארשי-

To the best of my knowledge, no partners in the company, if it is a partnership, are

residents of the State of Israel

הטילשה לע רבח ינב םדאה הניא היוצמ לארשיב-

To the best of my knowledge, control of the entity is not in the State of Israel

לוהינ רבח ינב םדאה וניא יוצמ בלארשי –

To the best of my knowledge, the majority of management of the entity is not located in

the State of Israel

רבחל ינב םדאה ןיא לעפמ עבק לארשיב –

To the best of my knowledge, the entity does not have a permanent establishment in

the State of Israel

ןיא בשות לארשי קיזחמה ןירשימב וא ןיפיקעב

תויוכזב וא תוינמב רועישב הלועה לע 25%

No resident of Israel directly or indirectly

holds

rights or shares in the company in excess of

25%

א .תוכזב ףתתשהל םיחוורב

a. Right to participate in any profits

ב .תוכזב תונמל רוטקריד

b. Right to appoint a director

ג .תוכזב העבצהה

c. Any voting rights

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואקנב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע6 ךותמ7

ד .תוכזב קלחל יסכנמ רבח ינב םדאה ,

תעב וקוריפ

d. Right to direct the division of the entity’s

assets

at liquidation

ה .תוכזב תורוהל לע ךרדה תלעפהל תחא

תויוכזה תורומאה ליעל

e. Right to make the decision regarding any

of the aforementioned actions above

3 . תונמאנ/ Tr

ust:

יננה ריהצמ/ה יכ תונמאנה הניה תבשות ץוח ןוויכ ש: )ןמס x תומוקמב םייטנבלרה(

I declare that the trust is a foreign entity and that the following details are correct (mark x in the relevant

phrases):

תונמאנה אל המשרנ לארשיב The trust was not registered in Israel

2 רצוי/ת תונמאנה וניה/ה בשות/ת ץוח The settlor or grantor of the trust is a foreign resident

3 הנהנה/ת וניה/ה בשות/ת ץוח The beneficiary of the trust is a foreign resident

4 ןמאנה וניה/ה בשות/ת ץוח The trustee is a foreign resident

ב .תואכזה רוטפל סממ לע תודועת סדנוב לש בשות ץוח וא ימ היהש בשות ץוח תעב תשיכר רגיאות סדנובה /Tax

exemption Eligibility for bonds certificates for a foreign resident or an individual who was a foreign resident

and is a foreign resident as of the date of execution of this form swhen purchasing the Bond

יננה ריהצמ/ה יכ עודי יל היהאש יאכז/ת תונהיל רוטפמ סממ לע הסנכה תיבירמ לע תודועת סדנובה קר הדימב ולאו ודמעי לכב םיאנתה

םיאבה: I declare that I am aware that I will be entitled for tax exemption on interest income only if the bonds

meet all of the following conditions:

1 . דועתות סדנובה אל מושרתו ואל בייחות םושירב ירפסב לעפמ עבק לארשיב /

The bonds are not registered in the books of a permanent establishment/fiscal agent in Israel

2 . תסנכה תיבירה דועתמות סדנובה הניא הסנכה קסעמ וא חלשמ די/

Bond interest income received is derived from the bond holding and was not derived as payment from business

activities or an occupation

הרהצה /

DECLARATION

1. ינא ריהצמ/ה תאזב יתנבהש תא ספוט הז יתאלימו ותוא קיודמב ובםאתה תוארוהל./

I declare that, to the best of my knowledge and ability at this time, I fully understand this form and filled it out

correctly

2 . ספוטב הז יתרסמ תא לכ םיטרפה םינוכנה םיאלמה םימלשהו./

n this form I have provided full correct and complete details

3. ינא בייחתמ/ת םאש לוחי יוניש טרפב והשלכ, טרופש ספוטב הז , הנפא דימ קנבל לארשי אלמאו ספוט שדח.

If there is any change of any detail specified in this form within one year following the date of execution of the form

or the date of bond redemption, whichever is earlier, I will immediately contact the Bank of Israel and fill out a new

form

__________________________________________________________________________________________________________________________

קנב לארשי ,ףגא תובשחה ,תדיחי יתוריש תואק

נב םיפסכו |ת.ד .780 םילשורי 9100701

רודמ תוולמ הנידמ |mil[email protected]rg.i |לט :'2165521-02 |סקפ :4996669-02

דומע7 ךותמ7

תמיתח ריהצ

מה/ Signature Declarant

ץחל ןאכ תנזהל טסקט.ץחל ןאכ תנזהל טסקט.ץחל ןאכ תנזהל טסקט.

םש/FullName

רפסמ תוהז/Passport#/or

Registration#

המיתח/Signature ךיראת/Date

ונתמיתח לע בתכ הז הווהמ ונתמכסה רומאל ףדב ,1 בףד 2 ובףד 3 /

Our signature on this page constitutes our agreement to what is stated on the previous pages.

Notary signature____________________________

Notary Name_______________________________

Date________________________________________:

INSERT NOTARY STAMP HERE

הסנכה סמ תדוקפ לע הריבע םיווהמ םינוכנ יתלב םיטרפ תריסמ וא הטמשהש יל עודי

I am aware that any intentional omission or misrepresentation of any detail included in this form constitutes a

violation of the law