186

Recto.

(1)  Name  and
address  of
Banker  or  Merchant
  acting  as
Agent  of  Owner
of  Bonds  and
Coupons  to  be
written  in  full.
(2)  The
amount  of
Coupons  to  be
set  out  in  writing.


(3)  Name,
address,  and
occupation  of
Owner  of  Bonds
and  Coupons  to
be  written  in  full.

Form  C.
1N  COM  E  TAX.

FOREIGN  DIVIDENDS.
DECLAMATION  to  be  made  by  a  Banker  or  Merchant  in
London,  holding  Bonds  the  property  of  a  Eoreigner  residing
abroad.

I, 1
of
do  hereby  solemnly  déclaré  that  the  Schedule  at  the  back
hereof  contains  a  true  account  of  the  Coupons,  amounting
to  £  ,  say  ( 2 )
due  on  the  days  specified
therein,  and  that  such  Coupons  are  derived  from  Bonds
which  are  in  my  possession,  and  are  claimed  by  me  on
behalf  of  ( 3 )
of
to  be  paid  free  of  Income  Tax,  and  that  the  said  Coupons
and  Bonds  to  which  Bonds  the  said  Coupons  appertain,  are
the  property  of  the  said
and  that  no  British  Subject  wherever  residing,  or  Foreigner
residing  in  the  United  Kingdom  of  Great  Britain  and  Ireland,
has  any  interest  whatever  in  the  said  Coupons  or  Bonds,  or  in
any  or  either  of  them.  Furthermore,  I  hereby  undertake  to
refund  to  the  Board  of  Inland  Revenue  any  Income  Tax  which
may  be  allowed  under  this  Déclaration  through  any  inaccuracy
of  statement  contained  therein.
Signature
Date

Declared  at
this  day  of.  19.
before  me,