JAPANESE DECLARATION LETTER FOR US GROUP TRUST

Date:	{Macro value="LongDate" Macro}
Attn:	Globe Tax Services, Inc. One New York Plaza, 34th Floor New York, NY 10004 Phone: (212) 747-9100

Re: Name of Group Trust: {Macro value = "BoLegalName" Macro}
Number of Trust Participants: ____________

***In the case of Rule 81-100 Group Trusts all of the pensions in the trust must be listed here with each of their counts of plan participants.

1. The group Trust was established under (please select as appropriate):

• Revenue Ruling 81-100
• State/Country Code: {Macro value="State" Macro}  {Macro value="Country" Macro}
• Other (please specify):________________

2. Is the group trust exempt from federal income tax under Internal Revenue Code section 501 (a), while the participating pension plans are established under section 401(a), 457 (b), 403 (b) or 401 (a) (24) of the Internal Revenue Code? _________________

On December 31, {Macro value="PriorYear" Macro}, the {Macro value = "BoLegalName" Macro}, tax identification number {Macro value="TaxId" Macro} had _____________ (Number of total plan participants) as shown above. _____________ participants are United States residents. Consequently, _____________ (i.e., PERCENTAGE) of the participants, members, beneficiaries in this group trust are United States residents. The Tax Officer (Trustee of the Group Trust) has confirmed that the numbers are correct and can be contacted to validate the number provided.

Name of Trustee of Group Trust: {Macro value = "BoLegalName" Macro}
Street Address of Group Trust: {Macro value="StreetAddress" Macro}
City/State/Zip of Group Trust: {Macro value="CityStateZip" Macro}
Phone# of Trustee: ________________________________________________________________
Email of Trustee: __________________________________________________________________

This letter certifies that more than 50% of participants in the “beneficiary’s name” are United States residents under the Income Tax Convention between Japan and United States, para. 1(e) of Article 22.

Regards,

Authorized signature: __________________________________________________________________
Signer’s Name: ______________________________________________________________________

Name of Group Trust: __________________________________________________________________
Street Address: ______________________________________________________________________
City/State/ Zip: ______________________________________________________________________
Phone#: ______________________________ Email: ________________________________________

Claim for refund of Japanese Withholding Tax
RE: {Macro value="BoLegalName" Macro}

To Whom It May Concern

Attached to this letter is a request for refund of withholding under the Convention between the United States of America and Japan for the Avoidance of Double Taxation for the above named 81-100 Group Trust.

{Macro value = "BoLegalName" Macro} is an IRC 81-100 collective investment trust organized and residing in {Macro value = "State" Macro}, {Macro value = "Country" Macro}. The tax identification number for the trust is {Macro value = "TaxId" Macro}. We confirm that all of the participating plans in the trust are US persons as defined under the Convention between the United States of America and Japan for the Avoidance of Double Taxation.

See in this letter a list of all the underlying plans as of {Macro value = "PriorYear" Macro} within the group trust which details the Name, Tax ID, Address and Total US Participants of each plan, as well as the Percentage of US Participants among the Total number of Plan Participants within each of the plans:

Plan Name	Tax ID	Address	Residency	Total US Participants	US Participants (% of Total)

Name:_________________________________________________________________________

Title:__________________________________________________________________________

Date:__________________________________________________________________________

Signature:______________________________________________________________________