Note: (a) This form has
to be completed in triplicate by the beneficial owner of the interest and/or
royalties derived in the Portuguese territory or by the legal representative in
Portugal. After each copy is duly certified by the competent tax authority of
the beneficial owners’ State of residence, it must be sent to the entity
indicated at the right bottom.The form is issued in three copies,
being the fourth page the reverse side/second page of each copy, so that the
fourth page has to be printed out in triplicate.