Foreign Vendor 1042 Questionnaire

1. Name of Vendor:

2. Country of Residence:

3. Business Address (not P.O. box):

4.Do you file a U.S. federal income tax return? Yes  No 

5. Are you a (check only one box to describe your status): Individual  Corporation  Partnership  Qualified Intermediary Nonqualified Intermediary  Tax-Exempt or Governmental Entity Other

STATEMENT OF VENDOR REGARDING TYPE OF BUSINESS

BEING CONDUCTED WITH SIEMENS

PLEASE CHECK THE BOX(S) IN EITHER SECTION 1 OR 2 (NOT BOTH)

Section 1

(Check Section 1, even if you intend to make a claim for treaty benefits)

 The activities we are performing for Siemens and which we expect to receive payment constitute at least one or more of the following and thus some or all of the paymentsare subject to US income tax withholding (please check all that apply):

Licensing intangible property for use in the U.S. such as trademarks, trade names, service marks, patents, secret processes and formulas, goodwill, franchises, "know-how," and other similar rights or copyrights, or

 Renting tangible property located on U.S. soil, or

 Providing services on U.S. soil

Section 2

To the best of my knowledge and belief, I declare that the activities we are performing for Siemens are:

 Selling of goods only (including software and software maintenance contracts provided the user license grants the user the perpetual right to use the software, and restricts the rights to reproduce the software and distribute to the public) and/or

 Providing of services outside the U.S.(You must check the box in Section 1, if any services will be performed on U.S. soil).

______

Signature of individual authorized to sign for Vendor/ Title Date

Concurrence of Siemens Representative:

______

Siemens Procurement or Commodity Manager/ Title Date

Questionnaire to determine application of new FATCA provisions of the

HIRE ACT of 2010(must be completed by 12/31/2012)

1. Are you a “foreign financial institution[1]”? Yes  No 

2. Are you a publicly traded corporation or member of an expanded affiliated group of a publicly traded corporation[2]? Yes  No 

3. Are you a foreign government, political subdivision of a foreign government, or any agency or instrumentality thereof? Yes  No 

4. Are you a foreign central bank? Yes  No 

5. Are you an international organization or wholly owned agency or instrumentality hereof? Yes  No 

6. Are you an entity organized under the laws of a U.S. possession and which is wholly owned by residents of that possession? Yes  No 

7. If you answered “No” to all of the questions above, do you have a substantial U.S. owner[3]? Yes  No  Not Applicable 

8. If you answered “Yes” to question 7, provide the name, address and TIN of each substantial U.S.owner. (Attach additional pages if necessary).

NameAddressTIN

I hereby certify to the best of my knowledge and belief that the above information is true and correct as of the date hereof:

______

Signature of individual authorized to sign for Vendor/ Title Date

[1] The HIRE Act defines “foreign financial institution” broadly to include (1) any entity that accepts deposits in the ordinary course of a banking or similar business, (2) any entity that holds financial assets for the account of others as a substantial portion of its business, and (3) any entity engaged in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, or any interest in such securities, partnership interests, or commodities (including futures, forwards or options). Accordingly, the term foreign financial institution includes investment vehicles like hedge funds and private equity funds.

[2] A publicly traded corporation is a corporation the stock of which is regularly traded on an established securities market. A member of expanded affiliated group of a publicly traded corporation generally includes any corporate entity that is owned by a publicly traded corporation, directly or indirectly, by more than 50% of its vote and value.

[3] A “substantial U.S. owner” is defined as any U.S. person that (a) owns, directly or indirectly, more than 10% of the stock of a corporation, by vote or value; (b) owns, directly or indirectly, more than 10% of the profits interest or capital interest in a partnership; (c) owns any interest in a foreign grantor trust; or (d) owns more than 10% of the beneficial interest in a trust.