I hereby declare that at the time of signing this request for conservancy:
•the amount of the tax claim to which the request for conservancy relates is xxxx.•the tax claim to which the request for conservancy action relates concerns a tax covered by the Convention for which the requested State has not reserved the right not to provide assistance in the recovery of tax claims.•the stage in the process of assessment or recovery that the tax claim has reached under the laws and administrative practices of the applicant State.•the applicant State is able to take conservancy measures in relation to the tax claim in conformity with the laws and administrative practices of the applicant State.•the applicant State will make a request for the recovery of the tax claim to which the conservancy action relates (within xx days of this request).•(please provide details as to how and in what respects conservancy relates to assets, including ‘claims and expectancies’, of the taxpayer against whom the tax claim applies or relates to a third party against whom process is available as a consequence of the tax claim, pursuant to which the third party may be obliged to surrender property or otherwise contribute to the funds or property of the taxpayer)•The information in the request and in the attached documents is correct.Dated:
.....
^name of competent authority^
Competent authority
XXXX
