W-8BEN

Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)
For use by individuals. Entities must use Form W-8BEN-E.

Department of the Treasury Internal Revenue Service

Go to www.irs.gov/FormW8BEN for instructions and the latest information.

Give this form to the withholding agent or payer. Do not send it to the IRS.
- You are a U.S. citizen or other U.S. person, including a resident alien individual - Please use the W9 form.
- You are a beneficial owner claiming that income is effectively connected with the conduct of a trade or business within the United States (other than personal services)
- You are a beneficial owner who is receiving compensation for personal services performed in the United States.
- You are a person acting as an intermediary.
Note: If you are a resident in a FATCA partner jurisdiction (that is, a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be provided to your jurisdiction of residence.

Under U.S. law, payments to non-resident alien individuals and foreign entities are subject to a mandatory 30% tax withholding unless an exemption or reduced rate applies under a tax treaty.

To claim a tax treaty benefit, the independent contractor must provide a properly completed IRS form W-8BEN (for individuals) or W-8BEN-E (for entities). The independent contractor also must complete Form 8233 with a valid U.S. Taxpayer Identification Number (TIN), such as an Individual Taxpayer Identification Number (ITIN) or Employer Identification Number (EIN).

If the appropriate W-8 form and Form 8233 with any necessary TIN are not provided in a timely manner, we are required by law to withhold 30% of the gross payment and remit it to the IRS. You are solely responsible for determining and reporting your tax obligations in your country of residence.
Part I | Identification of Beneficial Owner
Name of individual who is the beneficial owner*
Country of citizenship*
Permanent Residence Address*

Permanent residence address (street, apt. or suite no., or rural routes) Do not use P.O. Box or in-care-of address.

City or town, state or province. Include postal code where appropriate.Country

Postal / Zip Code
Mailing Address (if different from above)

Mailing address (if different from above)

City or town, state or province. Include postal code where appropriate.Country

Postal / Zip Code
Primary Mobile Phone Number*
Please enter a valid phone number.
U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)
Foreign tax identifying number (FTIN) (see instructions)
AOA ID Number*
Date of birth (MM-DD-YYYY) (see instructions)*

MonthDayYear
Part II | Claim of Tax Treaty Benefits

(for chapter 3 purposes only) (see instructions)
I certify that the beneficial owner is a resident of Type a label within the meaning of the income tax treaty between the United States and that Country.
Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article and paragraph Type a label of the treaty identified in line 9 above to claim a % rate of withholding on (specify type of income):
(specify type of income)
Explain the additional conditions in the Article and Paragraph the beneficial owner meets to be eligible for the rate of withholding:
Part III | Certification
- Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:
- I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income or proceeds to which this form relates or am using this form to document myself for chapter 4 purposes;
- The person named on line 1 of this form is not a U.S. person;
- This form relates to: (a) income not effectively connected with the conduct of a trade or business in the United States; (b) income effectively connected with the conduct of a trade or business in the United States but is not subject to tax under an applicable income tax treaty; (c) the partner’s share of a partnership’s effectively connected taxable income; or (d) the partner’s amount realized from the transfer of a partnership interest subject to withholding under section 1446(f);
- The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the United States and that country; and
- For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.

I certify that I have the capacity to sign for the person identified on line 1 of this form.
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner)

Clear
Date (MM-DD-YYYY)*

MonthDayYear
Date
Name of signer*
Should be Empty:

Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)

Part I | Identification of Beneficial Owner

Part II | Claim of Tax Treaty Benefits

Part III | Certification

Sign Here