W-8BEN - Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)

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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 to the IRS.

. • You are a U.S. citizen or other U.S. person, including a resident alien individual • You are a beneficial owner claiming that income is effectively connected with the conduct of 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 ....... 8233 or W-4 • You are a person acting as an intermediary ............................

Note: If you are 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.

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Identification of Beneficial Owner (see instructions)

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1 Name of individual who is the beneficial owner* This field is required.

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2 Country of citizenship* This field is required.

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3 Permanent residence address street, apt. or suite no., or rural routeDo not use a P.O. box or in-care-of address.* This field is required.

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City or town, state or province. Include postal code where appropriate.* This field is required.

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Country* This field is required.

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4 Mailing address (if different from above)

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

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Country

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U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)

You can leave this field blank.

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U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)You can leave this field blank

6bCheck if FTIN not legally required...........

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6a Foreign tax identifying number (see instructions)* This field is required.

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7 Reference number(s) (see instructions)

You can leave this field blank.

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8 Date of birth (MM-DD-YYYY) (see instructions)* This field is required.

Date

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Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)

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I certify that the beneficial owner is a resident of* This field is required.Type your country

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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

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of the treaty identified on line 9 above to claim a

You can leave this field blank.

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ofthe treaty identified on line 9 above to claim a

You can leave this field blank.

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% rate of withholding on (specify type of income):

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.

You can leave this field blank.

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Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding

You can leave this field blank.

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Part III

You can leave this field blank.

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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.

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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.* This field is required.

I certify that I have the capacity to sign for the person identified on line 1 of this form.

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Signature of beneficial owner (or individual authorized to sign for beneficial owner)* This field is required.

Clear

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Date (MM-DD-YYYY)* This field is required.

Date

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Print name of signer* This field is required.

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For Paperwork Reduction Act Notice, see separate instructions.

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Would you like to receive a copy of your signed form by email? Insert it here:

example@example.com