TDA 2689 F 01/21
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*TDA2689*
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TD Ameritrade, Inc., member FINRA/SIPC, a subsidiary of The Charles Schwab Corporation. TD Ameritrade is a trademark jointly owned by
TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank. ©2021 Charles Schwab & Co. Inc. All rights reserved.
W-8BEN
Department of the Treasury
Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner
for United States Tax Withholding
Give this form to the withholding agent or payer. Do not send to the IRS.
For complete instructions or more information on the W-8 forms, please refer to www.irs.gov/formw8ben. If you have any other questions regarding your
application or account, please contact TD Ameritrade. Note: If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity),
certain tax account information may be provided to your jurisdiction of residence.
Part I
Part II
Identification of Beneficial Owner (See instructions.)
1 2
3
4
5 6
Name of individual who is the beneficial owner Country of citizenship
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
yrtnuoC.etairporppa erehw edoc latsop edulcnI .ecnivorp ro etats ,nwot ro ytiC
(see instructions) rebmun gniyfitnedi xat ngieroF
8
Date of birth (MM-DD-YYYY) (see instructions)
)snoitcurtsni ees( deriuqer fi r (SSN or ITIN)ebmun noitacifitnedi reyapxat .S.U
Mailing address (if different from above)
yrtnuoC.etairporppa erehw edoc latsop edulcnI .ecnivorp ro etats ,nwot ro ytiC
Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
I certify that the beneficial owner is a resident of within the meaning of the income
tax treaty between the United States and that country.
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 to which this
form relates or am using this form to document myself for chapter 4 purposes,
• The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected
but is not subject to tax under an applicable income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income,
• 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
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
between the United States and that country, and
• The person named on line 1 of this form is not a U.S. person,
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY)
For use by individuals. Entities must use Form W-8BEN-E.
Certification
9
Print name of signer Capacity in which acting (if form is not signed by beneficial owner)
Part III
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.
The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your
status as a non-U.S. person and, if applicable, obtain a reduced rate of withholding.
7 TD Ameritrade Account Number (if no account number yet, write New Account)
tdameritrade.com
TD Ameritrade
200 S 108th Ave
Omaha, NE 68154-2631
Special rates and conditions (if applicable – see instructions): The beneficial owner is claiming the provisions of Article and paragraph of the
treaty identified on line 9 above to claim a % rate of withholding on (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:
10
Afdavit of Unchanged Status (if applicable)
Under penalties of perjury I declare that I have examined and signed the above Form W-8BEN and that the information and certications contained therein remained the
same and unchanged for the period beginning January 1, 2021 (or later account opening date) to the present, and were true, correct, and complete during that period.
Signature: _________________________________________________________ Signature Capacity: ______________________________________________
Please fax all requested paperwork to 866-468-6268 or attach to an email through the Secure Message Center. If mailing is preferred, send original W-8BEN to the
address in the upper right hand corner.
