Form W-8BEN
(Rev. July 2017)
Department of the Treasury
Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner for United
States Tax Withholding and Reporting (Individuals)
For use by individuals. Entities must use Form W8-BEN-E.
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.
OMB No. 1545-1621
Do NOT use this form if: Instead, use Form:
You are not an individual
W-8BEN-E
You are a U.S. citizen or other U.S. person, including a resident alien individual
W-9
You are a benecial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) W-8ECI
You are a benecial 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
W-8IMY
Note: If you are a 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 Identification of Beneficial Owner (see instructions)
1 Name of individual who is the benecial owner 2 Country of citizenship
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate. Country
4 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate. Country
5 U.S. taxpayer identication number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions)
7 Reference number(s) (see instructions) 8 Date of birth (MM-DD-YYYY) (see instructions)
Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 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.
9 Special rates and conditions (if applicable — see instructions): The benecial owner is claiming the provisions of Article and paragraph
of the treaty identied on line 9 above to claim a % rate of withholding on (specify type of income):
Explain the additional conditions in Article and paragraph the benecial 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 benecial owner (or am authorized to sign for the individual that is the benecial owner) of all the income 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,
The income to which this form relates is:
(a) not effectively connect with the conduct of 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 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 between
the United States and that country, and
For broker transactions or barter exchanges, the benecial owner is an exempt foreign person as dened 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 benecial owner or
any withholding agent that can disburse or payments of the income of which I am the benecial owner. I agree that I will submit a new form within 30 days
if any certification made on this form becomes incorrect.
Sign Here }
Signature of benecial owner (or individual authorized to sign for benecial owner) Date (MM-DD-YYYY)
Print name of signer Capacity in which acting (if form is not signed by benecial owner)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 7-2017)
AFFIDAVIT FOR UNCHANGED STATUS: under penalties of perjury I declare that I have examined and signed the above Form W-8BEN and that the
information and certications contained therein remained the same and unchanged for the period beginning to the present, and were
true, correct and complete for those years. (Please attach a separate statement if any information has changed.)
Sign Here }
Signature of benecial owner (or individual authorized to sign for benecial owner) Date (MM-DD-YYYY)
1099 07/17
NCU
10
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