Fillable Form W-8BEN: Certicate of Status of Benecial Owner (Australian National University)

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Form W-8BEN: Certicate of Status of Benecial Owner (Australian National University)

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Form W-8BEN
(Rev. July 2017)
Department of the Treasury
Internal Revenue Service
Certificate of Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
►For use by entities. Individuals must use Form W-8BEN. ►Section references are to the Internal Revenue Code.
►Go to www.irs.gov/FormW8BENE 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 for: Instead use Form:
• U.S. entity or U.S. citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-9
• A foreign individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN (Individual) or Form 8233
• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benets) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benets) (see instructions for exceptions) . . . W-8IMY
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or
government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
501(c), 892, 895, or 1443(b) (unless claiming treaty benets) (see instructions for other exceptions) . . . . . . . . . . . . W-8ECI or W-8EXP
• Any person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8IMY
Part I Identification of Beneficial Owner
1 Name of organization that is the benecial owner 2 Country of incorporation or organization
3 Name of disregarded entity receiving the payment (if applicable, see instructions)
4 Chapter 3 Status (entity type) (Must check one box only):
Corporation Disregarded entity Partnership
Simple trust Grantor trust Complex trust Estate Government
Central Bank of Issue Tax-exempt organization Private foundation International organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If “Yes” complete Part III.
Yes No
5 Chapter 4 Status (FATCA status) (See instructions for details and complete the certication below for the entity’s applicable status).
Nonparticipating FFI (including a limited FFI or an FFI related
to a Reporting IGA FFI other than a deemed-compliant FFI,
participating FFI, or exempt benecial owner).
Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.
Registered deemed-compliant FFI (other than a reporting Model
1 FFI, sponsored FFI, or nonreporting IGA FFI covered in Part
XII). See instructions.
Sponsored FFI. Complete Part IV.
Certied deemed-compliant nonregistering local bank. Complete
Part V.
Certied deemed-compliant FFI with only low-value accounts.
Complete Part VI.
Certied deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Certied deemed-compliant limited life debt investment entity.
Complete Part VIII.
Certied deemed-compliant investment advisors and investment
managers. Complete Part IX.
Owner-documented FFI. Complete Part X.
Restricted distributor. Complete Part XI.
Nonreporting IGA FFI. Complete Part XII.
Foreign government, government of a U.S. possession, or foreign
central bank of issue. Complete Part XIII.
International organization. Complete Part XIV.
Exempt retirement plans. Complete Part XV.
Entity wholly owned by exempt benecial owners. Complete Part XVI.
Territory nancial institution. Complete Part XVII.
Nonnancial group entity. Complete Part XVIII.
Excepted nonnancial start-up company. Complete Part XIX.
Excepted nonnancial entity in liquidation or bankruptcy.
Complete Part XX.
501(c) organization. Complete Part XXI.
Nonprot organization. Complete Part XXII.
Publicly traded NFFE or NFFE afliate of a publicly traded
corporation. Complete Part XXIII.
Excepted territory NFFE. Complete Part XXIV.
Active NFFE. Complete Part XXV.
Passive NFFE. Complete Part XXVI.
Excepted inter-afliate FFI. Complete Part XXVII.
Direct reporting NFFE.
Sponsored direct reporting NFFE. Complete Part XXVIII.
Account that is not a nancial account.
6 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
City or town, state or province. Include postal code where appropriate. Country
7
Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate. Country
8
U.S. taxpayer identication number (TIN), if required 9a GIIN b Foreign TIN
10
Reference number(s) (see instructions)
Note: Please complete remainder of the form including signing the form in Part XXX.
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 59689N Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 2
Part II
Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a
branch of an FFI in a country other than the FFI’s country of residence. See instructions.)
11 Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment
Branch treated as nonparticipating FFI.
Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.
U.S. Branch.
12 Address of disregarded entity or branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a
registered address).
City or town, state or province. Include postal code where appropriate.
Country
12 GIIN (if any)
Part III Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only.)
14
I certify that (check all that apply):
a
The benecial owner is a resident of within the meaning of the income tax treaty
between the United States and that country.
b
The benecial owner derives the item (or items) of income for which the treaty benets are claimed, and, if applicable, meets the
requirements of the treaty provision dealing with limitation on benets. The following are types of limitation on benets provisions that may
be included in an applicable tax treaty (check only one; see instructions):
Government Company that meets the ownership and base erosion test
Tax exempt pension trust or pension fund Company that meets the derivative benets test
Other tax exempt organization Company with an item of income that meets active trade or business test
Publicly traded corporation Favorable discretionary determination by the U.S. competent authority received
Subsidiary of a publicly traded corporation Other (specify Article and paragraph):
c
The benecial owner is claiming treaty benets for U.S. source dividends received from a foreign corporation or interest from a U.S.
trade or business of a foreign corporation and meets qualied resident status (see instructions).
15
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 14a above to claim a % rate of withholding on (specify type of income):
Explain the additional conditions in the Article the benecial owner meets to be eligible for the rate of withholding:
Part IV Sponsored FFI
16
Name of sponsoring entity:
17 Check whichever box applies.
I certify that the entity identied in Part I:
• Is an investment entity;
• Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
• Has agreed with the entity identied above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
I certify that the entity identied in Part I:
• Is a controlled foreign corporation as dened in section 957(a);
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. nancial institution identied above that agrees to act as the sponsoring entity for this entity; and
• Shares a common electronic account system with the sponsoring entity (identied above) that enables the sponsoring entity to identify all
account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not
limited to, customer identication information, customer documentation, account balance, and all payments made to account holders or
payees.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 3
Part V Certified Deemed-Compliant Nonregistering Local Bank
18
I certify that the FFI identied in Part I:
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without prot) in its country
of incorporation or organization;
• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated
to such bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a
greater than 5% interest in such credit union or cooperative credit organization;
• Does not solicit account holders outside its country of organization;
• Has no xed place of business outside such country (for this purpose, a xed place of business does not include a location that is not
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded afliated group, the group has no
more than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded afliated group that is a foreign nancial institution, other than a foreign nancial institution that
is incorporated or organized in the same country as the FFI identied in Part I and that meets the requirements set forth in this part.
Part VI Certified Deemed-Compliant FFI with Only Low-Value Accounts
19
I certify that the FFI identied in Part I:
• Is not engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional
principal contracts, insurance or annuity contracts, or any interest (including a futures or forward contract or option) in such security,
partnership interest, commodity, notional principal contract, insurance contract or annuity contract;
• No nancial account maintained by the FFI or any member of its expanded afliated group, if any, has a balance or value in excess of
$50,000 (as determined after applying applicable account aggregation rules); and
• Neither the FFI nor the entire expanded afliated group, if any, of the FFI, have more than $50 million in assets on its consolidated or
combined balance sheet as of the end of its most recent accounting year.
Part VII Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
20 Name of sponsoring entity:
21
I certify that the entity identied in Part I:
• Is an FFI solely because it is an investment entity described in Regulation section 1.1471-5(e)(4);
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fullled by
the sponsoring entity identied on line 20; and
• 20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. nancial
institutions, participating FFIs, registered deemed-compliant FFIs, and certied deemed-compliant FFIs and equity interests owned by
an entity if that entity owns 100% of the equity interests in the FFI and is itself a sponsored FFI).
Part VIII Certified Deemed-Compliant Limited Life Debt Investment Entity
22
I certify that the FFI identied in Part I:
• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar
agreement; and
• Is certied deemed-compliant because it satises the requirements to be treated as a limited life debt investment entity (such as the
restrictions with respect to its assets and other requirements under Regulations section 1.1471-5(f)(2)(iv)).
Part IX Certain Investment Entities that Do Not Maintain Financial Accounts
23
I certify that the FFI identied in Part I:
• Is a nancial institution solely because it is an investment entity described in Regulations section 1.1471-5(e)(4)(i)(A), and
• Does not maintain nancial accounts.
Part X Owner-Documented FFI
Note: This status only applies if the U.S. nancial institution, participating FFI, or reporting Model 1 FFI to which this form is given has agreed that it
will treat the FFI as an owner-documented FFI (see instructions for eligibility requirements). In addition, the FFI must make the certications below.
24a
(All owner-documented FFIs check here) I certify that the FFI identied in Part I:
• Does not act as an intermediary;
• Does not accept deposits in the ordinary course of a banking or similar business;
• Does not hold, as a substantial portion of its business, nancial assets for the account of others;
• Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a nancial account;
• Is not owned by or in an expanded afliated group with an entity that accepts deposits in the ordinary course of a banking or similar
business, holds, as a substantial portion of its business, nancial assets for the account of others, or is an insurance company (or the
holding company of an insurance company) that issues or is obligated to make payments with respect to a nancial account;
• Does not maintain a nancial account for any nonparticipating FFI; and
• Does not have any specied U.S. persons that own an equity interest or debt interest (other than a debt interest that is not a nancial
account or that has a balance or value not exceeding $50,000) in the FFI other than those identied on the FFI owner reporting
statement.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 4
Part X Owner-Documented FFI (continued)
Check box 24b or 24c, whichever applies.
b
I certify that the FFI identied in Part I:
• Has provided, or will provide, an FFI owner reporting statement that contains:
(i) The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specied
U.S. person that owns a direct or indirect equity interest in the owner-documented FFI (looking through all entities other than
specied U.S. persons);
(ii) The name, address, TIN (if any), and chapter 4 status of every individual and specied U.S. person that owns a debt interest in
the ownerdocumented FFI (including any indirect debt interest, which includes debt interests in any entity that directly or indirectly
owns the payee or any direct or indirect equity interest in a debt holder of the payee) that constitutes a nancial account in excess
of $50,000 (disregarding all such debt interests owned by participating FFIs, registered deemed-compliant FFIs, certied deemed-
compliant FFIs, excepted NFFEs, exempt benecial owners, or U.S. persons other than specied U.S. persons); and
(iii) Any additional information the withholding agent requests in order to fulll its obligations with respect to the entity.
• Has provided, or will provide, valid documentation meeting the requirements of Regulations section1.1471-3(d)(6)(iii) for each person
identied in the FFI owner reporting statement.
c
I certify that the FFI identied in Part I has provided, or will provide, an auditor’s letter, signed within 4 years of the date of payment,
from an independent accounting rm or legal representative with a location in the United States stating that the rm or representative
has reviewed the FFI’s documentation with respect to all of its owners and debt holders identied in Regulations section 1.1471-3(d)(6)
(iv)(A)(2), and that the FFI meets all the requirements to be an owner-documented FFI. The FFI identied in Part I has also provided, or
will provide, an FFI owner reporting statement of its owners that are specied U.S. persons and Form(s) W-9, with applicable waivers.
Check box 24d if applicable (optional, see instructions).
d
I certify that the entity identied on line 1 is a trust that does not have any contingent beneciaries or designated classes with
unidentied beneciaries.
Part XI Restricted Distributor
25a
(All restricted distributors check here) I certify that the entity identied in Part I:
• Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished;
• Provides investment services to at least 30 customers unrelated to each other and less than half of its customers are related to each
other;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is an
FATFcompliant jurisdiction);
• Operates solely in its country of incorporation or organization, has no xed place of business outside of that country, and has the same
country of incorporation or organization as all members of its afliated group, if any;
• Does not solicit customers outside its country of incorporation or organization;
• Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement
for the most recent accounting year;
• Is not a member of an expanded afliated group that has more than $500 million in total assets under management or more than $20
million in gross revenue for its most recent accounting year on a combined or consolidated income statement; and
• Does not distribute any debt or securities of the restricted fund to specied U.S. persons, passive NFFEs with one or more substantial
U.S. owners, or nonparticipating FFIs.
Check box 24b or 24c, whichever applies.
I further certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made
after December 31, 2011, the entity identied in Part I:
b
Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and
U.S. resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities
to any specied U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.
c
Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specied U.S.
person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that
such a restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the
procedures identied in Regulations section 1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any, or caused
the restricted fund to transfer the securities to a distributor that is a participating FFI or reporting Model 1 FFI securities which were
sold to specied U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 5
Part XII Nonreporting IGA FFI
26
I certify that the entity identied in Part I:
• Meets the requirements to be considered a nonreporting nancial institution pursuant to an applicable IGA between the United States
and
. The applicable IGA is a Model 1 IGA or a Model 2 IGA; and
is treated as a under the provisions of the applicable IGA or Treasury
regulations (if applicable, see instructions);
• If you are a trustee documented trust or a sponsored entity, provide the name of the trustee or sponsor.
The trustee is:
U.S. Foreign
Part XIII Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue
27
I certify that the entity identied in Part I is the benecial owner of the payment, and is not engaged in commercial nancial activities of
a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or
obligations for which this form is submitted (except as permitted in Regulations section 1.1471-6(h)(2)).
Part XIV International Organization
Check box 28a or 28b, whichever applies.
28a
I certify that the entity identied in Part I is an international organization described in section 7701(a)(18)
b
I certify that the entity identied in Part I:
• Is comprised primarily of foreign governments;
• Is recognized as an intergovernmental or supranational organization under a foreign law similar to the International Organizations
Immunities Act or that has in effect a headquarters agreement with a foreign government;
• The benet of the entity’s income does not inure to any private person; and
• Is the benecial owner of the payment and is not engaged in commercial nancial activities of a type engaged in by an insurance
company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is
submitted (except as permitted in Regulation section 1.1471-6(h)(2)).
Part XV Exempt Retirement Plans
Check box 29a, b, c, d, e, or f, whichever applies.
29a
I certify that the entity identied in Part I:
• Is established in a country with which the United States has an income tax treaty in force (see Part III if claiming treaty benets);
• Is operated principally to administer or provide pension or retirement benets; and
• Is entitled to treaty benets on income that the fund derives from U.S. sources (or would be entitled to benets if it derived any such
income) as a resident of the other country which satises any applicable limitation on benets requirement.
b
I certify that the entity identied in Part I:
• Is organized for the provision of retirement, disability, or death benets (or any combination thereof) to beneciaries that are former
employees of one or more employers in consideration for services rendered;
• No single beneciary has a right to more than 5% of the FFI’s assets;
• Is subject to government regulation and provides annual information reporting about its beneciaries to the relevant tax authorities in the
country in which the fund is established or operated; and
(i) Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its
status as a retirement or pension plan;
(ii) Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans
described in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds
described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulation section 1.1471-5(b)(2)(i)(A));
(iii) Either does not permit or penalizes distributions or withdrawals made before the occurrence of specied events related to retirement,
disability, or death (except rollover distributions to accounts described in Regulation section 1.1471-5(b)(2)(i)(A) (referring to retirement
and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, or to other retirement
funds described in this part or in an applicable Model 1 or Model 2 IGA); or
(iv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
c
I certify that the entity identied in Part I:
• Is organized for the provision of retirement, disability, or death benets (or any combination thereof) to beneciaries that are former
employees of one or more employers in consideration for services rendered;
• Has fewer than 50 participants;
• Is sponsored by one or more employers each of which is not an investment entity or passive NFFE;
• Employee and employer contributions to the fund (disregarding transfers of assets from other plans described in this part, retirement and
pension accounts described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulation section 1.1471-5(b)(2)(i)(A))
are limited by reference to earned income and compensation of the employee, respectively;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20 percent of
the fund’s assets; and
• Is subject to government regulation and provides annual information reporting about its beneciaries to the relevant tax authorities in the
country in which the fund is established or operates.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 6
Part XV Exempt Retirement Plans (continued)
d
I certify that the entity identied in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a),
other than the requirement that the plan be funded by a trust created or organized in the United States
e
I certify that the entity identied in Part I is established exclusively to earn income for the benet of one or more retirement funds
described in this part or in an applicable Model 1 or Model 2 IGA, accounts described in Regulation section 1.1471-5(b)(2)(i)(A)
(referring to retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 IGA.
f
I certify that the entity identied in Part I:
• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S.
possession (each as dened in Regulation section 1.1471-6) or an exempt benecial owner described in an applicable Model 1 or Model
2 IGA to provide retirement, disability, or death benets to beneciaries or participants that are current or former employees of the
sponsor (or persons designated by such employees); or
• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S.
possession (each as dened in Regulation section 1.1471-6) or an exempt benecial owner described in an applicable Model 1 or Model
2 IGA to provide retirement, disability, or death benets to beneciaries or participants that are not current or former employees of such
sponsor, but are in consideration of personal services performed for the sponsor.
Part XVI Entity Wholly Owned by Exempt Beneficial Owners
30
I certify that the entity identied in Part I:
• Is an FFI solely because it is an investment entity;
• Each direct holder of an equity interest in the investment entity is an exempt benecial owner described in Regulation section 1.1471-6
or in an applicable Model 1 or Model 2 IGA;
• Each direct holder of a debt interest in the investment entity is either a depository institution (with respect to a loan made to such entity)
or an exempt benecial owner described in Regulation section 1.1471-6 or an applicable Model 1 or Model 2 IGA.
• Has provided an owner reporting statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the type
of documentation provided to the withholding agent for every person that owns a debt interest constituting a nancial account or direct
equity interest in the entity; and
• Has provided documentation establishing that every owner of the entity is an entity described in Regulation section 1.1471-6(b), (c), (d),
(e), (f) and/or (g) without regard to whether such owners are benecial owners.
Part XVII Territory Financial Institution
31
I certify that the entity identied in Part I is a nancial institution (other than an investment entity) that is incorporated or organized
under the laws of a possession of the United States.
Part XVIII Excepted Nonfinancial Group Entity
32
I certify that the entity identied in Part I:
• Is a holding company, treasury center, or captive nance company and substantially all of the entity’s activities are functions described in
Regulation section 1.1471-5(e)(5)(i)(C) through (E);
• Is a member of a nonnancial group described in Regulation section 1.1471-5(e)(5)(i)(B);
• Is not a depository or custodial institution (other than for members of the entity’s expanded afliated group); and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or
any investment vehicle with an investment strategy to acquire or fund companies and then hold interests in those companies as capital
assets for investment purposes.
Part XIX Excepted Nonfinancial Start-Up Company
33
I certify that the entity identied in Part I:
• Was formed on (or, in the case of a new line of business, the date of board resolution approving the new line of business)
(date must be less than 24 months prior to date of payment);
• Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of
business other than that of a nancial institution or passive NFFE;
• Is investing capital into assets with the intent to operate a business other than that of a nancial institution; and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or
any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for
investment purposes.
Part XX Excepted Nonfinancial Entity in Liquidation or Bankruptcy
34
I certify that the entity identied in Part I:
• Filed a plan of liquidation, led a plan of reorganization, or led for bankruptcy on
;
• During the past 5 years has not been engaged in business as a nancial institution or acted as a passive NFFE;
• Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a
nonnancial entity; and
• Has, or will provide, documentary evidence such as a bankruptcy ling or other public documentation that supports its claim if it remains
in bankruptcy or liquidation for more than 3 years.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 7
Part XXI 501(c) Organization
35
I certify that the entity identied in Part I is a 501(c) organization that:
• Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization
that is dated
; or
• Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization (without regard to whether
the payee is a foreign private foundation).
Part XXII Non-Profit Organization
36
I certify that the entity identied in Part I is a non-prot organization that meets the following requirements:
• The entity is established and maintained in its country of residence exclusively for religious, charitable, scientic, artistic, cultural or
educational purposes;
• The entity is exempt from income tax in its country of residence;
• The entity has no shareholders or members who have a proprietary or benecial interest in its income or assets;
• Neither the applicable laws of the entity’s country of residence nor the entity’s formation documents permit any income or assets of the
entity to be distributed to, or applied for the benet of, a private person or noncharitable entity other than pursuant to the conduct of the
entity’s charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market
value of property which the entity has purchased; and
• The applicable laws of the entity’s country of residence or the entity’s formation documents require that, upon the entity’s liquidation or
dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled
entity of a foreign government, or another organization that is described in this part or escheats to the government of the entity’s country
of residence or any political subdivision thereof.
Part XXIII Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation
Check box 37a or 37b, whichever applies.
37a
I certify that:
• The entity identied in Part I is a foreign corporation that is not a nancial institution; and
• The stock of such corporation is regularly traded on one or more established securities markets, including
(name one securities exchange upon which the stock is regularly traded).
b
I certify that:
• The entity identied in Part I is a foreign corporation that is not a nancial institution;
• The entity identied in Part I is a member of the same expanded afliated group as an entity the stock of which is regularly traded on an
established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is
; and
• The name of the securities market on which the stock is regularly traded is
.
Part XXIV Excepted Territory NFFE
38
I certify that:
• The entity identied in Part I is an entity that is organized in a possession of the United States;
• The entity identied in Part I:
(i) Does not accept deposits in the ordinary course of a banking or similar business,
(ii) Does not hold, as a substantial portion of its business, nancial assets for the account of others, or
(iii) Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a nancial account; and
• All of the owners of the entity identied in Part I are bona de residents of the possession in which the NFFE is organized or
incorporated.
Part XXV Active NFFE
39
I certify that:
• The entity identied in Part I is a foreign entity that is not a nancial institution;
• Less than 50% of such entity’s gross income for the preceding calendar year is passive income; and
• Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income (calculated as a
weighted average of the percentage of passive assets measured quarterly) (see instructions for the denition of passive income).
Part XXVI Passive NFFE
40a
I certify that the entity identied in Part I is a foreign entity that is not a nancial institution (other than an investment entity organized in
a possession of the United States) and is not certifying its status as a publicly traded NFFE (or afliate), excepted territory NFFE, active
NFFE, direct reporting NFFE, or sponsored direct reporting NFFE.
Check box 37a or 37b, whichever applies.
b
I further certify that the entity identied in Part I has no substantial U.S. owners (or, if applicable, no controlling U.S. persons), or
c
I further certify that the entity identied in Part I has provided the name, address, and TIN of each substantial U.S. owner (or, if
applicable, controlling U.S. person) of the NFFE in Part XXIX.
Form W-8BEN-E (Rev. 7-2017)
Form W-8BEN-E (Rev. 7-2017) Page 7
Part XXVII Excepted Inter-Affiliate FFI
41
I certify that the entity identied in Part I:
• Is a member of an expanded afliated group;
• Does not maintain nancial accounts (other than accounts maintained for members of its expanded afliated group);
• Does not make withholdable payments to any person other than to members of its expanded afliated group;
• Does not hold an account (other than a depository account in the country in which the entity is operating to pay for expenses) with or
receive payments from any withholding agent other than a member of its expanded afliated group; and
• Has not agreed to report under Regulation section 1.1471-4(d)(2)(ii)(C) or otherwise act as an agent for chapter 4 purposes on behalf of
any nancial institution, including a member of its expanded afliated group.
Part XXVIII Sponsored Direct Reporting NFFE (see instructions for when this is permitted)
42 Name of sponsoring entity:
43
I certify that the entity identied in Part I is a direct reporting NFFE that is sponsored by the entity identied on line 42.
Part XXIX Substantial U.S. Owners of Passive NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for denition of
substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or reporting Model 2 FFI, an NFFE may also use this part for
reporting its controlling U.S. persons under an applicable IGA.
Name Address TIN
Part XXX 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:
• The entity identied on line 1 of this form is the benecial owner of all the income to which this form relates, is using this form to certify its status
for chapter 4 purposes, or is a merchant submitting this form for purposes of section 6050W,
• The entity identied on line 1 of this form is not a U.S. person,
• 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 income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income, 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 the entity on
line 1 is the benecial owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the benecial
owner.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
Sign Here }
Signature of individual authorized to sign for benecial owner Print Name Date (MM-DD-YYYY)
I certify that I have the capacity to sign for the entity identified on line 1 of this form. Form W-8BEN-E (Rev. 7-2017)
AFFIDAVIT FOR UNCHANGED STATUS: under penalties of perjury I declare that I have examined and signed the above Form W-8BEN-E and that the
information andcerti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 signed statement if any information has changed.)
Print Name Signature of individual authorized to sign for benecial owner Date
X
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Form W-8BEN: Certicate of Status of Benecial Owner (Australian National University)

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Completed 10 November 2020

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