Form W-8BEN-E
(February 2014)
Department of the Treasury
Internal Revenue Service
Certificate of Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
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For use by entities. Individuals must use Form W-8BEN.
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Section references are to the Internal Revenue Code.
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Information about Form W-8BEN-E and its separate instructions is at www.irs.gov/formw8bene.
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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)
• 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 benefits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (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 benefits) (see instructions) . . . . 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 beneficial owner 2 Country of incorporation or organization
3 Name of disregarded entity receiving the payment (if applicable)
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
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) (Must check one box only unless otherwise indicated). (See instructions for details and complete the
certification 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 registered deemed-compliant FFI
or participating FFI).
Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.
Registered deemed-compliant FFI (other than a reporting Model 1
FFI or sponsored FFI that has not obtained a GIIN).
Sponsored FFI that has not obtained a GIIN. Complete Part IV.
Certified deemed-compliant nonregistering local bank. Complete
Part V.
Certified deemed-compliant FFI with only low-value accounts.
Complete Part VI.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Certified deemed-compliant limited life debt investment entity.
Complete Part VIII.
Certified deemed-compliant investment advisors and investment
managers. Complete Part IX.
Owner-documented FFI. Complete Part X.
Restricted distributor. Complete Part XI.
Nonreporting IGA FFI (including an FFI treated as a registered
deemed-compliant FFI under an applicable Model 2 IGA).
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 beneficial owners. Complete Part XVI.
Territory financial institution. Complete Part XVII.
Nonfinancial group entity. Complete Part XVIII.
Excepted nonfinancial start-up company. Complete Part XIX.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XX.
501(c) organization. Complete Part XXI.
Nonprofit organization. Complete Part XXII.
Publicly traded NFFE or NFFE affiliate 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-affiliate FFI. Complete Part XXVII.
Direct reporting NFFE.
Sponsored direct reporting NFFE. Complete Part XXVIII.
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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
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U.S. taxpayer identification 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 XXIX.
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 59689N
Form W-8BEN-E (2-2014)