Form W-8ECI
(Rev. December 2000)
Department of the Treasury
Internal Revenue Service
Certificate of Foreign Person’s Claim for Exemption From
Withholding on Income Effectively Connected With the
Conduct of a Trade or Business in the United States
See separate instructions.
Section references are to the Internal Revenue Code.
Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No. 1545-1621
Part I
Part II
Identification of Beneficial Owner (See instructions.)
1 2
3
4
5
6 7
8
Name of individual or organization that is the beneficial owner Country of incorporation or organization
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box.
City or town, state or province. Include postal code where appropriate. Country (do not abbreviate)
U.S. taxpayer identification number (required—see instructions) Foreign tax identifying number, if any (optional)
Reference number(s) (see instructions)
Type of entity (check the appropriate box): Individual Corporation
Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box.
City or town, state, and ZIP code
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 beneficial owner (or I am authorized to sign for the beneficial owner) of all the income to which this form relates,
The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States
and are includible in my gross income (or the beneficial owner’s gross income) for the taxable year, and
Sign
Here
Signature of beneficial owner (or individual authorized to sign for the beneficial owner) Date (MM-DD-YYYY)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25045D Form W-8ECI (Rev. 12-2000)
Disregarded entity
Simple trust or grantor trustPartnership
Government International organization
9 Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade
or business in the United States
Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively
connected with a U.S. trade or business (see instructions).
SSN or ITIN EIN
Capacity in which acting
Complex trust
Do not use this form for:
A beneficial owner solely claiming foreign status or treaty benefits
A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively
connected with the conduct of a trade or business in the United States)
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 the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)
A person acting as an intermediary
Instead, use Form:
W-8BEN
W-8EXP
W-8BEN or W-8IMY
W-8IMY
The beneficial owner is not a U.S. person.
Note: See instructions for additional exceptions.
Private foundation
Tax-exempt organization
Central bank of issue
Estate
Note: These entities should use Form W-8ECI if they received effectively connected income (e.g., income from commercial activities).
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.
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