WEBFORM 06_2017
MIADOCS 9177490 2
Substitute Form W-8BEN
DO NOT USE THIS FORM IF YOU ARE: (i) AN ENTITY; (ii) A U.S. CITIZEN OR OTHER U.S. PERSON; (iii) A BENEFICIAL OWNER CLAIMING THAT
INCOME IS EFFECTIVELY CONNECTION WITH THE CONDUCT OF A U.S. TRADE OR BUSINESS; (iv) A BENEFICIAL OWNER WHO IS RECEIVING
COMPENSATION FOR PERSONAL SERVICES PERFORMED IN THE U.S.; or (v) A PERSON ACTING AS AN INTERMEDIARY
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.
Identification of Beneficial Owner
.
3. Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in care of address.
Claim of Tax Treaty Benefits (for chapter 3 purposes only) (if applicable)
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.
10. 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:
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 acknowledge receipt of the Instructions for Form W-8BEN.
•
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Signature of the beneficial owner or
authorized person
Capacity in which acting (if form is not
signed by beneficial owner)
Print name of signer
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AFFIDAVIT OF UNCHANGED STATUS: Under penalties of perjury, I declare that I have examined and signed the above Substitute Form
W-8BEN and that the information and certifications contained therein are true and remained the same and unchanged during the last three calendar
years and to date this year. (Please attach a separate, signed statement if any information has changed.)
(i) I am the individual that is the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates or I am using
this form to document myself for chapter 4 purposes; (ii) the beneficial owner listed on Line 1 of this form is not a U.S. person; (iii) the income to which this
form relates is not effectively connected with the conduct of a trade or business in the United States, or is effectively connected but is not subject to tax under
an applicable income tax treaty, or is the partner’s share of a partnership’s (iv) the person named on line 1 of this form is a resident of the treaty country listed
on line 9 of this form (if any) within the meaning of the income tax treaty between the United States and that country; and (v) for broker transactions or barter
exchanges, the beneficial owner is an exempt foreign person as defined in the Instructions to Form W-8BEN.
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 formwithin 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.
City or town state or province. Include postal code where appropriate. Country (do not abbreviate)
City or town state or province. Include postal code where appropriate. Country (do not abbreviate)
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)
1. Name of individual who is the beneficial owner 2 Country of citizenship
4. Mailing address (if different from above)
5. U.S. taxpayer identification number (SSN or ITIN) if required (see instructions for Form W-8BEN)
6. Foreign tax identifying number if any (see instructions for Form W-8BEN)
7. Reference number(s) 8. Date of birth (MM-DD-YYYY)
Sign Here: Date ,
Sign Here: Date ,
