Form W-8EXP (Rev. 7-2017)
Page 2
Part II Qualification Statement for Chapter 3 Status (continued)
13 For a foreign tax-exempt organization, including foreign private foundations:
If any of the income to which this certification relates constitutes income includible under section 512 in computing the
entity’s unrelated business taxable income, attach a statement identifying the amounts.
Check either box 13a or box 13b.
a
I certify that the entity identified in Part I has been issued a determination letter by the IRS dated
that is currently in effect and that concludes that it is an exempt organization described in section 501(c).
b
I have attached to this form an opinion from U.S. counsel concluding that the entity identified in Part I is described in
section 501(c).
For section 501(c)(3) organizations only, check either box 13c or box 13d.
c
If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section 501(c)(3),
I certify that the organization is not a private foundation described in section 509. I have attached an affidavit of the
organization setting forth sufficient facts for the IRS to determine that the organization is not a private foundation because it
meets one of the exceptions described in section 509(a)(1), (2), (3), or (4).
d
If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section 501(c)(3),
I certify that the organization is a private foundation described in section 509.
14 For a government of a U.S. possession:
I certify that the entity identified in Part I is a government of a possession of the United States, or is a political subdivision
thereof, and is claiming the exemption granted by section 115(2).
Part III Qualification Statement for Chapter 4 Status (if required)
15 For a nonreporting IGA FFI:
I certify that the entity identified in Part I:
•
Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States
and
;
• Is treated as a under the provisions of the applicable IGA (see instructions); and
• If you are an FFI treated as a registered deemed-compliant FFI under an applicable Model 2 IGA, provide your GIIN:
▶
.
16 For a territory financial institution:
I certify that the entity identified in Part I is a financial institution (other than an investment entity) that is incorporated or
organized under the laws of a possession of the United States.
17
For a foreign government (including a political subdivision), government of a U.S. possession, or foreign central bank of issue:
I certify that the entity identified in Part I is the beneficial owner of the payment and is not engaged in commercial financial
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)).
18 For an exempt retirement plan of a foreign government:
I certify that the entity identified 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 defined in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA) to provide
retirement, disability, or death benefits to beneficiaries 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 defined in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA) to provide
retirement, disability, or death benefits to beneficiaries or participants that are not current or former employees of such
sponsor, but are in consideration of personal services performed for the sponsor.
19 For a 501(c) organization:
I certify that the entity identified in Part I is an entity described in section 501(c) but is not an insurance company described
in section 501(c)(15).
20 For a passive NFFE:
a I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity
organized in a possession of the United States).
Check box 20b or 20c, whichever applies.
b I further certify that the entity identified in Part I has no substantial U.S. owners, or
c
I further certify that the entity identified in Part I has provided a statement including the name, address, and TIN of each
substantial U.S. owner of the NFFE (see instructions).
21 Name of sponsoring entity:
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 21.
Form W-8EXP (Rev. 7-2017)
