Form
W-8BEN
(October 1998)
Department of the Treasury
Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner
for United States Tax Withholding
See separate instructions.
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:
A foreign partnership (see instructions for exceptions)
W-8ECI or W-8IMY
A foreign government, international organization, foreign central bank of issue, tax-exempt organization,
or private foundation, claiming the applicability of section(s) 501(c), 892, 895, or 1443(b)
W-8ECI or W-8EXP
A person acting as an intermediary
W-8IMY
A person claiming an exemption from U.S. withholding on income effectively connected with the conduct
of a trade or business in the United States
W-8ECI
Part I
Part II
Identification of Beneficial Owner
(See instructions.)
1
3
2
4
5
6
7
8
Name of individual or organization that is the beneficial owner
Type of 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, if required (see instructions)
Foreign tax identifying number, if any (optional)
Account number(s) (optional)
Individual
Corporation
Partnership
Trust
Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country (do not abbreviate)
Claim of Tax Treaty Benefits (if applicable)
I certify that (check all that apply):
The beneficial owner is a resident of
within the meaning of the income tax treaty between the United States and that country.
If required, the U.S. taxpayer identification number is stated on line 6 (see instructions).
The beneficial owner is not an individual, derives the income for which the treaty benefits are claimed, and, if applicable, meets the
requirements of the treaty article dealing with limitation on benefits (see instructions).
The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a
U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions).
The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file
Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000.
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 am authorized to sign for the beneficial owner) of all the income to which this form relates,
The beneficial owner is a foreign person,
The income to which this form relates is not effectively connected with the conduct of a trade or business in the United States,
For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions,
I am not a former citizen or long-term resident of the United States subject to section 877 (relating to certain acts of expatriation) or, if I am subject to section 877,
I am nevertheless entitled to treaty benefits with respect to the amounts received.
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Date
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 25047Z
Form
W-8BEN
(10-98)
Section references are to the Internal Revenue Code.
a
b
c
d
e
Estate
SSN or ITIN
EIN
Capacity in which acting
Disregarded entity
Certification
9
Special rates and conditions (if applicable--see instructions): The beneficial owner is claiming the provisions of Article
of the
treaty identified on line 9a above to claim a
% rate of withholding on (specify type of income):
.
Explain the reasons the beneficial owner meets the terms of the treaty article:
10
Foreign government
International organization
Foreign central bank of issue
Foreign tax-exempt organization
Any income from a notional principal contract to which this form relates is not effectively connected with the conduct of a trade or business within the United
States, and
Part IV
Part III
Notional Principal Contracts
11
I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively
connected with the conduct of a trade or business in the United States. I agree to update this statement as required.
A U.S. citizen or other U.S. person, including a resident alien individual
W-9