Form W-8BEN Draft Certificate of Foreign Status of Beneficial Owner

Version A, Cycle 3

Form

W-8BEN

Certificate of Foreign Status of Beneficial Owner for United
States Tax Withholding and Reporting (Individuals)

(Rev. July 2013)
Department of the Treasury
Internal Revenue Service

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OMB No. 1545-1621

For use by individuals. Entities must use Form W-8BEN-E.

▶ Information about Form W-8BEN and its separate instructions is at www.irs.gov/formw8ben.
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Give this form to the withholding agent or payer. Do not send to the IRS.

Do NOT use this form if:
• You are NOT an individual

Instead, use Form:
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. W-8BEN-E

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• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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. W-8ECI

• You are a U.S. citizen or other U.S. person, including a resident alien individual

• You are a beneficial owner who is receiving compensation for personal services performed in the United States .

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• A person acting as an intermediary

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Part I

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Name of individual who is the 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.

2

Country (do not abbreviate)

Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)

7

Reference number(s) (see instructions)

Part II

Country (do not abbreviate)

Internal Use Only
DRAFT AS OF
April 1, 2013

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10

. W-8IMY

Country of citizenship (do not abbreviate)

City or town, state or province. Include postal code where appropriate.

9

8233 or W-4
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Identification of Beneficial Owner (see instructions)

1

4

. W-9

8

6

Foreign tax identifying number (see instructions)

Date of birth (MM-DD-YYYY) (only complete if you do not have a foreign tax identifying number)

Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)

within the meaning of the income tax treaty

I certify that the beneficial owner is a resident of

between the United States and that country.
Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article
of the treaty identified on line 9 above to claim a
% rate of withholding on (specify type of income):

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Explain the reasons the beneficial owner meets the terms of the treaty article:

Part III

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:
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I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or
am using this form to document myself as an individual that is an owner of a foreign financial institution,

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The person named on line 1 of this form is not a U.S. person,

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The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or
(c) the partner’s share of a partnership's effectively connected income,

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The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between
the United States and that country, and

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For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
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 form within 30 days
if any certification made on this form becomes incorrect.

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Sign Here

Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Print name of signer

For Paperwork Reduction Act Notice, see separate instructions.

Date (MM-DD-YYYY)

Capacity in which acting (if form is not signed by beneficial owner)
Cat. No. 25047Z

Form

W-8BEN

(Rev. 7-2013)