Form W-8IMY Certificate of Foreign Intermediary, Foreign Flow-Throug

Version A, Cycle 8

Form

W-8IMY

Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain
U.S. Branches for United States Tax Withholding and Reporting

(Rev. December 2013)

OMB No. 1545-1621

▶ Section

references are to the Internal Revenue Code.
▶ Information about Form W-8IMY and its separate instructions is at www.irs.gov/formw8imy.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.

Department of the Treasury
Internal Revenue Service

Do not use this form for:
• A beneficial owner solely claiming foreign status or treaty benefits .

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• A hybrid entity claiming treaty benefits on its own behalf

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

• A person claiming that income is effectively connected with the conduct of a trade or business in the United States .

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. W-8ECI

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• A disregarded entity with a single foreign owner that is the beneficial owner of the income to which this form relates. Instead, the single foreign owner should
use .

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. W-8BEN, W-8ECI or W-8BEN-E

• 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)
• U.S. entity or U.S. citizen or resident

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• A person documenting themselves for purposes of section 6050W

Part I

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Identification of Entity

1

Name of individual or organization that is acting as intermediary

3

Name of disregarded entity (if applicable)

2

4 Chapter 3 Status:
Qualified intermediary. Complete Part III.
Nonqualified intermediary. Complete Part IV.

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. W-8EXP

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. W-9
W-8BEN, W-8BEN-E, or W-8ECI
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Country of incorporation or organization

Withholding foreign trust. Complete Part VII.
Nonwithholding foreign partnership. Complete Part VIII.
Nonwithholding foreign simple trust. Complete Part VIII.

Internal Use Only
DRAFT AS OF
August 16, 2013

Territory financial institution. Complete Part V.
U.S. branch. Complete Part VI.
Withholding foreign partnership. Complete Part VII.

Nonwithholding foreign grantor trust. Complete Part VIII.

5 Chapter 4 Status:
Nonparticipating FFI (including a limited FFI or limited branch).
Complete Part IX (if applicable).
Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.

Restricted distributor. Complete Part XVI.

Foreign government, Government of a U.S. possession, or
foreign central bank of issue. Complete Part XVII.
Nonreporting IGA FFI. Complete Part XVIII.

Exempt retirement funds. Complete Part XIX.

Registered deemed-compliant FFI (other).
Territory financial institution. Complete Part V.

Excepted nonfinancial group entity. Complete Part XX.
Excepted nonfinancial start-up company. Complete Part XXI.

Sponsored FFI that has not obtained a GIIN (other than a certified
deemed-compliant sponsored, closely held investment vehicle).
Complete Part X.

Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XXII.

Certified deemed-compliant nonregistering local bank. Complete Part
XII.
Certified deemed-compliant FFI with only low-value accounts. Complete Part XIII.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part XIV.
Certified deemed-compliant limited life debt investment company.
Complete Part XV.

Publicly traded NFFE or NFFE affiliate of a publicly traded
corporation. Complete Part XXIII.

Excepted territory NFFE or affiliate. Complete Part XXIV.
Active NFFE. Complete Part XXV.
Passive NFFE. Complete Part XXVI.
Other status (see instructions for applicable code):
▶

Owner-documented FFI. Complete Part XI.
6

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

7 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
8 U.S. taxpayer identification number, if required
QI-EIN
9 GIIN (if applicable)

Country

▶

WP-EIN

WT-EIN

EIN

SSN or ITIN

10 Reference number(s) (see instructions)
For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 25402Q

Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Page 2
Disregarded Entity or Branch Receiving Payment. (Complete only if disregarded entity or branch of an FFI
in a country other than the FFI's country of residence.)

Form W-8IMY (Rev. 12-2013)

Part II

11

12

Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment.
Limited branch
Reporting Model 1 FFI.
U.S. Branch
Participating FFI
Reporting Model 2 FFI.
Address of branch identified on line 3 (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.

13

GIIN (if any)

Country

▶

Chapter 3 Status Certifications
Part III
14a

Qualified Intermediary
(All qualified intermediaries check here) I certify that the entity identified in Part I (or branch, if relevant);

• Is a qualified intermediary and is not acting for its own account with respect to the account(s) identified on line 10 or in a withholding
statement associated with this form;
• Has provided or will provide a withholding statement, as required, for purposes of chapters 3 and 4 that is subject to the certifications made
on this form.
Check all that apply:

Internal Use Only
DRAFT AS OF
August 16, 2013

b

(If applicable) I certify that the entity identified in Part I has assumed primary withholding responsibility for purposes of both chapters 3 and
4 with respect to payments of U.S. source FDAP income made to the account(s) identified on this line 14b or in a withholding statement
associated with this form ▶

c

(If applicable) I certify that the entity identified in Part I has NOT assumed primary withholding responsibility under chapters 3 and 4 with
respect to payments of U.S. source FDAP income made to the accounts identified on this line 14c or in the withholding statement
associated with this form ▶

d

(If applicable) I certify that the entity identified in Part I is reporting payments of U.S. source FDAP income made to U.S. persons (or the
accounts to which such payments are made) as a participating FFI, registered deemed-compliant FFI, reporting Model 1 FFI, or reporting
Model 2 FFI to the extent required and is otherwise assuming primary Form 1099 reporting and backup withholding responsibility with
respect to the account(s) identified on this line 14d or in a withholding statement associated with this form ▶

e

(If applicable) I certify that the entity identified in Part I is reporting payments of U.S. source FDAP income made to U.S. persons (or the
accounts to which such payments are made) as a participating FFI, registered deemed-compliant FFI, reporting Model 1 FFI, or reporting
Model 2 FFI to the extent required, or otherwise is transmitting Forms W-9 with respect to each U.S. non-exempt recipient account(s)
identified on this line 14e or in a withholding statement associated with this form ▶

f

Part IV

(If applicable) I certify that the entity identified in Part I is acting as a Qualified Securities Lender with respect to the account(s) identified on
this line 14f or in a withholding statement associated with this form, and, with respect to any substitute dividend received from the
withholding agent, will withhold and remit or pay the proper amount of U.S. gross-basis tax ▶

Nonqualified Intermediary

15a

(All nonqualified intermediaries check here) I certify that the entity identified in Part I is not a qualified intermediary and is not acting for its
own account.

b

(If applicable) I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentation
and has provided or will provide a withholding statement, as required for purposes of chapters 3 and 4, that is subject to the certifications
made on this form.

c

(If applicable) I certify that the entity identified in Part I is reporting payments of U.S. source FDAP income made to U.S. persons (or the
accounts to which such payments are made) as a participating FFI, registered deemed-compliant FFI, reporting Model 1 FFI or reporting
Model 2 FFI to the extent required, or otherwise is transmitting Forms W-9 with respect to each U.S. non-exempt recipient account(s)
identified on this line 15c or in a withholding statement associated with this form ▶

d

(If applicable) I certify that the entity identified in Part I is acting as a Qualified Securities Lender with respect to the account(s) identified on
this line 15d or in a withholding statement associated with this form, and, with respect to any substitute dividend received from the
withholding agent, will withhold and remit or pay the proper amount of U.S. gross-basis tax ▶

e

(All registered deemed-compliant local FFIs and restricted funds check here) I certify that the entity identified on line 1 has chapter 4
reporting requirements that it is satisfying with respect to any specified U.S. person for which pooled information is being provided to the
withholding agent in lieu of a Form W-9.
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Form W-8IMY (Rev. 12-2013)

Part V
16 a

Page

3

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.

Check whichever box applies:
b

I further certify that the entity identified in Part I is using this form as evidence of its agreement with the withholding agent to be treated as
a U.S. person for purposes of chapters 3 and 4 with respect to any payments associated with this withholding certificate.

c

I further certify that the entity identified in Part I:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom the branch receives a
payment; and
• Has provided or will provide a withholding statement, as required.

Part VI

Certain U.S. Branches

Note: You may use this Part if the entity identified in line 3 of Part I is a U.S. branch of a foreign bank or insurance company and is subject to certain
regulatory requirements.
17 a

I certify that the entity identified in Part I is a U.S. branch of a foreign bank or insurance company and that the payments are not effectively
connected with the conduct of a trade or business in the United States.

Check whichever box applies:
b

I certify that the entity identified in Part I is a U.S. branch of a participating FFI that is using this form as evidence of its agreement with the
withholding agent to be treated as a U.S. person with respect to any payments associated with this withholding certificate.

c

I certify that the entity identified in Part I is a U.S. branch of a participating FFI or registered deemed-compliant FFI that:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom the branch receives a
payment; and
• Has provided or will provide a withholding statement, as required.

Part VII

Internal Use Only
DRAFT AS OF
August 16, 2013

Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT)

I certify that the entity identified in Part I:
• Is a withholding foreign partnership or a withholding foreign trust that is compliant with the terms of its WP or WT agreement.

18

Part VIII Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
19

I certify that the entity identified in Part I:

• Is a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and that the
payments to which this certificate relates are not effectively connected, or are not treated as effectively connected, with the conduct of a
trade or business in the United States; and
• Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding
statement, as required for purposes of chapters 3 and 4, that is subject to the certifications made on this form.

Chapter 4 Status Certifications

Part IX
20

Nonparticipating FFI with Exempt Beneficial Owners

I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentation and has
provided or will provide a withholding statement that indicates the portion of the payment allocated to one or more exempt beneficial
owners.

Part X
21 a
b

c

Sponsored FFI That Has Not Obtained a GIIN
Name of sponsoring entity: ▶
Check whichever box applies.
I certify that the entity identified in Part I:
• Is an FFI solely because it is an investment entity;
• Is not a QI, WP, or WT; and
• Has agreed with the entity identified above to act as the sponsoring entity for this entity.
I certify that the entity identified in Part I:
• Is a controlled foreign corporation as defined in section 957(a);
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
entity; and
• Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all
account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not
limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or
payees.
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Form W-8IMY (Rev. 12-2013)

Part XI

Page

4

Owner-Documented FFI

Note: This status only applies if the U.S. financial institution participating FFI, reporting Model 1 FFI, or reporting Model 2 FFI to which this form is
given has agreed that it will treat the FFI as an owner-documented FFI. In addition, the FFI must make the certifications below.
22a

(All owner documented FFIs check here) I certify that the FFI identified in Part I:
• Does not act as an intermediary;
• Does not accept deposits in the ordinary course of a banking or similar business;
• Does not hold, as a substantial portion of its business, financial assets for the account of others;
• Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a financial account;
• Is not affiliated with an entity (other than an FFI that is also treated as an owner-documented FFI) that accepts deposits in the ordinary
course of a banking or similar business, holds, as a substantial portion of its business, financial assets for the account of others, or is an
insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a
financial account; and
• Does not maintain a financial account for any nonparticipating FFI.

Check whichever box applies:
b

I certify that the FFI identified in Part I:
• Has provided, or will provide, an FFI owner reporting statement that contains:
(i) The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S.
person that owns a direct or indirect equity interest in the owner-documented FFI (looking through all entities other than specified U.S.
persons);
(ii) The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S.
person that owns a debt interest in the owner-documented FFI (including any indirect debt interest, which includes debt interests in any
entity that directly or indirectly owns the payee or any direct or indirect equity interest in a debt holder of the payee) that constitutes a
financial account in excess of $50,000 (disregarding all such debt interests owned by participating FFIs, registered deemed-compliant
FFIs, certified deemed compliant FFIs, excepted NFFEs, exempt beneficial owners, or U.S. persons other than specified U.S. persons);
and

c

Part XII
23

Internal Use Only
DRAFT AS OF
August 16, 2013

(iii) Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.
I certify that the FFI identified in Part I:
• Has provided, or will provide, an auditor's letter, signed no more than four years prior to the date of payment, from an independent
accounting firm or legal representative with a location in the United States stating that the firm or representative has reviewed the FFI's
documentation with respect to all of its owners, that the FFI meets all the requirements to be an owner-documented FFI, and that no owner
that owns a direct or indirect interest in the payee is a nonparticipating FFI, specified U.S. person, or passive NFFE with any substantial
U.S. owners.

Certified Deemed-Compliant Nonregistering Local Bank

I certify that the FFI identified in Part I:
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country
of incorporation or organization;
• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, unrelated retail customers and,
with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater than five percent
interest in such credit union or cooperative credit organization;
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no
more than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution
that is incorporated or organized in the same country as the bank identified in Part I and that meets the requirements set forth in this Part XII.

Part XIII
24

Certified Deemed-Compliant FFI with Only Low-Value Accounts
I certify that the FFI identified in Part I:
• Is not engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional
principal contracts, insurance or annuity contracts, or any interest (including a futures or forward contract or option) in such security,
partnership interest, commodity, notional principal contract, insurance contract or annuity contract;
• No financial account maintained by the FFI or any member of its expanded affiliated group, if any, has a balance or value in excess of
$50,000 (as determined after applying applicable account aggregation rules); and
• Neither the FFI nor the FFI's entire expanded affiliated group, if any, have more than $50 million in assets on its consolidated or
combined balance sheet as of the end of its most recent accounting year.
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Form W-8IMY (Rev. 12-2013)

Page

5

Part XIV Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
25a
b

Name of sponsoring entity: ▶
I certify that the FFI identified in Part I:
• Is an FFI solely because it is an investment entity described in Regulations section 1.1471-5(e)(4);
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fulfilled by
the sponsoring entity identified in line 25a;
• Does not hold itself out as an investment vehicle for unrelated parties; and
• Twenty or fewer individuals own all of the debt and equity interests in the entity.

Part XV

Certified Deemed-Compliant Limited Life Debt Investment Company (only for payments made prior to
January 1, 2017.)
I certify that the FFI identified in Part I:

26

• Is a collective investment vehicle that is an FFI solely because it is an investment entity that offers interests primarily to unrelated
investors and satisfies the organization and formation requirements of Regulations section 1.1471-5(f)(2)(iv) (including any requirements
regarding amendments or liquidation);
• Was formed for the purpose of purchasing and holding (and did in fact purchase) specific types of indebtedness;
• Makes payments made to investors in the entity that are cleared through a clearing organization that is a participating FFI, reporting
Model 1 FFI, reporting Model 2 FFI, or U.S. financial institution or makes payments through a trustee that is a participating FFI, reporting
Model 1 FFI, reporting Model 2 FFI, or U.S. financial institution;
• The entity's trust indenture or similar fiduciary arrangement only authorizes the trustee or fiduciary to engage in activities specifically
designated in the trust indenture, and the trustee or fiduciary is not authorized to fulfill the obligations required of a participating FFI under
an FFI agreement; and

Internal Use Only
DRAFT AS OF
August 16, 2013

• No other person has the authority to fulfill the obligations required of a participating FFI agreement on behalf of the entity.

Part XVI Restricted Distributor
27a

(All restricted distributors check here) I certify that the entity identified in Part I:
• Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished;
• Provides investment services to at least 30 unrelated customers and no more than half of its customers are related persons;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is a
FATF-compliant jurisdiction);
• Operates solely in its country of incorporation or organization, has no fixed place of business outside of that country, and has the same
country of incorporation or organization as all members of its affiliated group, if any;
• Does not solicit customers outside its country of incorporation or organization;
• Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement
for the most recent accounting year;
• Is not a member of an expanded affiliated group that has more than $500 million in total assets under management or more than $20
million in gross revenue for its most recent accounting year on a combined or consolidated income statement; and
• Does not distribute any debt or securities of the restricted fund to specified U.S. persons, passive NFFEs with one or more substantial
U.S. owners, or nonparticipating FFIs.

Check whichever box applies:
I further certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made
after December 31, 2011, the entity identified in Part I:
b

Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and U.S.
resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any
specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.

c

Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specified U.S. person,
passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a
restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the procedures
identified in Regulations section 1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any securities which were sold
to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs, or will transfer the securities
to a distributor that is a participating FFI reporting Model 1 FFI, or reporting Model 2 FFI.

Part XVII Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue
28

I certify that the entity identified in Part I is considered the beneficial owner of the payment for purposes of chapter 4 only and is not
engaged in commercial 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)).
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Form W-8IMY (Rev. 12-2013)

Page

6

Part XVIII Nonreporting IGA FFI
29

I certify that the entity identified in Part I:
• Meets the requirements to be considered a nonreporting financial institutution pursuant to an IGA between the United States and
;
• Is entitled to the provisions of the IGA because the entity (or relevant branch) is considered a
under the provisions of the applicable IGA; and
• Explain the reasons the entity identified on line 1 meets the terms of the applicable IGA (if required):

▶

Part XIX Exempt Retirement Funds
Check whichever box applies.
30a

I certify that the entity identified in Part I:
• Is established in a country with which the United States has an income tax treaty in force;
• Is operated principally to administer or provide pension or retirement benefits; and
• Is entitled to treaty benefits on income that the fund derives from U.S. sources (or would be entitled to benefits if it derived any such
income) as a resident of the other country which satisfies any applicable limitation on benefits requirement.

b

I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former
employees of one or more employers in consideration for services rendered;
• No single beneficiary has a right to more than 5% of the FFI's assets;
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the
country in which the fund is established or operated; and
(i) Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its status
as a retirement or pension plan;

Internal Use Only
DRAFT AS OF
August 16, 2013

(ii) Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described
in this part or accounts described in Regulations section 1.1471-5(b)(2)(i)(A));
(iii) Either does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to retirement,
disability, or death; or
(iv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
c

I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former
employees of one or more employers in consideration for services rendered;
• Has fewer than 50 participants;
• Is sponsored by one or more employers that are not investment entities or passive NFFEs;

• Employee and employer contributions to the fund (disregarding transfers of assets from other plans described in this part or accounts
described in Regulations section 1.1471-5(b)(2)(i)(A)) are limited be reference to earned income and compensation of the employee,
respectively;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20 percent of
the fund's assets; and
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the
country in which the fund is established or operates.
d

I certify that the entity identified in Part I is considered the beneficial owner of the payment for purposes of chapter 4 only and is not
engaged in commercial 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 section1.1471-6(h)(2)).

e

I certify that the entity identified in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other
than the requirement that the plan be funded by a trust created or organized in the United States.

f

I certify that the entity identified in Part I is established exclusively to earn income for the benefit of one or more retirement funds described
in this part or for retirement and pension accounts described in Regulations section 1.1471-5(b)(2)(i)(A).

g

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) 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) 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.
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Form W-8IMY (Rev. 12-2013)

Part XX
31

Page

7

Excepted Nonfinancial Group Entity
I certify that the entity identified in Part I:
• Is a holding company, treasury center, or captive finance company and substantially all of the entity's activities are functions described in
Regulations section 1.1471-5(e)(5)(i)(C) through (E);
• Is a member of a nonfinancial group described in Reguations section 1.1471-5(e)(5)(i)(B);
• Is not a depository or custodial institution (other than for members of the entity's expanded affiliated group); and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund or
any investment vehicle with an investment strategy to acquire or fund companies and then hold interests in those companies as capital
assets for investment purposes.

Part XXI Excepted Nonfinancial Start-Up Company
32

I certify that the entity identified in Part I:
• Was formed on (or, in the case of a new line of business, the date of board resolution approving the new line of business)
(date must be less than 24 months prior to date of payment);
• Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of
business other than that of a financial institution or passive NFFE;
• Is investing capital into assets with the intent to operate a business other than that of a financial institution; and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or
any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for
investment purposes.

Part XXII Excepted Nonfinancial Entity in Liquidation or Bankruptcy
33

I certify that the entity identified in Part I:
• Filed a plan of liquidation, filed a plan or reorganization, or filed for bankruptcy on the following date:
• Has not been engaged during the past 5 years in business as a financial institution or acted as a passive NFFE;
• Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a
nonfinancial entity; and

Internal Use Only
DRAFT AS OF
August 16, 2013

• Has, or will provide, documentary evidence such as a bankruptcy filing or other public documentation that supports its claim if it remains
in bankruptcy or liquidation for more than three years.

Part XXIII Publicly Traded NFFE or Affiliate
Check whichever box applies:
34a

b

I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution;
(name one securities exchange upon which the stock is regularly traded).
• The stock of such corporation is regularly traded on one or more established securities markets, including
I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution;
• The entity identified in Part I is an affiliate of an entity the stock of which is regularly traded on an established securities market;
• The name of the affiliate, the stock of which is regularly traded on an established securities market, is
• The name of the securities market on which the stock is regularly traded is

; and
.

Part XXIV Excepted Territory NFFE
35

I certify that:
• The entity identified in Part I is an entity that is organized in a possession of the United States;
• The entity identified in Part I:
(i) Does not accept deposits in the ordinary course of a banking or similar business,
(ii) Does not hold, as a substantial portion of its business, financial assets for the account of others, and
(iii) Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a financial account; and
• All of the owners of the entity identified in Part I are bona fide residents of the possession in which the NFFE was organized or
incorporated.

Part XXV Active NFFE
36

I certify that:
• The entity identified in Part I is a foreign entity that is not a financial institution;
• Less than 50% of such entity's gross income for the preceding calendar year is passive income; and
• Less than 50% of the assets held by such entity at any time during the preceding calendar year are assets that produce or are held for
the production of passive income. See the instructions for the definition of passive income.
Form

W-8IMY

(Rev. 12-2013)

Version A, Cycle 8
Page 8

Form W-8IMY (Rev. 12-2013)

Part XXVI Passive NFFE
37

I certify that the entity identified in Part I:
• Is a foreign entity that is not a financial institution (this category includes an entity organized in a possession of the United States that
engages (or holds itself out as being engaged) primarily in the business of investing, reinvesting, or trading in securities, partnership
interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest in such security, partnership interest,
commodity, notional principal contract, insurance contract or annuity contract); and
• Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding
statement, as required.

Part XXVII 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.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any
withholding agent that can disburse or make payments of the amounts for which I am providing this form.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.

▲

Sign Here

Signature of authorized official

Date (MM-DD-YYYY)
Form

W-8IMY

Internal Use Only
DRAFT AS OF
August 16, 2013

(Rev. 12-2013)