W-14 Certificate of Foreign Contracting Party

acquiring agency

Form

W-14

Certificate of Foreign Contracting Party
Receiving Federal Procurement Payments
OMB No. 1545-XXXX

(June 2015)

Part I .

Ź Information about Form W-14 and its separate instructions is at
www.irs.gov/formw14.
Ź Give this form to the withholding agent or payer. Do not send to the IRS.

Identification of Foreign Contracting Party

1 Name of foreign contracting party

2 Country of organization, if applicable
(do not abbreviate)

3 Permanent residence address (street, apt. no. or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate.

Country (do not abbreviate)

4 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.

5 U.S. TIN, if any

Country (do not abbreviate)

6 Contract/reference number (if known)

7 Name and address of the acquiring agency
City or town, state or province. Include postal code where appropriate.

Country (do not abbreviate)

Part II .
Exemption Based on an International Agreement (If Applicable)
8 …Check this box if claiming relief from the tax under section 5000C pursuant to an
international agreement with the United States (such as a qualified income tax treaty).
Also complete Part IV.
Part III .
Exemption Based on an International Procurement Agreement
or because Goods/Services Produced/Performed in the U.S.
9 …Check this box if identifying specific
exempt and nonexempt amounts (for example,
by contract line item number). Skip lines 10
through 14 and complete Part IV, line 15.

10 Total Contract Price or Estimated Total
Contract Price

11 Nonexempt Amount or Estimated
Nonexempt Amount

12 Contract Ratio (line 11 divided by line 10)

Part IV .

Explanation (Complete if Part II or Part III Is Applicable)

13 If you checked the box in Part II, state the name of the agreement and specific provision relied
upon (for example, the nondiscrimination article of a qualified income tax treaty); and the basis
on which you are entitled to the benefits of that provision (for example, because you are a
corporation organized in a foreign country with which the United States has a qualified income
tax treaty that covers all nationals). (Use additional sheets as necessary.)

14 If you completed Part III, but did not check the box on line 9, state the relevant countries
where the goods are manufactured or produced or services provided and the international
procurement agreements relied upon, if relevant. If applicable, explain the method relied upon to
allocate the total contract price between exempt and nonexempt amounts. (Use additional sheets
as necessary.)

15 If you checked the box on line 9, provide an explanation for each item by stating the relevant
countries where the goods are manufactured or produced or services provided and the
international procurement agreements relied upon, if relevant. If applicable, explain the method
relied upon to allocate the total contract price between exempt and nonexempt amounts. For
example, you may attach a spreadsheet listing the various contract line items with an explanation
for the treatment of each line item as exempt or nonexempt. (Use additional sheets as necessary.)
If the contract includes details necessary to complete
this section (such as exempt or nonexempt amounts
by contract line item), you may incorporate by
reference the relevant information in the explanation.

Part V .

Certificate

Under penalties of perjury, I declare that I have examined the information on this certificate (and
in the contract, if relevant) and to the best of my knowledge and belief it is true, correct, and
complete. I further certify under penalties of perjury that:
1 I am the foreign person (or am authorized to sign on behalf of the foreign person) identified in
line 1 above,
2 I am not acting as an agent or nominee for another foreign person,
3 I agree to pay an amount equal to any tax due under section 5000C that the acquiring agency
does not withhold under section 5000C and pay any applicable penalties and interest,
4 I acknowledge and understand the rules in §1.5000C-4 relating to procedural obligations under
and
insert period
section 5000C,
5 I have not engaged in any transaction (or series of transactions) with a principal purpose of
avoiding the tax imposed under section 5000C as defined in §1.5000C-5, and
6 To the extent I am claiming any nonexempt amounts based on a contract line item, I incorporate
the details set forth in the contract by reference.

Sign Here Ź

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ /_ /_

_______

Signature of Foreign Person (or Authorized Representative)

Capacity to Act

Date

delete until such time as
proposed regulations are issued

2