Form W-8ECI Certificate of Foreign Person¿s Claim That Income Is Eff

Version A, Cycle 4

Form

W-8ECI

(Rev. July 2017)

Certificate of Foreign Person's Claim That Income Is
Effectively Connected With the Conduct of a Trade or
Business in the United States

OMB No. 1545-1621

▶ Section

Department of the Treasury
Internal Revenue Service

references are to the Internal Revenue Code.
▶ Go to www.irs.gov/FormW8ECI for instructions and the latest information.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.

Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively
connected with a U.S. trade or business. See instructions.
Do not use this form for:
Instead, use Form:
• A beneficial owner solely claiming foreign status or treaty benefits . . . . . . . . . . . . . . . . . W-8BEN or W-8BEN-E
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private
W-8EXP
foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)
. . . .
Note: These entities should use Form W-8ECI if they received effectively connected income and are not eligible to claim an exemption for chapter 3
or 4 purposes on Form W-8EXP.
• A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively connected with the
conduct of a trade or business in the United States) . . . . . . . . . . . . . . . . . . . . .
W-8BEN-E or W-8IMY
• A person acting as an intermediary . . . .
Note: See instructions for additional exceptions.

Part I

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Name of individual or organization that is the beneficial owner

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Name of disregarded entity receiving the payments (if applicable)

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W-8IMY

2 Country of incorporation or organization

Simple trust
Grantor trust
International organization

Individual

Corporation

Complex trust
Central bank of issue

Estate
Tax-exempt organization

Permanent residence address (street, apt. or suite 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.

6

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INTERNAL USE ONLY
DRAFT AS OF
June 28, 2017
Type of entity (check the appropriate box):
Partnership
Government
Private foundation

5

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Identification of Beneficial Owner (see instructions)

1

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Country

Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state, and ZIP code

7
9
11

8 Foreign tax identifying number

U.S. taxpayer identification number (required—see instructions)
SSN or ITIN
EIN
Reference number(s) (see instructions)

10 Date of birth (MM-DD-YYYY)

Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade or
business in the United States (attach statement if necessary).

Part II

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:
• I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the payments to which this form relates,
• The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States,
• The income for which this form was provided is includible in my gross income (or the beneficial owner’s gross income) for the taxable year, and

Sign
Here

• The beneficial owner is not a U.S. person.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the payments of which I am the
beneficial owner or any withholding agent that can disburse or make payments of the amounts 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.

Signature of beneficial owner (or individual authorized to sign for the beneficial owner)

Date (MM-DD-YYYY)

Print name

I certify that I have the capacity to sign for the person identified on line 1 of this form.

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 25045D

Form

W-8ECI

(Rev. 7-2017)