W-8 BEN-E Certificate of Status of Beneficial Owner for United Sta

U.S. Business Income Tax Return

fw-8_ben-e--2017-07-00

OMB: 1545-0123

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Form

W-8BEN-E

(Rev. July 2017)
Department of the Treasury
Internal Revenue Service

Certificate of Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
▶ For

OMB No. 1545-1621

use by entities. Individuals must use Form W-8BEN. ▶ Section references are to the Internal Revenue Code.
▶ Go to www.irs.gov/FormW8BENE for instructions and the latest information.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.

Do NOT use this form for:
• U.S. entity or U.S. citizen or resident .
• A foreign individual . . . . . .

.
.

Instead use Form:
. . . . . . . . . W-9
W-8BEN (Individual) or Form 8233

.
.

• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. W-8ECI

• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . . W-8IMY
• 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 that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) . . . . . . . . .
W-8ECI or W-8EXP
• Any person acting as an intermediary (including a qualified intermediary acting as a qualified derivatives dealer) .

Part I

. W-8IMY

Identification of Beneficial Owner

Name of organization that is the beneficial owner

2 Country of incorporation or organization

Name of disregarded entity receiving the payment (if applicable, see instructions)

Chapter 3 Status (entity type) (Must check one box only):
Simple trust
Grantor trust
Central Bank of Issue
Tax-exempt organization

Corporation
Complex trust
Private foundation

Disregarded entity
Estate
International organization

Partnership
Government

If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If "Yes" complete Part III.

Yes
No
Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity's applicable status.)
Nonparticipating FFI (including an FFI related to a Reporting IGA
Nonreporting IGA FFI. Complete Part XII.
FFI other than a deemed-compliant FFI, participating FFI, or
Foreign government, government of a U.S. possession, or foreign
exempt beneficial owner).
central bank of issue. Complete Part XIII.
Participating FFI.
Reporting Model 1 FFI.

International organization. Complete Part XIV.
Exempt retirement plans. Complete Part XV.

Reporting Model 2 FFI.
Registered deemed-compliant FFI (other than a reporting Model 1
FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII).
See instructions.

Entity wholly owned by exempt beneficial owners. Complete Part XVI.
Territory financial institution. Complete Part XVII.

Sponsored FFI

Name of sponsoring entity:
Check whichever box applies.
I certify that the entity identified in Part I:
• Is an investment entity;
• Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
• Has agreed with the entity identified above (that is not a nonparticipating FFI) 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.
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Part V
18

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, retail customers unrelated to such
bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater than 5%
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 FFI identified in Part I and that meets the requirements set forth in this part.

Part VI
19

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 entire expanded affiliated group, if any, of the FFI, have more than $50 million in assets on its consolidated or
combined balance sheet as of the end of its most recent accounting year.

Part VII
20
21

Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle

Name of sponsoring entity:
I certify that the entity 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 on line 20; and
• 20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial institutions,
participating FFIs, registered deemed-compliant FFIs, and certified deemed-compliant FFIs and equity interests owned by an entity if that
entity owns 100% of the equity interests in the FFI and is itself a sponsored FFI).

Part VIII
22

Certified Deemed-Compliant Limited Life Debt Investment Entity

I certify that the entity identified in Part I:
• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar agreement; and
• Is certified deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the
restrictions with respect to its assets and other requirements under Regulations section 1.1471-5(f)(2)(iv)).

Part IX
23

Certain Investment Entities that Do Not Maintain Financial Accounts

I certify that the entity identified in Part I:
• Is a financial institution solely because it is an investment entity described in Regulations section 1.1471-5(e)(4)(i)(A), and
• Does not maintain financial accounts.

Part X

Owner-Documented FFI

Note: This status only applies if the U.S. financial institution, participating FFI, or reporting Model 1 FFI to which this form is given has agreed that it will
treat the FFI as an owner-documented FFI (see instructions for eligibility requirements). In addition, the FFI must make the certifications below.
24a

(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 owned by or in an expanded affiliated group with an entity 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;
• Does not maintain a financial account for any nonparticipating FFI; and
• Does not have any specified U.S. persons that own an equity interest or debt interest (other than a debt interest that is not a financial
account or that has a balance or value not exceeding $50,000) in the FFI other than those identified on the FFI owner reporting statement.
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Part X

Owner-Documented FFI (continued)

Check box 24b or 24c, whichever applies.
I certify that the FFI identified in Part I:
b
• 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), and chapter 4 status 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 deemedcompliant FFIs, excepted NFFEs, exempt beneficial owners, or U.S. persons other than specified U.S. persons); and
(iii) Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.

• Has provided, or will provide, valid documentation meeting the requirements of Regulations section 1.1471-3(d)(6)(iii) for each person
identified in the FFI owner reporting statement.
I certify that the FFI identified in Part I has provided, or will provide, an auditor's letter, signed within 4 years of 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 and debt holders identified in Regulations section 1.1471-3(d)(6)(iv)(A)(2),
and that the FFI meets all the requirements to be an owner-documented FFI. The FFI identified in Part I has also provided, or will provide,
an FFI owner reporting statement of its owners that are specified U.S. persons and Form(s) W-9, with applicable waivers.

Check box 24d if applicable (optional, see instructions).
d
I certify that the entity identified on line 1 is a trust that does not have any contingent beneficiaries or designated classes with unidentified
beneficiaries.

Part XI
25a

Restricted Distributor

(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 customers unrelated to each other and less than half of its customers are related to each other;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is an FATFcompliant 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 box 25b or 25c, whichever 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.

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, or caused the restricted
fund to transfer the securities to a distributor that is a participating FFI or reporting Model 1 FFI securities which were sold to specified U.S.
persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.
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Part XII
26

Nonreporting IGA FFI

I certify that the entity identified in Part I:
• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
. The applicable IGA is a
Model 1 IGA or a
Model 2 IGA; and
is treated as a
under the provisions of the applicable IGA or Treasury regulations
(if applicable, see instructions);
.
• If you are a trustee documented trust or a sponsored entity, provide the name of the trustee or sponsor
The trustee is:
U.S.
Foreign

Part XIII
27

Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue
I certify that the entity identified in Part I is the beneficial owner of the payment, and is not engaged in commercial financial 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)).

Part XIV

International Organization

Check box 28a or 28b, whichever applies.
I certify that the entity identified in Part I is an international organization described in section 7701(a)(18).
28a
I certify that the entity identified in Part I:
b
• Is comprised primarily of foreign governments;
• Is recognized as an intergovernmental or supranational organization under a foreign law similar to the International Organizations Immunities
Act or that has in effect a headquarters agreement with a foreign government;
• The benefit of the entity's income does not inure to any private person; and
• Is the beneficial owner of the payment and is not engaged in commercial financial 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)).

Part XV

Exempt Retirement Plans

Check box 29a, b, c, d, e, or f, whichever applies.
29a
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 (see Part III if claiming treaty benefits);
• 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;
(ii) Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described
in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds described in
an applicable Model 1 or Model 2 IGA, 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 (except rollover distributions to accounts described in Regulations section 1.1471-5(b)(2)(i)(A) (referring to retirement
and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, or to other retirement
funds described in this part or in an applicable Model 1 or Model 2 IGA); or
(iv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.

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Part XV
d
e

Exempt Retirement Plans (continued)

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.
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 in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section 1.1471-5(b)(2)(i)(A) (referring to
retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 IGA.

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) or an exempt beneficial owner described in an applicable Model 1 or Model 2 IGA 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) or an exempt beneficial owner described in an applicable Model 1 or Model 2 IGA 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.

Part XVI
30

Entity Wholly Owned by Exempt Beneficial Owners

I certify that the entity identified in Part I:
• Is an FFI solely because it is an investment entity;
• Each direct holder of an equity interest in the investment entity is an exempt beneficial owner described in Regulations section 1.1471-6 or in
an applicable Model 1 or Model 2 IGA;
• Each direct holder of a debt interest in the investment entity is either a depository institution (with respect to a loan made to such entity) or an
exempt beneficial owner described in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA.
• Has provided an owner reporting statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the type of
documentation provided to the withholding agent for every person that owns a debt interest constituting a financial account or direct equity
interest in the entity; and
• Has provided documentation establishing that every owner of the entity is an entity described in Regulations section 1.1471-6(b), (c), (d), (e),
(f) and/or (g) without regard to whether such owners are beneficial owners.

Part XVII
31

Part XVIII
32

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.

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 Regulations 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 XIX
33

Excepted Nonfinancial Start-Up Company

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 XX
34

Excepted Nonfinancial Entity in Liquidation or Bankruptcy

I certify that the entity identified in Part I:
• Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on

;

• During the past 5 years has not been engaged 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
• 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 3 years.
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Part XXI

501(c) Organization

I certify that the entity identified in Part I is a 501(c) organization that:
• Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization that is
; or
dated
• Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization (without regard to whether the
payee is a foreign private foundation).

Part XXII
36

Nonprofit Organization

I certify that the entity identified in Part I is a nonprofit organization that meets the following requirements.
• The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes;
• The entity is exempt from income tax in its country of residence;
• The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
• Neither the applicable laws of the entity's country of residence nor the entity's formation documents permit any income or assets of the entity
to be distributed to, or applied for the benefit of, a private person or noncharitable entity other than pursuant to the conduct of the entity's
charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property
which the entity has purchased; and
• The applicable laws of the entity's country of residence or the entity's formation documents require that, upon the entity's liquidation or
dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled entity
of a foreign government, or another organization that is described in this part or escheats to the government of the entity's country of
residence or any political subdivision thereof.

Part XXIII

Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation

Check box 37a or 37b, whichever applies.
I certify that:
37a
• The entity identified in Part I is a foreign corporation that is not a financial institution; and
• The stock of such corporation is regularly traded on one or more established securities markets, including
(name one securities exchange upon which the stock is regularly traded).
b

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 a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an
established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is

; and
.

• The name of the securities market on which the stock is regularly traded is

Part XXIV
38

Excepted Territory NFFE

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; or
(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 is organized or incorporated.

Active NFFE

Part XXV
39

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 are assets that produce or are held for the production of passive income (calculated as a
weighted average of the percentage of passive assets measured quarterly) (see instructions for the definition of passive income).

Part XXVI
40a

Passive NFFE

I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a
possession of the United States) and is not certifying its status as a publicly traded NFFE (or affiliate), excepted territory NFFE, active
NFFE, direct reporting NFFE, or sponsored direct reporting NFFE.

Check box 40b or 40c, whichever applies.
b
I further certify that the entity identified in Part I has no substantial U.S. owners (or, if applicable, no controlling U.S. persons); or
c

I further certify that the entity identified in Part I has provided the name, address, and TIN of each substantial U.S. owner (or, if applicable,
controlling U.S. person) of the NFFE in Part XXIX.
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Part XXVII Excepted Inter-Affiliate FFI
41

I certify that the entity identified in Part I:
• Is a member of an expanded affiliated group;
• Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group);
• Does not make withholdable payments to any person other than to members of its expanded affiliated group;
• Does not hold an account (other than depository accounts in the country in which the entity is operating to pay for expenses) with or receive
payments from any withholding agent other than a member of its expanded affiliated group; and
• Has not agreed to report under Regulations section 1.1471-4(d)(2)(ii)(C) or otherwise act as an agent for chapter 4 purposes on behalf of any financial
institution, including a member of its expanded affiliated group.

Part XXVIII Sponsored Direct Reporting NFFE (see instructions for when this is permitted)
42
43

Name of sponsoring entity:
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 42.

Part XXIX Substantial U.S. Owners of Passive NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see the instructions for a definition of
substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or reporting Model 2 FFI, an NFFE may also use this part for
reporting its controlling U.S. persons under an applicable IGA.
Name

Part XXX

Address

TIN

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:

• The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4
purposes, or is a merchant submitting this form for purposes of section 6050W;
• The entity identified on line 1 of this form is not a U.S. person;
• 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 income tax treaty, or (c) the partner's share of a partnership's effectively connected income; and

• 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 the entity on line 1 is the beneficial
owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.

▲

Sign Here

Signature of individual authorized to sign for beneficial owner

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Date (MM-DD-YYYY)

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

W-8BEN-E

(Rev. 7-2017)

File Type	application/pdf
File Title	Form W-8BEN-E (Rev. July 2017)
Subject	Fillable
Author	SE:W:CAR:MP
File Modified	2017-07-11
File Created	2017-07-11