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Form

W-8BEN

(Rev. February 2006)
Department of the Treasury
Internal Revenue Service

Certificate of Foreign Status of Beneficial Owner
for United States Tax Withholding

OMB No. 1545-1621

Section references are to the Internal Revenue Code.
See separate instructions.
Give this form to the withholding agent or payer. Do not send to the IRS.

Do not use this form for:
● A U.S. citizen or other U.S. person, including a resident alien individual ● A person claiming that income is effectively connected with the conduct of a trade or business in the United States
● A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) ● A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions) Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. ● A person acting as an intermediary

Note: See instructions for additional exceptions.

W-8ECI
W-8ECI or W-8IMY
W-8ECI or W-8EXP

W-8IMY

Identification of Beneficial Owner (See instructions.)

Part I
1

Name of individual or organization that is the beneficial owner

3

Type of beneficial owner:
Grantor trust
Central bank of issue

4

Instead, use Form:
W-9

Individual

2

Country of incorporation or organization

Disregarded entity

Complex trust

Estate

Tax-exempt organization

Partnership

Government

Corporation

International organization

Simple trust

Private foundation

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.

5

Country (do not abbreviate)

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

6

Country (do not abbreviate)
7

U.S. taxpayer identification number, if required (see instructions) SSN or ITIN

8

Foreign tax identifying number, if any (optional)

EIN

Reference number(s) (see instructions)

Claim of Tax Treaty Benefits (if applicable)

Part II
9

I certify that (check all that apply):
a

If required, the U.S. taxpayer identification number is stated on line 6 (see instructions).

c

The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions).

d

The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions).

e
10

The beneficial owner is a resident of

b

within the meaning of the income tax treaty between the United States and that country.

The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000. Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article % rate of withholding on (specify type of income):

treaty identified on line 9a above to claim a
Explain the reasons the beneficial owner meets the terms of the treaty article:

Notional Principal Contracts

Part III
11

of the
.

I have provided or will provide a statement that identifies those notional principal contracts from...
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