Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) Page 2
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Form W-8BEN-E (Rev. 4-2016)
Page
Part II
Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a
branch of an FFI in a country other than the FFI's country of residence. See instructions.)
11
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment
Limited Branch (see instructions).
Reporting Model 1 FFI.
U.S. Branch.
Participating FFI.
Reporting Model 2 FFI.
12
Address of disregarded entity or branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a
registered address).
City or town, state or province. Include postal code where appropriate.
Country
GIIN (if any)
13
Part III
Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only.)
14
I certify that (check all that apply):
The beneficial owner is a resident of
a
within the meaning of the income tax
treaty between the United States and that country.
b
The beneficial owner 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. The following are types of limitation on benefits provisions that may
be included in an applicable tax treaty (check only one; see instructions):
Government
Company that meets the ownership and base erosion test
Tax exempt pension trust or pension fund
Company that meets the derivative benefits test
Other tax exempt organization
Company with an item of income that meets active trade or business test
Publicly traded corporation
Favorable discretionary determination by the U.S. competent authority received
Subsidiary of a publicly traded corporation
Other (specify Article and paragraph):
c
The beneficial owner is claiming treaty benefits for U.S. source 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).
15
Special rates and conditions (if applicable—see instructions):
The beneficial owner is claiming the provisions of Article and paragraph
of the treaty identified on line 14a above to claim a
% rate of withholding on (specify type of income):
Explain the additional conditions in the Article the beneficial owner meets to be eligible for the rate of withholding:
Part IV
Sponsored FFI
16
Name of sponsoring entity:
GIIN of sponsoring entity:
17
Check whichever box applies.
I certify that the entity identified in Part I:
• Is an investment entity;
• Is not a QI, WP, 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.
W-8BEN-E
Form
(Rev. 4-2016)
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