Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) Page 3
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Form W-8BEN-E (Rev. 4-2016)
Page
Part V
Certified Deemed-Compliant Nonregistering Local Bank
18
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 five
percent 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 V.
Part VI
Certified Deemed-Compliant FFI with Only Low-Value Accounts
19
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
Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
20
Name of sponsoring entity:
21
I certify that the entity identified in Part I:
• Is an FFI solely because it is an investment entity described in §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
• Twenty 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 percent of the equity interests in the FFI and is itself a sponsored FFI).
Part VIII
Certified Deemed-Compliant Limited Life Debt Investment Entity
22
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 § 1.1471-5(f)(2)(iv)).
Part IX
Certified Deemed-Compliant Investment Advisors and Investment Managers
23
I certify that the entity identified in Part I:
• Is a financial institution solely because it is an investment entity described in §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.
W-8BEN-E
Form
(Rev. 4-2016)
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