Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) Page 4
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Form W-8BEN-E (Rev. 4-2016)
Page
Part X
Owner-Documented FFI (continued)
Check box 24b or 24c, whichever applies.
b
I certify that the FFI identified in Part I:
• Has provided, or will provide, an FFI owner reporting statement that contains:
• 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);
• 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 deemed-compliant FFIs, excepted NFFEs,
exempt beneficial owners, or U.S. persons other than specified U.S. persons); and
• 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 §1.1471-3(d)(6)(iii) for each person identified in the FFI owner
reporting statement.
c
I certify that the FFI identified in Part I has provided, or will provide, an auditor's letter, signed within four 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 §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
Restricted Distributor
25a
(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 FATF-
compliant 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.
c
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 §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.
W-8BEN-E
Form
(Rev. 4-2016)
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