Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) Page 5
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Form W-8BEN-E (Rev. 4-2016)
Page
Part XII
Nonreporting IGA FFI
26
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 whose GIIN is provided on
line 9a (if any)
; and your GIIN (if issued to you)
.
Part XIII
Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue
27
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 §1.1471-6(h)(2)).
Part XIV
International Organization
Check box 28a or 28b, whichever applies.
28a
I certify that the entity identified in Part I is an international organization described in section 7701(a)(18).
b
I certify that the entity identified in Part I:
• 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;
• 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 §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
• 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;
• 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 §1.1471-5(b)(2)(i)(A));
• 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 §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
• Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
c
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;
• Has fewer than 50 participants;
• Is sponsored by one or more employers each of which is not an investment entity or passive NFFE;
• Employee and employer contributions to the fund (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, or accounts described in §1.1471-5(b)(2)(i)(A)) are limited by reference to
earned income and compensation of the employee, respectively;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20 percent of the
fund's assets; and
• 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 operates.
W-8BEN-E
Form
(Rev. 4-2016)
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