Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) Page 7

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Form W-8BEN-E (Rev. 4-2016)
Page
Part XXI
501(c) Organization
35
I certify that the entity identified in Part I is a 501(c) organization that:
• Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization that is
dated
; or
• Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization (without regard to whether the
payee is a foreign private foundation).
Part XXII
Non-Profit Organization
36
I certify that the entity identified in Part I is a non-profit organization that meets the following requirements:
• The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes;
• The entity is exempt from income tax in its country of residence;
• The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
• Neither the applicable laws of the entity's country of residence nor the entity's formation documents permit any income or assets of the entity
to be distributed to, or applied for the benefit of, a private person or non-charitable entity other than pursuant to the conduct of the entity's
charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property
which the entity has purchased; and
• The applicable laws of the entity's country of residence or the entity's formation documents require that, upon the entity's liquidation or
dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled entity
of a foreign government, or another organization that is described in this Part XXII or escheats to the government of the entity's country of
residence or any political subdivision thereof.
Part XXIII
Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation
Check box 37a or 37b, whichever applies.
37a
I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution; and
• The stock of such corporation is regularly traded on one or more established securities markets, including
(name one securities exchange upon which the stock is regularly traded).
b
I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution;
• The entity identified in Part I is a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an
established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is
; and
• The name of the securities market on which the stock is regularly traded is
.
Part XXIV
Excepted Territory NFFE
38
I certify that:
• The entity identified in Part I is an entity that is organized in a possession of the United States;
• The entity identified in Part I:
• 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, or
• 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; and
• All of the owners of the entity identified in Part I are bona fide residents of the possession in which the NFFE is organized or incorporated.
Active NFFE
Part XXV
39
I certify that:
• The entity identified in Part I is a foreign entity that is not a financial institution;
• Less than 50% of such entity's gross income for the preceding calendar year is passive income; and
• Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income (calculated as a
weighted average of the percentage of passive assets measured quarterly) (see instructions for the definition of passive income).
Passive NFFE
Part XXVI
40a
I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a
possession of the United States) and is not certifying its status as a publicly traded NFFE (or affiliate), excepted territory NFFE, active
NFFE, direct reporting NFFE, or sponsored direct reporting NFFE.
Check box 40b or 40c, whichever applies.
I further certify that the entity identified in Part I has no substantial U.S. owners (or, if applicable, no controlling U.S. persons), or
b
c
I further certify that the entity identified in Part I has provided the name, address, and TIN of each substantial U.S. owner (or, if applicable,
controlling U.S. person) of the NFFE in Part XXIX.
W-8BEN-E
Form
(Rev. 4-2016)

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