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

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Form W-8BEN-E (Rev. 4-2016)

Page

Excepted Inter-Affiliate FFI

Part XXVII

I certify that the entity identified in Part I:

• Is a member of an expanded affiliated group;

• Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group);

• Does not make withholdable payments to any person other than to members of its expanded affiliated group that are not limited FFIs or

limited branches;

• Does not hold an account (other than a depository account in the country in which the entity is operating to pay for expenses) with or receive

payments from any withholding agent other than a member of its expanded affiliated group; and

• Has not agreed to report under §1.1471-4(d)(2)(ii)(C) or otherwise act as an agent for chapter 4 purposes on behalf of any financial institution, including

a member of its expanded affiliated group.

Sponsored Direct Reporting NFFE (see instructions for when this is permitted)

Part XXVIII

Name of sponsoring entity:

GIIN of sponsoring entity:

I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 42.

Part XXIX

Substantial U.S. Owners of Passive NFFE

As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for definition of

substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or reporting Model 2 FFI, an NFFE may also use this Part for

reporting its controlling U.S. persons under an applicable IGA.

Name

Address

TIN

Certification

Part XXX

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further

certify under penalties of perjury that:

•

The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4

purposes, or is a merchant submitting this form for purposes of section 6050W,

•

The entity identified on line 1 of this form is not a U.S. person,

•

The income to which this form relates is: (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is

not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, and

•

For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which the entity on line 1 is the beneficial

owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner.

I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.

Sign Here

Signature of individual authorized to sign for beneficial owner

Print Name

Date (MM-DD-YYYY)

I certify that I have the capacity to sign for the entity identified on line 1 of this form.

W-8BEN-E

Form

(Rev. 4-2016)