Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) - 2016
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1W-8BEN-E
Certificate of Status of Beneficial Owner for
Form
United States Tax Withholding and Reporting (Entities)
(Rev. April 2016)
OMB No. 1545-1621
(Rev. April 2016)
Substitute Form for
For use by entities. Individuals must use Form W-8BEN.
Section references are to the Internal Revenue Code.
Department of the Treasury
Information about Form W-8BEN-E and its separate instructions is at
Non-FATCA Payments
Internal Revenue Service
Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form for:
Instead use Form:
Do NOT use this form for:
Instead use Form:
FATCA withholdable payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IRS Form W-8BEN-E
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• U.S. entity or U.S. citizen or resident .
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. W-9
U.S. entity or U.S. citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .W-9
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A foreign individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN (Individual) or 8233
• A foreign individual
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. W-8BEN (Individual) or Form 8233
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A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
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• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
(unless claiming treaty benefits) .
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. W-8ECI
A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . . . . . . W-8IMY
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A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions)
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. W-8IMY
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government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or
P
501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) . . . . . . . . . . . . . . .
W-8ECI or W-8EX
government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
Y
Any person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8IM
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501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) .
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W-8ECI or W-8EXP
Part I
Identification of Beneficial Owner
• Any person acting as an intermediary .
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. W-8IMY
1
Name of organization that is the beneficial owner
2 Country of incorporation or organization
Part I
Identification of Beneficial Owner
1
Name of organization that is the beneficial owner
2 Country of incorporation or organization
Chapter 3 Status (entity type) (Must check one box only):
Corporation
Disregarded entity
Partnership
4
Simple trust
Grantor trust
Complex trust
Estate
Government
3
Name of disregarded entity receiving the payment (if applicable, see instructions)
Central Bank of Issue
Tax-exempt organization
Private foundation
International organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
4
claim? If "Yes" complete Part III.
Chapter 3 Status (entity type) (Must check one box only):
Corporation
Disregarded entity
Partnership
Yes
No
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
6
Simple trust
Grantor trust
Complex trust
Estate
Government
Central Bank of Issue
Tax-exempt organization
Private foundation
International organization
City or town, state or province. Include postal code where appropriate.
Country
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If "Yes" complete Part III.
Yes
No
7
Mailing address (if different from above)
5
Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity's applicable status).
Nonparticipating FFI (including a limited FFI or an FFI related to a
Nonreporting IGA FFI. Complete Part XII.
City or town, state or province. Include postal code where appropriate.
Country
Reporting IGA FFI other than a deemed-compliant FFI,
Foreign government, government of a U.S. possession, or foreign
participating FFI, or exempt beneficial owner).
central bank of issue. Complete Part XIII.
8
U.S. taxpayer identification number (TIN), if required
9b Foreign TIN
10 Reference number(s) (see instructions)
Participating FFI.
International organization. Complete Part XIV.
Reporting Model 1 FFI.
Exempt retirement plans. Complete Part XV.
Part III
Claim of Tax Treaty Benefits
(if applicable). (For chapter 3 purposes only.)
Reporting Model 2 FFI.
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
14
I certify that (check all that apply):
Registered deemed-compliant FFI (other than a reporting Model 1
Territory financial institution. Complete Part XVII.
a
The beneficial owner is a resident of
within the meaning of the income tax
FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII).
Nonfinancial group entity. Complete Part XVIII.
treaty between the United States and that country.
See instructions.
Excepted nonfinancial start-up company. Complete Part XIX.
b
The beneficial owner derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the
requirements of the treaty provision dealing with limitation on benefits. The following are types of limitation on benefits provisions that may
Sponsored FFI. Complete Part IV.
Excepted nonfinancial entity in liquidation or bankruptcy.
be included in an applicable tax treaty (check only one; see instructions):
Complete Part XX.
Certified deemed-compliant nonregistering local bank. Complete
Government
Company that meets the ownership and base erosion test
Part V.
501(c) organization. Complete Part XXI.
Tax exempt pension trust or pension fund
Company that meets the derivative benefits test
Certified deemed-compliant FFI with only low-value accounts.
Nonprofit organization. Complete Part XXII.
Other tax exempt organization
Company with an item of income that meets active trade or business test
Complete Part VI.
Publicly traded NFFE or NFFE affiliate of a publicly traded
Publicly traded corporation
Favorable discretionary determination by the U.S. competent authority received
corporation. Complete Part XXIII.
Certified deemed-compliant sponsored, closely held investment
Subsidiary of a publicly traded corporation
Other (specify Article and paragraph):
vehicle. Complete Part VII.
Excepted territory NFFE. Complete Part XXIV.
c
The beneficial owner is claiming treaty benefits for U.S. source dividends received from a foreign corporation or interest from a U.S. trade
Active NFFE. Complete Part XXV.
Certified deemed-compliant limited life debt investment entity.
or business of a foreign corporation and meets qualified resident status (see instructions).
Complete Part VIII.
Passive NFFE. Complete Part XXVI.
15
Special rates and conditions (if applicable—see instructions):
Certified deemed-compliant investment advisors and investment
Excepted inter-affiliate FFI. Complete Part XXVII.
The beneficial owner is claiming the provisions of Article and paragraph
managers. Complete Part IX.
Direct reporting NFFE.
of the treaty identified on line 14a above to claim a
% rate of withholding on (specify type of income):
Owner-documented FFI. Complete Part X.
Sponsored direct reporting NFFE. Complete Part XXVIII.
Explain the additional conditions in the Article the beneficial owner meets to be eligible for the rate of withholding:
Restricted distributor. Complete Part XI.
Account that is not a financial account.
6
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
Part XXX
Certification
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
City or town, state or province. Include postal code where appropriate.
Country
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,
7
Mailing address (if different from above)
•
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
City or town, state or province. Include postal code where appropriate.
Country
•
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.
8
U.S. taxpayer identification number (TIN), if required
9a GIIN
b Foreign TIN
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
Sign Here
10
Reference number(s) (see instructions)
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.
Note: Please complete remainder of the form including signing the form in Part XXX.
W-8BEN-E
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 59689N
Form
(Rev. 4-2016)
Note: Lines in this substitute form are numbered to match the official IRS form. Refer to IRS instructions for Form W-8BEN-E when completing this form.
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