2
Form W-8EXP (Rev. 12-2000)
Page
Part II
Qualification Statement (continued)
12
For a foreign tax-exempt organization, including foreign private foundations:
If any of the income to which this certification relates constitutes income includible under section 512 in computing the
entity’s unrelated business taxable income, attach a statement identifying the amounts.
Check either box 12a or box 12b:
a
I certify that the entity identified in Part I has been issued a determination letter by the IRS dated
that is currently in effect and that concludes that it is an exempt organization described in section 501(c).
b
I have attached to this form an opinion from U.S. counsel concluding that the entity identified in Part I is described in
section 501(c).
For section 501(c)(3) organizations only, check either box 12c or box 12d:
c
If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section
501(c)(3), I certify that the organization is not a private foundation described in section 509. I have attached an affidavit
of the organization setting forth sufficient facts for the IRS to determine that the organization is not a private foundation
because it meets one of the exceptions described in section 509(a)(1), (2), (3), or (4).
d
If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section
501(c)(3), I certify that the organization is a private foundation described in section 509.
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For a government of a U.S. possession:
I certify that the entity identified in Part I is a government of a possession of the United States, or is a political
subdivision thereof, and is claiming the exemption granted by section 115(2).
Part III
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 penalties of perjury that:
● The organization for which I am signing is the beneficial owner of the income to which this form relates,
● The beneficial owner is not a U.S. person,
● For a beneficial owner that is a controlled entity of a foreign sovereign (other than a central bank of issue wholly owned by
a foreign sovereign), the beneficial owner is not engaged in commercial activities within or outside the United States, and
● For a beneficial owner that is a central bank of issue wholly owned by a foreign sovereign, the beneficial owner is not
engaged in commercial activities within the United States.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income
of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I
am the beneficial owner.
Sign
Here
Signature of authorized official
Date (MM-DD-YYYY)
Capacity in which acting