Form W-8eci - Certificate Of Foreign Person'S Claim That Income Is Effectively Connected With The Conduct Of A Trade Or Business In The United States - 2014

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W-8ECI

Certificate of Foreign Person's Claim That Income Is

Form

Effectively Connected With the Conduct of a Trade or

Business in the United States

(Rev. February 2014)

OMB No. 1545-1621

Section references are to the Internal Revenue Code.

▶

Information about Form W-8ECI and its separate instructions is at

▶

Department of the Treasury

Give this form to the withholding agent or payer. Do not send to the IRS.

▶

Internal Revenue Service

Note. Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively

connected with a U.S. trade or business (see instructions).

Do not use this form for:

Instead, use Form:

• A beneficial owner solely claiming foreign status or treaty benefits

W-8BEN or W-8BEN-E

• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private

foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)

W-8EXP

Note. These entities should use Form W-8ECI if they received effectively connected income and are not eligible to claim an exemption for chapter 3

or 4 purposes on Form W-8EXP.

• A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively connected with the

W-8BEN-E

conduct of a trade or business in the United States)

or W-8IMY

• A person acting as an intermediary

W-8IMY

Note. See instructions for additional exceptions.

Part I

Identification of Beneficial Owner

(see instructions.)

Name of individual or organization that is the beneficial owner

2 Country of incorporation or organization

Name of disregarded entity receiving the payments (if applicable)

Type of entity (check the appropriate box):

Individual

Corporation

Partnership

Simple trust

Complex trust

Estate

Government

Grantor trust

Central bank of issue

Tax-exempt organization

Private foundation

International organization

Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.

City or town, state or province. Include postal code where appropriate.

Country

Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.

City or town, state, and ZIP code

U.S. taxpayer identification number (required—see instructions)

8 Foreign tax identifying number

SSN or ITIN

EIN

10 Date of birth

Reference number(s) (see instructions)

(MM-DD-YYYY)

Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade or

business in the United States. (attach statement if necessary)

Part II

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:

• I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the payments to which this form relates,

• The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States,

• The income for which this form was provided is includible in my gross income (or the beneficial owner’s gross income) for the taxable year, and

Sign

• The beneficial owner is not a U.S. person.

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the payments of which I am the

Here

beneficial owner or any withholding agent that can disburse or make payments of the amounts of which I am the beneficial owner.

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

Signature of beneficial owner (or individual authorized to sign for the beneficial owner)

Print name

Date (MM-DD-YYYY)

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

W-8ECI

For Paperwork Reduction Act Notice, see separate instructions.

Form

(Rev. 2-2014)

Cat. No. 25045D

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