Form W-8ben Certificate Of Foreign Status Of Beneficial Owner For United States Tax Withholding And Reporting (Individuals)

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W-8BEN

Certificate of Foreign Status of Beneficial Owner for United States

Form

Tax Withholding and Reporting (Individuals)

(Rev. February 2014)

OMB No. 1545-1621

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For use by individuals receiving Royalty payments, Independent Contractor Services and Scholarship/Fellowship Payments

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This form has been adapted for University of Chicago use only.

Department of the Treasury

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

Internal Revenue Service

Instead, use Form:

Do NOT use this form if:

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You are NOT an individual

W-8BEN-E

•

You are a U.S. citizen or other U.S. person, including a resident alien individual .

W-9

• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal services) .

W-8ECI

• You are a beneficial owner who is receiving compensation for personal services performed in the United States . . .

8233 or W-4

• A person acting as an intermediary .

W-8IMY

Are you a University of Chicago Student? _______________

If yes, please provide Student ID#_____________________________

Have you ever been employed by the University of Chicago? __________

If yes, please provide dates _________________________________

Part I

Identification of Beneficial Owner (see instructions)

Name of individual who is the beneficial owner

2 Country of citizenship

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

Mailing address (if different from above)

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

Country

U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)

6 Foreign tax identifying number (see instructions)

Reference number(s) (see instructions)

8 Date of birth (MM-DD-YYYY) (see instructions)

Part II

Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)

I certify that the beneficial owner is a resident of

within the meaning of the income tax treaty

between the United States and that country.

Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article

of the treaty identified on line 9 above to claim a

% rate of withholding on (specify type of income):

Explain the reasons the beneficial owner meets the terms of the treaty article:

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:

•

I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or am using

this form to document myself as an individual that is an owner or account holder of a foreign financial institution,

•

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

The income to which this form relates is:

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(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 applicable income tax treaty, or

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The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the United

States and that country, 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 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. I agree that I will submit a new form within 30 days if any

certification made on this form becomes incorrect.

Sign Here

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

Date (MM-DD-YYYY)

Print name of signer

Capacity in which acting (if form is not signed by beneficial owner)

W-8BEN

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 25047Z

Form

(Rev. 2-2014)