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THEN the Form

8802 penalties of

IF the applicant perjury statement STATING: “This certification is given under penalties of perjury and to the best of

is...

must include...

my knowledge and belief, the statements are true, correct, and complete.”

a statement from

[Insert name of shareholder and TIN] is a U.S. resident and will continue to be throughout

each individual

the current tax year, and

an S corporation shareholder for

which certification is

requested

a statement from an [Insert name of S corporation and EIN] has filed its required return and the entity

officer of the

classification has not changed since the return was filed.

corporation with the

authority to legally

bind the corporation

a statement from [Insert name and TIN] is a U.S. resident and will continue to be throughout the current tax

year, and

each individual

a common trust participant/

fund, grantor

beneficiary/

trust, or simple

owner

trust

a statement from

[Insert name of trust and EIN] has filed its required return and the entity classification has

the trustee with

not changed since the return was filed.

Note: When the participant, beneficiary, or owner, is other than an individual, use the

authority to legally

bind the trust

statement that corresponds to the type of entity.

a statement from the [Insert name of trust and EIN] is a U.S. resident and will continue to be throughout the

t r u s t e e

w i t h current tax year.

a trust

authority to legally

bind the trust

a statement from an [Insert name of corporation and EIN] is a U.S. resident and will continue to be throughout

officer of the

the current tax year.

a corporation

corporation with the

authority to legally

bind the corporation

a statement from an [Insert name of organization and EIN] is a U.S. resident and will continue to be throughout

officer of the

the current tax year.

an exempt

organization with

organization

authority to legally

bind the

organization

a statement from

[Insert name of estate and EIN] is a U.S. resident and will continue to be throughout the

the personal

current tax year.

an estate of a

representative

decedent

a statement from an [Insert name of plan/trust and EIN] is a U.S. resident and will continue to be throughout

officer of the plan/

the current tax year.

an employee

trust with authority

benefit plan/trust to legally bind the

plan/trust

a statement from

[Insert name of partner and TIN] is a U.S. resident and will continue to be throughout the

current tax year, and

a partnership

each partner for

under IRC section which certification is

761(a) election

requested

a statement from a

a. [Insert name of partnership and EIN] has made an election pursuant to IRC section

general partner

761(a). As a result, it is not required to file Form 1065 on an annual basis and all of its

partners report their respective shares of income, gain, loss, deductions, and credits on

their tax returns as required.

b. The [insert name of partnership] ’s entity classification has not changed since the filing

of the partners’ returns.

a foreign

an additional

[Insert name of partnership and EIN] is not required to file Form 1065 under Regulations

partnership under statement from a

section 1.6031(a)-1(b) and the entity classification has not changed since the filing of the

Regulations

general partner

partners’ returns.

section

1.6031(a)-1(b)

-10-

Instructions For Form 8802 - Application For United States Residency Certification - 2012 Page 10

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