Form W-8imy - Certificate Of Foreign Intermediary, Foreign Flow-Through Entity, Or Certain U.s. Branches For United States Tax Withholding And Reporting - 2017 Page 2
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82
Form W-8IMY (Rev. 6-2017)
Page
Part II
Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a
branch of an FFI in a country other than the FFI’s country of residence. Do not complete Part II for QDD
branches. See instructions.)
11
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment.
Branch treated as nonparticipating FFI.
Reporting Model 1 FFI.
U.S. Branch.
Participating FFI.
Reporting Model 2 FFI.
12
Address of branch (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).
City or town, state or province. Include postal code where appropriate.
Country
13
GIIN (if any)
▶
Chapter 3 Status Certifications
Part III
Qualified Intermediary
All Qualified Intermediaries
14
I certify that the entity identified in Part I (or branch, if relevant):
• Is a QI with respect to the accounts identified on line 10 or in a withholding statement associated with this form (as required) that is one
or more of the following:
(i) not acting for its own account;
(ii) a QDD receiving payments on underlying securities and/or potential section 871(m) transactions;
(iii) a QI assuming primary withholding responsibility for payments of substitute interest, as permitted by the QI Agreement.
• Has provided or will provide a withholding statement (as required) for purposes of chapters 3 and 4 that is subject to the certifications
made on this form.
Qualified Intermediaries not Acting as Qualified Derivatives Dealers (check all that apply)
I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 for each
15a
account identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts).
I certify that the entity identified in Part I of this form assumes primary Form 1099 reporting and backup withholding responsibility or
b
reporting responsibility as a participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains that are held
by specified U.S. persons as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting for each
account identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all
accounts).
c
I certify that the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding responsibility.
(Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup
d
withholding responsibility.) If the entity identified in Part I of this form has allocated or will allocate a portion of a payment to a chapter 4
withholding rate pool of U.S. payees on a withholding statement associated with this form, I certify that the entity meets the requirements
of Regulations section 1.6049-4(c)(4)(iii) with respect to any account holder of an account it maintains that is included in such a withholding
rate pool.
e
(Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup
withholding responsibility.) If the entity identified in Part I of this form has allocated or will allocate a portion of a payment to a chapter 4
withholding rate pool of U.S. payees on a withholding statement associated with this form, to the extent the U.S. payees are account
holders of an intermediary or flow-through entity receiving a payment from the entity, I certify that the entity has obtained, or will obtain,
documentation sufficient to establish each such intermediary or flow-through entity status as a participating FFI, registered deemed-
compliant FFI, or FFI that is a QI.
I certify that the entity identified in Part I of this form is acting as a qualified securities lender with respect to payments associated with this
f
form that are U.S. source substitute dividends received from the withholding agent.
g
I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 and
primary Form 1099 reporting and backup withholding responsibility for all payments of substitute interest associated with this form, as
permitted by the QI Agreement.
Qualified Derivatives Dealers
16a
I certify that each QDD identified in Part I of this form or on a withholding statement associated with this form meets the requirements to
act as a QDD and assumes primary withholding and reporting responsibilities under chapters 3, 4, and 61 and section 3406 with respect
to any payments it makes with respect to potential section 871(m) transactions.
b
Entity classification of QDD:
Corporation
Partnership
Disregarded Entity
W-8IMY
Form
(Rev. 6-2017)
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