Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) - 2014 Page 3
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Form W-8BEN-E (2-2014)
Page
Part II
Disregarded Entity or Branch Receiving Payment. (Complete only if disregarded entity or branch of an
FFI in a country other than the FFI's country of residence.)
11
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment
Limited Branch.
Reporting Model 1 FFI.
U.S. Branch.
Participating FFI.
Reporting Model 2 FFI.
12
Address of disregarded entity or 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)
Part III
Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only)
14
I certify that (check all that apply):
a
The beneficial owner is a resident of
within the meaning of the income tax
treaty between the United States and that country.
b
The beneficial owner derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the
requirements of the treaty provision dealing with limitation on benefits (see instructions).
c
The beneficial owner is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business
of a foreign corporation and meets qualified resident status (see instructions).
15
Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article
of the treaty identified on line 14a 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 IV
Sponsored FFI That Has Not Obtained a GIIN
16
Name of sponsoring entity:
17
Check whichever box applies.
I certify that the entity identified in Part I:
• Is an FFI solely because it is an investment entity;
• Is not a QI, WP, or WT; and
• Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
I certify that the entity identified in Part I:
• Is a controlled foreign corporation as defined in section 957(a);
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
entity; and
• Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all
account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not
limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or
payees.
Part V
Certified Deemed-Compliant Nonregistering Local Bank
18
I certify that the FFI identified in Part I:
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of
incorporation or organization;
• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to such
bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater than five
percent interest in such credit union or cooperative credit organization;
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more
than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that
is incorporated or organized in the same country as the FFI identified in Part I and that meets the requirements set forth in this Part V.
W-8BEN-E
Form
(2-2014)
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