Form W-8ben-E - Certificate Of Status Of Beneficial Owner For United States Tax Withholding And Reporting (Entities) - 2014 Page 2
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9W-8BEN-E
Certificate of Status of Beneficial Owner for
Form
United States Tax Withholding and Reporting (Entities)
OMB No. 1545-1621
(February 2014)
For use by entities. Individuals must use Form W-8BEN.
Section references are to the Internal Revenue Code.
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Department of the Treasury
Information about Form W-8BEN-E and its separate instructions is at
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Internal Revenue Service
Give this form to the withholding agent or payer. Do not send to the IRS.
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Do NOT use this form for:
Instead use Form:
• U.S. entity or U.S. citizen or resident .
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. W-9
• A foreign individual
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W-8BEN (Individual)
• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits).
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. W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions)
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. W-8IMY
• 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 that income is effectively connected U.S. income or that is claiming
the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions) .
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W-8ECI or W-8EXP
• Any person acting as an intermediary .
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. W-8IMY
Part I
Identification of Beneficial Owner
1
Name of organization that is the beneficial owner
2 Country of incorporation or organization
3
Name of disregarded entity receiving the payment (if applicable)
4
Corporation
Chapter 3 Status (entity type) (Must check one box only):
Disregarded entity
Partnership
Simple trust
Grantor trust
Complex trust
Estate
Government
Central Bank of Issue
Tax-exempt organization
Private foundation
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If "Yes" complete Part III.
Yes
No
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Chapter 4 Status (FATCA status) (Must check one box only unless otherwise indicated). (See instructions for details and complete the
certification below for the entity's applicable status).
Nonparticipating FFI (including a limited FFI or an FFI related to a
Nonreporting IGA FFI (including an FFI treated as a registered
Reporting IGA FFI other than a registered deemed-compliant FFI
deemed-compliant FFI under an applicable Model 2 IGA).
or participating FFI).
Complete Part XII.
Participating FFI.
Foreign government, government of a U.S. possession, or foreign
central bank of issue. Complete Part XIII.
Reporting Model 1 FFI.
Reporting Model 2 FFI.
International organization. Complete Part XIV.
Registered deemed-compliant FFI (other than a reporting Model 1
Exempt retirement plans. Complete Part XV.
FFI or sponsored FFI that has not obtained a GIIN).
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
Sponsored FFI that has not obtained a GIIN. Complete Part IV.
Territory financial institution. Complete Part XVII.
Certified deemed-compliant nonregistering local bank. Complete
Nonfinancial group entity. Complete Part XVIII.
Part V.
Excepted nonfinancial start-up company. Complete Part XIX.
Certified deemed-compliant FFI with only low-value accounts.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part VI.
Complete Part XX.
501(c) organization. Complete Part XXI.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Nonprofit organization. Complete Part XXII.
Certified deemed-compliant limited life debt investment entity.
Publicly traded NFFE or NFFE affiliate of a publicly traded
Complete Part VIII.
corporation. Complete Part XXIII.
Certified deemed-compliant investment advisors and investment
Excepted territory NFFE. Complete Part XXIV.
managers. Complete Part IX.
Active NFFE. Complete Part XXV.
Owner-documented FFI. Complete Part X.
Passive NFFE. Complete Part XXVI.
Restricted distributor. Complete Part XI.
Excepted inter-affiliate FFI. Complete Part XXVII.
Direct reporting NFFE.
Sponsored direct reporting NFFE. Complete Part XXVIII.
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Permanent residence address (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
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Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
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U.S. taxpayer identification number (TIN), if required
10 Reference number(s) (see instructions)
b
Foreign TIN
9a
GIIN
Note. Please complete remainder of the form including signing the form in Part XXIX.
W-8BEN-E
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 59689N
Form
(2-2014)
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