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Form W-8BEN-E (2-2014)
Page
Sponsored Direct Reporting NFFE
Part XXVIII
Name of sponsoring entity:
42
43
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 42.
Certification
Part XXIX
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:
•
The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4
purposes, or is a merchant submitting this form for purposes of section 6050W,
•
The entity identified on line 1 of this form is not a U.S. person,
•
The income to which this form relates is: (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 income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, 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 the entity on line 1 is the beneficial
owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
Sign Here
Signature of individual authorized to sign for beneficial owner
Print Name
Date (MM-DD-YYYY)
I certify that I have the capacity to sign for the entity identified on line 1 of this form.
Part XXX
Substantial U.S. Owners of Passive NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for definition of
substantial U.S. owner.
Name
Address
TIN
W-8BEN-E
Form
(2-2014)
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