Form W-8imy - Certificate Of Foreign Intermediary, Foreign Flow-Through Entity, Or Certain U.s. Branches For United States Tax Withholding And Reporting - 2014 Page 6
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95
Form W-8IMY (Rev. 4-2014)
Page
Part XIV
Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
25a
Name of sponsoring entity:
▶
I certify that the FFI identified in Part I:
b
• Is an FFI solely because it is an investment entity described in Regulations section 1.1471-5(e)(4);
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fulfilled by
the sponsoring entity identified in line 25a; and
• Twenty or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial
institutions, participating FFIs, registered deemed-compliant FFIs, and certified deemed-compliant FFIs and equity interests owned by an
entity that owns 100 percent of the equity interests in the FFI identified in Part I and is itself a sponsored FFI).
Part XV
Certified Deemed-Compliant Limited Life Debt Investment Entity
I certify that the FFI identified in Part I:
26
• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013 pursuant to a trust indenture or similar
agreement; and
• Is certified deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the
restrictions with respect to its assets and other requirements under Regulations section 1.1471-4(f)(2)(iv)).
Part XVI
Restricted Distributor
27a
(All restricted distributors check here) I certify that the entity identified in Part I:
• Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished;
• Provides investment services to at least 30 customers unrelated to each other and less than half of its customers are related to each
other;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is a
FATF-compliant jurisdiction);
• Operates solely in its country of incorporation or organization, has no fixed place of business outside of that country, and has the same
country of incorporation or organization as all members of its affiliated group, if any;
• Does not solicit customers outside its country of incorporation or organization;
• Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement
for the most recent accounting year;
• Is not a member of an expanded affiliated group that has more than $500 million in total assets under management or more than $20
million in gross revenue for its most recent accounting year on a combined or consolidated income statement; and
• Does not distribute any debt or securities of the restricted fund to specified U.S. persons, passive NFFEs with one or more substantial
U.S. owners, or nonparticipating FFIs.
Check whichever box applies:
I further certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made
after December 31, 2011, the entity identified in Part I:
b
Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and U.S.
resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any
specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.
c
Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specified U.S. person,
passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a
restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the procedures
identified in Regulations section 1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any securities which were sold
to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs, or will transfer the securities
to a distributor that is a participating FFI reporting Model 1 FFI, or reporting Model 2 FFI.
Part XVII
Foreign Central Bank of Issue
I certify that the entity identified in Part I is treated as the beneficial owner of the payment solely for purposes of chapter 4 under
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Regulations section 1.1471-6(d)(4).
W-8IMY
Form
(Rev. 4-2014)
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