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 2

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W-8IMY

Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain

Form

U.S. Branches for United States Tax Withholding and Reporting

(Rev. April 2014)

Section references are to the Internal Revenue Code.

OMB No. 1545-1621

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Information about Form W-8IMY and its separate instructions is at

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Department of the Treasury

Give this form to the withholding agent or payer. Do not send to the IRS.

Internal Revenue Service

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Do not use this form for:

Instead, use Form:

W-8BEN or W-8BEN-E

• A beneficial owner solely claiming foreign status or treaty benefits .

W-8BEN-E

• A hybrid entity claiming treaty benefits on its own behalf

W-8ECI

• A foreign person claiming that income is effectively connected with the conduct of a trade or business in the United States .

• A disregarded entity with a single foreign owner that is the beneficial owner of the income to which this form relates. Instead,

W-8BEN, W-8ECI, or W-8BEN-E

the single foreign owner should use

• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private

W-8EXP

foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)

W-9

• U.S. entity or U.S. citizen or resident

W-8BEN, W-8BEN-E, or W-8ECI

• A foreign person documenting themselves for purposes of section 6050W .

Part I

Identification of Entity

Name of individual or organization that is acting as intermediary

Country of incorporation or organization

Name of disregarded entity (if applicable)

4 Chapter 3 Status:

Qualified intermediary. Complete Part III.

Withholding foreign trust. Complete Part VII.

Nonqualified intermediary. Complete Part IV.

Nonwithholding foreign partnership. Complete Part VIII.

Territory financial institution. Complete Part V.

Nonwithholding foreign simple trust. Complete Part VIII.

U.S. branch. Complete Part VI.

Nonwithholding foreign grantor trust. Complete Part VIII.

Withholding foreign partnership. Complete Part VII.

5 Chapter 4 Status:

Nonparticipating FFI (including a limited FFI or limited branch).

Owner-documented FFI. Complete Part XI.

Complete Part IX (if applicable).

Restricted distributor. Complete Part XVI.

Participating FFI.

Foreign central bank of issue. Complete Part XVII.

Reporting Model 1 FFI.

Nonreporting IGA FFI. Complete Part XVIII.

Reporting Model 2 FFI.

Exempt retirement plans. Complete Part XIX.

Registered deemed-compliant FFI (other than a reporting Model 1 FFI

Excepted nonfinancial group entity. Complete Part XX.

or sponsored FFI that has not obtained a GIIN).

Excepted nonfinancial start-up company. Complete Part XXI.

Territory financial institution. Complete Part V.

Excepted nonfinancial entity in liquidation or bankruptcy.

Complete Part XXII.

Sponsored FFI that has not obtained a GIIN (other than a certified

deemed-compliant sponsored, closely held investment vehicle).

Publicly traded NFFE or NFFE affiliate of a publicly traded

Complete Part X.

corporation. Complete Part XXIII.

Excepted territory NFFE. Complete Part XXIV.

Certified deemed-compliant nonregistering local bank. Complete Part

XII.

Active NFFE. Complete Part XXV.

Certified deemed-compliant FFI with only low-value accounts. Complete Part XIII.

Passive NFFE. Complete Part XXVI.

Direct reporting NFFE.

Certified deemed-compliant sponsored, closely held investment

vehicle. Complete Part XIV.

Sponsored direct reporting NFFE. Complete Part XXVII.

Certified deemed-compliant limited life debt investment entity.

Complete Part XV.

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

7 Mailing address (if different from above)

City or town, state or province. Include postal code where appropriate.

Country

8 U.S. taxpayer identification number, if required

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QI-EIN

WP-EIN

WT-EIN

EIN

SSN or ITIN