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 3
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Form W-8IMY (Rev. 4-2014)
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 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)
▶
Chapter 3 Status Certifications
Part III
Qualified Intermediary
14a
(All qualified intermediaries check here) I certify that the entity identified in Part I (or branch, if relevant):
• Is a qualified intermediary and is not acting for its own account with respect to the account(s) identified on line 10 or in a withholding
statement associated with this form; and
• Has provided or will provide a withholding statement, as required, for purposes of chapters 3 and 4 that is subject to the certifications made
on this form.
Check all that apply:
I certify that the entity identified in Part I of this form is not providing a withholding statement associated with this form because it assumes
b
primary withholding responsibility for purposes of chapters 3 and 4, and either:
• Primary Form 1099 reporting and backup withholding responsibility; or
• Reporting responsibility as a participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains and that are
held by specified U.S. persons as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting.
c
I certify that the entity identified in Part I of this form assumes primary withholding responsibility under chapters 3 and 4 with respect to
payments made to each account identified on this line 14c (or on an attachment to this form)
▶
d
I certify that the entity identified in Part I of this form assumes primary Form 1099 reporting and backup withholding responsibility with
respect to payments made to each account identified on this line 14d or on an attachment to this form or reporting responsibility as a
participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains and that are held by specified U.S. persons
as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting
▶
e
I certify that the entity identified in Part I of this form does NOT assume primary Form 1099 reporting and backup withholding responsibility
and is using this form to transmit Forms W-9 with respect to each account(s) held by a U.S. non-exempt recipient identified on this line 14e
or in a withholding statement associated with this form
▶
If the entity identified on Part I of this form has allocated or will allocate a portion of a payment to a chapter 4 withholding rate pool of
U.S. payees on a withholding statement associated with this form (check all that apply):
(i)
I certify that the entity meets the requirements of Regulations section 1.6049-4(c)(4)(iii) with respect to any account holder of an
account it maintains that is included in a withholding rate pool of U.S. payees provided on a withholding statement associated
with this form.
(ii)
To the extent the entity is providing a withholding statement that includes a chapter 4 withholding rate pool of U.S. payees that
are accountholders of an intermediary or flow-through entity receiving a payment from the entity identified on line 1, I certify
that the entity on line 1 has obtained or will obtain documentation sufficient to establish each such intermediary or flow-
through entity's status as a participating FFI, registered deemed-compliant FFI, or FFI that is a qualified intermediary.
f
I certify that the entity identified in Part I of this form is acting as Qualified Securities Lender with respect to payments associated with this
form that are U.S. source substitute dividends received from the withholding agent.
Part IV
Nonqualified Intermediary
Check all that apply:
15a
(All nonqualified intermediaries and qualified intermediaries that are not acting in their capacity as such check here) I certify that the entity
identified in Part I of this form is not acting as a qualified intermediary with respect to each account(s) for which this form is provided and is
not acting for its own account.
I certify that the entity identified in Part I of this form is using this form to transmit withholding certificates and/or other documentation and
b
has provided, or will provide, a withholding statement, as required.
c
I certify that the entity identified in Part I of this form meets the requirements of Regulations section 1.6049-4(c)(4)(iii) with respect to any
account holder of an account it maintains that is included in a withholding rate pool of U.S. payees provided on a withholding statement
associated with this form.
d
I certify that the entity identified in Part I of this form is acting as a Qualified Securities Lender with respect to payments associated with
this form that are U.S. source substitute dividends received from the withholding agent.
W-8IMY
Form
(Rev. 4-2014)
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