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 4
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Form W-8IMY (Rev. 4-2014)
Page
Territory Financial Institution
Part V
16 a
I certify that the entity identified in Part I is a financial institution (other than an investment entity that is not also a depository institution,
custodial institution, or specified insurance company) that is incorporated or organized under the laws of a possession of the United States.
Check whichever box applies:
b
I further certify that the entity identified in Part I is using this form as evidence of its agreement with the withholding agent to be treated as
a U.S. person for purposes of chapters 3 and 4 with respect to any payments associated with this withholding certificate.
c
I further certify that the entity identified in Part I:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom it receives a payment; and
• Has provided or will provide a withholding statement, as required.
Part VI
Certain U.S. Branches
17 a
I certify that the entity identified in Part I is receiving payments that are not effectively connected with the conduct of a trade or business in
the United States.
Check whichever box applies:
b
I certify that the entity identified in Part I is a U.S. branch of a foreign bank or insurance company described in Regulations
section 1.1441-1(b)(2)(iv)(A) that is a participating FFI (including a reporting Model 2 FFI), registered deemed-compliant FFI (including a
reporting Model 1 FFI), or NFFE that is using this form as evidence of its agreement with the withholding agent to be treated as a U.S.
person with respect to any payments associated with this withholding certificate.
c
I certify that the entity identified in Part I:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom the branch receives a
payment; and
• Has provided or will provide a withholding statement, as required.
Part VII
Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT)
I certify that the entity identified in Part I is a withholding foreign partnership or a withholding foreign trust that is compliant with the terms
18
of its WP or WT agreement.
Part VIII
Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
19
I certify that the entity identified in Part I:
• Is a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and that the
payments to which this certificate relates are not effectively connected, or are not treated as effectively connected, with the conduct of a
trade or business in the United States; and
• Is using this form to transmit withholding certificates and/or other documentation 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.
Chapter 4 Status Certifications
Part IX
Nonparticipating FFI with Exempt Beneficial Owners
20
I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentation and has provided
or will provide a withholding statement that indicates the portion of the payment allocated to one or more exempt beneficial owners.
Part X
Sponsored FFI That Has Not Obtained a GIIN
21
a
Name of sponsoring entity:
▶
Check whichever box applies.
b
I certify that the entity identified in Part I:
• Is an FFI solely because it is an investment entity;
• Is not a QI, WP, or WT; and
• Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
c
I certify that the entity identified in Part I:
• Is a controlled foreign corporation as defined in section 957(a);
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
entity; and
• Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all
account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not
limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or
payees.
W-8IMY
Form
(Rev. 4-2014)
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