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 9

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Form W-8IMY (Rev. 4-2014)
Page
Part XXVI
Passive NFFE
37
I certify that the entity identified in Part I:
• Is a foreign entity that is not a financial institution (this category includes an entity organized in a possession of the United States that
engages (or holds itself out as being engaged) primarily in the business of investing, reinvesting, or trading in securities, partnership
interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest in such security, partnership interest,
commodity, notional principal contract, insurance contract or annuity contract); and
• Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding
statement, as required.
Sponsored Direct Reporting NFFE
Part XXVII
Name of sponsoring entity:
38
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 38.
39
Part XXVIII
Certification
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.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any
withholding agent that can disburse or make payments of the amounts for which I am providing this form.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.
Sign Here
Signature of authorized official
Date (MM-DD-YYYY)
W-8IMY
Form
(Rev. 4-2014)

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