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Form W-8IMY (Rev. 2-2006)
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Part IV
Certain United States Branches
Note: You may use this Part if the entity identified in Part I is a U.S. branch of a foreign bank or insurance company
and is subject to certain regulatory requirements (see instructions).
I certify that the entity identified in Part I is a U.S. branch and that the payments are not effectively
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connected with the conduct of a trade or business in the United States.
Check box 12 or box 13, whichever applies:
I certify that the entity identified in Part I is using this form as evidence of its agreement with the
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withholding agent to be treated as a U.S. person with respect to any payments associated with this
certificate.
I certify that the entity identified in Part I:
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● Is using this form to transmit withholding certificates or other documentary evidence for the persons for
whom the branch receives a payment and
● Has provided or will provide a withholding statement, as required.
Part V
Withholding Foreign Partnership or Withholding Foreign Trust
I certify that the entity identified in Part I:
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● Is a withholding foreign partnership or a withhholding foreign trust and
● Has provided or will provide a withholding statement, as required.
Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
Part VI
I certify that the entity identified in Part I:
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● 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 documentary evidence and has
provided or will provide a withholding statement, as required.
Part VII
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 income for which I am providing this form.
Sign Here
Signature of authorized official
Date (MM-DD-YYYY)
W-8IMY
Form
(Rev. 2-2006)