Form 8233 - Exemption From Withholding On Compensation For Independent (And Certain Dependent) Personal Services Of A Nonresident Alien Individual Page 2
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1
22
Form 8233 (Rev. 3-2009)
Page
Part II
Claim for Tax Treaty Withholding Exemption and/or Personal Exemption Amount
11
Compensation for independent (and certain dependent) personal services:
a
Description of personal services you are providing
b
Total compensation you expect to be paid for these services in this calendar or tax year $
12
If compensation is exempt from withholding based on a tax treaty benefit, provide:
a Tax treaty and treaty article on which you are basing exemption from withholding
b Total compensation listed on line 11b above that is exempt from tax under this treaty $
c
Country of permanent residence
Note: Do not complete lines 13a through 13c unless you also received compensation for personal services from the same
withholding agent.
13
Noncompensatory scholarship or fellowship income:
a
Amount $
b Tax treaty and treaty article on which you are basing exemption from withholding
c Total income listed on line 13a above that is exempt from tax under this treaty $
14
Sufficient facts to justify the exemption from withholding claimed on line 12 and/or line 13 (see instructions)
Note: Lines 15 through 18 are to be completed only for certain independent personal services (see instructions).
16
15
Number of personal exemptions
How many days will you perform services in
claimed
the United States during this tax year?
17
Daily personal exemption amount claimed (see instructions)
18
Total personal exemption amount claimed. Multiply line 16 by line 17
Part III
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. I further certify under penalties of perjury that:
I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates.
The beneficial owner is not a U.S. person.
The beneficial owner is a resident of the treaty country listed on line 12a and/or 13b above within the meaning of the income tax treaty
between the United States and that country.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the
beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Date
Withholding Agent Acceptance and Certification
Part IV
Employer identification number
Name
Address (number and street) (Include apt. or suite no. or P.O. box, if applicable.)
City, state, and ZIP code
Telephone number
Under penalties of perjury, I certify that I have examined this form and any accompanying statements, that I am satisfied that an exemption from
withholding is warranted, and that I do not know or have reason to know that the nonresident alien individual is not entitled to the exemption or
that the nonresident alien’s eligibility for the exemption cannot be readily determined.
Date
Signature of withholding agent
8233
Form
(Rev. 3-2009)
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