Substitute Form W-8ben - Certificate Of Foreign Status Of Beneficial Owner For United States Tax Withholding And Reporting (Individuals)

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Substitute Form W-8BEN

Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)

DO NOT USE THIS FORM IF YOU ARE: (i) AN ENTITY; (ii) A U.S. CITIZEN OR OTHER U.S. PERSON; (iii) A BENEFICIAL OWNER CLAIMING THAT

INCOME IS EFFECTIVELY CONNECTION WITH THE CONDUCT OF A U.S. TRADE OR BUSINESS; (iv) A BENEFICIAL OWNER WHO IS RECEIVING

COMPENSATION FOR PERSONAL SERVICES PERFORMED IN THE U.S.; or (v) A PERSON ACTING AS AN INTERMEDIARY

Note: If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be provided to your jurisdiction of residence.

Identification of Beneficial Owner

1. Name of individual who is the beneficial owner

2 Country of citizenship

3. Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in care of address.

City or town state or province. Include postal code where appropriate.

Country (do not abbreviate)

4. Mailing address (if different from above)

City or town state or province. Include postal code where appropriate.

Country (do not abbreviate)

5. U.S. taxpayer identification number (SSN or ITIN) if required (see instructions for Form W-8BEN)

6. Foreign tax identifying number if any (see instructions for Form W-8BEN)

7. Reference number(s)

8. Date of birth (MM-DD-YYYY)

Claim of Tax Treaty Benefits (for chapter 3 purposes only) (if applicable)

9. I certify that:

The beneficial owner is a resident of

within the meaning of the income tax treaty between the United States and that country.

10. Special rates and conditions (if applicable _ see instructions): The beneficial owner is claiming the provisions of Article and paragraph

of the treaty identified on line 9 above

to claim a

% rate of withholding on (specify type of income):

Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:

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 acknowledge receipt of the Instructions for Form W-8BEN.

•

(i) I am the individual that is the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates or I am using

this form to document myself for chapter 4 purposes; (ii) the beneficial owner listed on Line 1 of this form is not a U.S. person; (iii) the income to which this

form relates is not effectively connected with the conduct of a trade or business in the United States, or is effectively connected but is not subject to tax under

an applicable income tax treaty, or is the partner’s share of a partnership’s (iv) the person named on line 1 of this form is a resident of the treaty country listed

on line 9 of this form (if any) within the meaning of the income tax treaty between the United States and that country; and (v) for broker transactions or barter

exchanges, the beneficial owner is an exempt foreign person as defined in the Instructions to Form W-8BEN.

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. I agree that I will submit a new formwithin 30 days if

any certification made on this form becomes incorrect.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status

as a non-U.S. person, and, if applicable, obtain a reduced rate of withholding.

Sign Here:

Date

►

Signature of the beneficial owner or

Capacity in which acting (if form is not

authorized person

signed by beneficial owner)

Print name of signer

AFFIDAVIT OF UNCHANGED STATUS:

Under penalties of perjury, I declare that I have examined and signed the above Substitute Form

W-8BEN and that the information and certifications contained therein are true and remained the same and unchanged during the last three calendar