Substitute Form W-8ben - Certificate Of Foreign Status Of Beneficial Owner For United States Tax Withholding And Reporting (Individuals) Page 2
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4Instructions for Completing the Form W-8BEN:
Certificate of Foreign Status of Beneficial Owner for
United States Tax Withholding and Reporting
You have been asked to complete this Substitute Form W-8BEN because you may
receive dividend payments from IDB-IIC FCU and you are not a U.S. citizen,
permanent resident, or other U.S. tax resident. IDB-IIC FCU must establish your
residency for tax purposes to determine the proper tax withholding (if any) and
may share your information with the U.S. Internal Revenue Service. The
Instructions below will assist you in completing this form. Any questions regarding
your income tax responsibilities should be directed to your own tax advisor.
Part I. Identification of Beneficial Owner
1. Name of Beneficial Owner – Enter the full name of the beneficial owner of the account(s) – Last, First, Middle. The
beneficial owner is generally the person who is required under U.S. tax principles to include the payment in gross
income on a tax return. An agent or nominee is not a beneficial owner.
2. Country of Citizenship – Enter your country of citizenship. If you are a dual citizen, enter the country where you are
both a citizen and a resident at the time you complete this form. If you are not a resident in any country in which you
have citizenship, enter the country where you were most recently a resident. If you are a U.S. citizen, you should not
complete this form even if you hold citizenship in another jurisdiction. Instead, provide Form W-9.
3. Permanent Residence Address – Enter your permanent address in the country where you claim to be a resident for
purposes of that country’s income tax. If the owner is an individual who does not have a tax residence in any
country (as is the case for most G-4 visa holders who live and work in the United States), the permanent
residence is where the owner “normally resides.” This can be a U.S. address. Do not use an address of a
financial institution, an employer, a P.O. Box, an address used solely for mailing purposes, or an “in care of”
address. If this is a U.S. address, please complete the Explanation of Foreign (non-U.S.) Status checklist and
provide a copy of your foreign passport.
4. Mailing Address – Enter your mailing address only if it is different from the address you show on line 3. If this is a
U.S. address, please complete the Explanation of Foreign (non-U.S.) Status checklist and provide a copy of
your foreign passport.
5. U.S. Taxpayer Identification Number – If you have a U.S. social security number (SSN), enter it here. If you do
not have an SSN and are not eligible to get one, you can get an individual taxpayer identification number (ITIN).
6. Foreign Tax Identifying Number – Please provide the tax identifying number (TIN) issued to you by your
jurisdiction of tax residence unless you have not been issued a TIN or the jurisdiction does not issue TINs. If you
have not provided your jurisdiction of residence TIN on line 6, provide your date of birth in line 8.
7. Member Number – Enter your IDB-IIC FCU Member Number.
8. Date of Birth – Use the following format to input your information: MM-DD-YYYY. For example, if you were born
on April 15, 1956, you would enter 04-15-1956.
Part II. Certification
Complete, sign and date the form, and return it to IDB-IIC FCU. If you are signing Form W-8BEN under a power of
attorney, attach a copy of the power of attorney. If any information on Form W-8BEN becomes incorrect, you must
submit a new form within 30 days. Failure to do so may result in incorrect Federal tax withholding and reporting.
This form will remain in effect through December 31 of the third succeeding year after the form is signed.
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