Substitute Form W-8ben - Certificate Of Foreign Status Of Beneficial Owner For United States Tax Withholding And Reporting (Individuals) Page 3

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Explanation of Foreign (non-U.S.) Status
___________________________________________________________________
Member Number
___________________________________________________________________
Member Name
I have submitted a completed and signed Form W-8BEN to the IDB-IIC Federal Credit
Union, and I provide the following explanation for the furnishing of a United States address
(or other U.S. contact information):
I am a full-time employee of an international organization holding a G4 visa
I am a diplomat holding a(n) _____ visa
I am a staff member of a mission, embassy, or consulate holding a(n) _____ visa
I am a foreign student, teacher, trainee, or intern at a U.S. educational institution
holding a(n) _____ visa
I am a spouse or unmarried child under the age of 21 of one of the persons described
above
I have enclosed information demonstrating that I have not met the substantial presence
test of U.S. income tax residency
I meet the closer connection exception (see IRS Form 8840 and Instructions); I have a
closer connection to ___________________ (country). Provide explanation: ____________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Other (please provide explanation):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Member Signature
Date (mm/dd/yyyy)

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