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INSTRUCTIONS for the completion of this form appear in the Important Tax Information brochure.

W-8BEN

Certificate of Foreign Status of Beneficial Owner

For United States Tax Withholding

(Substitute Form)

Part I

Identification of Beneficial Owner (See Instructions)

1 Name of individual or organization that is the beneficial owner

2 Country of incorporation or organization

 Individual

 Corporation

 Disregarded entity

 Partnership

3 Type of beneficial owner

 Simple Trust

 Grantor Trust

 Complex Trust

 Estate

 Government

 International organization

 Central bank of issue

 Tax-exempt organization

 Private foundation

4 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)

5 Mailing address (if different from above)

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

Country (do not abbreviate)

6 U.S. taxpayer identification number, if required (See instructions)

7 Foreign tax identifying number, if any (optional)

 SSN or ITIN

 EIN

8 Reference number(s) (see instructions)

Part II

Claim of Tax Treaty Benefits (if applicable)

I certify that (check all that apply):

The beneficial owner is a resident of _________________________within the meaning of the income tax treaty between the United States and that country.

If required, the U.S. taxpayer identification number is stated on line 6 (see instructions).

The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty

provision dealing with limitation on benefits (see instructions).

The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign

corporation, and meets qualified resident status (see instructions).

The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to

withholding received during a calendar year exceeds, in the aggregate, $500,000.

Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article __________ of the treaty identified on line 9a above to claim

a _________________% rate of withholding on (specify type of income): ________________________________________________

Explain the reasons the beneficial owner meets the terms of the treaty article: ______________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Part III

Notional Principal Contracts

I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or

business in the United States. I agree to update this statement as required.

Part IV

Certification

Under penalties of perjury, I declare that I have examined the information on this form 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 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 income tax treaty, and

•

For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

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.

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 ______________________________________________

___________________

_________________________

Signature of beneficial owner (or individual authorized to sign for beneficial owner)

Date (MM-DD-YYYY)

Capacity in which acting

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

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