Form W-8ben - Certificate Of Foreign Status Of Beneficial Owner For United States Tax Withholding - 2000

Certificate of Foreign Status of Beneficial Owner

W-8BEN

Form

(Rev. December 2000)

for United States Tax Withholding

OMB No. 1545-1621

Section references are to the Internal Revenue Code.

See separate instructions.

Department of the Treasury

Give this form to the withholding agent or payer. Do not send to the IRS.

Internal Revenue Service

Do not use this form for:

Instead, use Form:

l

A U.S. citizen or other U.S. person, including a resident alien individual ....................................................................................................

W-9

l

A person claiming an exemption from U.S. withholding on income effectively connected with the conduct

W-8ECI

of a trade or business in the United States ...................................................................................................................................................

W-8ECI or W-8IMY

A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) ..........................................

l

A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization,

l

foreign private foundation, or government of a U.S. possession that received effectively connected income or that is

claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions).............................................................

W-8ECI or W-8EXP

Note:

These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a

foreign person exempt from backup withholding.

l

A person acting as an intermediary ......................................................................................................................................................

W-8IMY

Note:

See instructions for additional exceptions.

Identification of Beneficial Owner For Instructions:

Part I

1 Name of individual or organization that is the beneficial owner

2 Country of incorporation or organization

3 Type of beneficial owner

Individual

Corporation

Disregarded entity

Partnership

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.

Country (do not abbreviate)

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

5 Mailing address (if different from above)

Country (do not abbreviate)

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

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)

Claim of Tax Treaty Benefits (if applicable)

Part II

9 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.

a

b

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

c

treaty provision dealing with limitation on benefits (see instrustions).

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

d

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 sub ject to

e

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

(if applicable - see instructions): The beneficial owner is claiming the provisions of Article ________________________________ of

10 Special rates and conditions

the treaty identified on line 9a above to claim a __________________ % rate of withholding on (special 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

11

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 and to the best of my kno wledge and belief it is true, correct, and complete. I further certify

under penalties of perjury that:

l I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates,

l The beneficial owner is not a U.S. person,

l 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

l 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.

Sign

Here

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

Date (MM-DD-YYYY)

Capacity in which acting

For Paperwork Reduction Act Notice, see separate instructions.

W-8BEN

Form

(12-2000)

X97525 R9-20-2001 0006A