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Form W-8EXP (Rev. 4-2014)

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 Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession

(each as defined in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA) to provide retirement, disability, or death benefits to

beneficiaries or participants that are current or former employees of the sponsor (or persons designated by such employees); or

為由外國政府、國際組織、中央發行銀行或美國屬地政府(各自定義於規章第§1.1471-6 節或適用的模式一或模式二跨政府協議)建立或贊助，以提供退

休、殘疾或死亡撫恤金給受益人或參加者，該參加者為贊助者(或被雇員指定的人)的現任或前任雇員;或

 Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession

(each as defined in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA) to provide retirement, disability, or death benefits to

beneficiaries or participants that are not current or former employees of such sponsor, but are in consideration of personal services performed for

the sponsor.

為由外國政府、國際組織、中央發行銀行或美國屬地政府(各自定義於規章第§1.1471-6 節或適用的模式一或模式二跨政府協議)建立或贊助，以提供退

休、殘疾或死亡撫恤金給受益人或參加者，該參加者非為贊助者(或被雇員指定的人)的現任或前任雇員，但因提供贊助者私人服務而列入考慮。

19 For a 501(c) organization: 符合第 501(c)節規範的組織：

□ I certify that the entity identified in Part I is an entity described in section 501(c) but is not an insurance company described in section 501(c)(15).

本人保證第一部份列示之法人為符合第 501(c)節規範的組織，但非於第 501(c)(15)節所述之保險公司。

20 For a passive NFFE: 消極的非金融外國法人：

a □ I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a

possession of the United States). 本人保證第一部份列示之法人為一非金融機構的外國法人(排除於美國屬地所成立之投資法人)。

Check box 20b or 20c, whichever applies. 依適用條件勾選 20b 或 20c。

b □ I further certify that the entity identified in Part I has no substantial U.S. owners, or 本人進一步保證第一部份列示之法人無實質美國持有人，或

c □ I further certify that the entity identified in Part I has provided a statement including the name, address, and TIN of each substantial U.S. owner of

the NFFE (see instructions). 本人進一步保證第一部份列示之法人已提供聲明，該聲明包括姓名、地址及消極的非金融外國法人的每一實質美國持有

人之美國稅及編號(詳見說明)。

21 Name of sponsoring entity: _________________________. 贊助法人名稱: _________________________。

□ I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 21.

本人保證第一部份列示之法人為一受於第 21 項辨識出的法人贊助之直接申報的非外國金融機構。

Part IV

Certification

第四部分

證明

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:

在知悉偽證罪之懲罰下，本人聲明：本人已盡力檢查本表格之資訊，並相信上開資訊係真實、正確且完整。本人進一步依偽證懲罰擔保：



The organization for which I am signing is the beneficial owner of the income and other payments to which this form relates,

由本人代表簽署的組織為與本表相關之收入或其他支付款項的最終受益人，



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

最終受益人並非美國人士，



For a beneficial owner that is a controlled entity of a foreign sovereign (other than a central bank of issue wholly owned by a foreign sovereign),

the beneficial owner is not engaged in commercial activities within or outside the United States, and

倘最終受益人為受外國主權政府控制之法人(由外國主權政府完全持有的中央銀行除外)，該最終受益人未於美國境內或境外從事商業活動，且



For a beneficial owner that is a central bank of issue wholly owned by a foreign sovereign, the beneficial owner is not engaged in commercial

activities within the United States.

倘最終受益人為由外國主權政府完全持有的中央銀行，該最終受益人未於美國境內從事商業活動。

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the payments of which I am the

beneficial owner or any withholding agent that can disburse or make payments of the amounts of which I am the beneficial owner.

此外，本人授權將此表格提供給對最終受益人為本人之款項，可控制、接收或保管的扣繳義務人，或可發放或支付最終受益人為本人之款項的扣繳義

務人。

I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.

本表格所提供的資料倘有變更，本人同意將於 30 天內主動提交新表格。

Date 日期►

Sign Here

受益人原留印鑑

第一金證券投資信託股份有限公司

10477 台北市中山區民權東路三段 6 號 7 樓

客戶服務專線：0800-005-908

FATCA_09_10306

Form W-8exp (Chinese) - Certificate Of Foreign Government Or Other Foreign Organization For United States Tax Withholding And Reporting - 2014 Page 3

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