reporting Model 2 FFI), registered deemed-compliant FFI, or
$20 to NPFFI, a nonparticipating FFI that is an account
reporting Model 1 FFI, an account holder not withheld on
holder of the QI;
under chapter 4 or section 3406 who you report under
$10 each on behalf of two recalcitrant account holders of
chapter 4 or an applicable IGA (including the account
the QI ($20 total), each with U.S. indicia (as described in
holder’s TIN).
Regulations section 1.1441-7(b)(5)) associated with the
account;
An FFI withholding statement must also identify each
$5 each on behalf of A and B, U.S. individual account
intermediary or flow-through entity that is receiving a
holders of the QI that the QI reports as U.S. accounts
payment on behalf of a payee and include such entity’s
pursuant to its chapter 4 reporting obligations as a
chapter 4 status and GIIN (if applicable), excluding any
participating FFI ($10 total);
intermediary or flow-through entity that is an account holder
$10 on behalf of C, a U.S. exempt recipient that is not a
or interest holder in another QI, WP, or WT. An FFI
specified U.S. person and is an indirect account holder of the
withholding statement of a QI may combine withholding rate
QI (who beneficially owns the payment through an account
pool information provided by such an entity to the QI with
with another participating FFI);
withholding rate pools comprised of accounts that the QI
$20 on behalf of D, a U.S. non-exempt recipient that is a
maintains.
specified U.S. person who is an indirect account holder of the
If you are a QI that is not an FFI and that does not assume
QI (that beneficially owns the payment through an account
primary withholding responsibility under chapter 3 and
with a certified deemed-compliant FFI described in
chapter 4, you must provide, for a withholdable payment, a
Regulations section 1.1471-5(f)(2)); and
chapter 4 withholding statement that contains the name,
$10 each on behalf of two nonresident alien individuals
address, TIN (if any), entity type (if applicable), and chapter 4
who are account holders of the QI, one of whom is entitled to
status of each payee, the amount allocated to each payee, a
a 15% rate of withholding under an applicable income tax
valid withholding certificate or other documentation sufficient
treaty.
to establish the payee’s chapter 4 status. However, a
The dividend payment is both a withholdable payment
chapter 4 withholding statement may include pooled
under chapter 4 and a reportable amount under chapter 3.
information for payees that are nonparticipating FFIs that
The QI assumes primary withholding and reporting
hold accounts that you maintain or hold accounts with an
responsibility under chapter 3 and chapter 4 as well as
intermediary or flow-through entity receiving the payment
primary Form 1099 reporting and backup withholding
from you. You may also provide another pool of payees as
responsibility. As a result, the QI is not required to provide a
permitted under the chapter 4 regulations for a chapter 4
withholding statement allocating the payment to specific
withholding statement. See Regulations section 1.1471-3(c)
payees or withholding rate pools. The QI will provide Form
(3)(iii)(B).
W-8IMY and check boxes 14, 15a, and 15b.
For chapter 3 purposes. In the case of a reportable
amount that is a withholdable payment, any portion of the
Example 2. The facts are the same as Example 1,
payment for which you are acting as a QI that is not allocated
except QI is a non-U.S. payor under Regulations section
to a chapter 4 withholding rate pool or a U.S. non-exempt
1.6049-5(c)(5) and does not assume primary Form 1099 and
recipient (including for backup withholding purposes) must
backup withholding responsibility but reports the accounts of
be allocated to a chapter 3 withholding rate pool or pool of
A and B as U.S. accounts under Regulations section
U.S. exempt recipients, if it is not required to be separately
1.1471-4(d).
reported. The chapter 3 withholding rate pool may be
The QI must provide a withholding statement allocating
established by any reasonable method agreed upon by you
$20 of the payment to D, $10 to C, and $10 to a chapter 4
and the withholding agent. For example, you may agree to
withholding rate pool of U.S. payees. The QI need not
establish a separate account for a single chapter 3
allocate any portion of the payment specifically to A or B
withholding rate pool or you may agree to divide a payment
because the QI is a non-U.S. payor that is permitted to
made to a single account into portions allocable to each
include A and B in a chapter 4 withholding rate pool of U.S.
chapter 3 withholding rate pool. You must provide the
payees under Regulations section 1.6049-4(c)(4)(i). For
chapter 3 withholding rate pool information that is required for
payments made on or after April 1, 2017, see the instructions
the withholding agent to meet its withholding and reporting
to Part IV of this form for when a withholding statement
obligations. A withholding agent may request any information
includes an allocation of a payment of an amount subject to
reasonably necessary to withhold and report payments
chapter 3 withholding that is made to a pool of U.S. payees.
correctly.
The QI must also provide a Form W-9 (or alternatively, name
Form 1099 reporting. If you do not assume primary Form
and TIN) for D. A Form W-9 is not required for C. The QI will
1099 reporting and backup withholding responsibility, you
provide Form W-8IMY and check boxes 14, 15a, and 15d.
must provide payee specific information for each U.S.
Example 3. The facts are the same as Example 1, except
non-exempt recipient account holder (other than those U.S.
the QI is a U.S. payor and does not assume primary Form
payees included in a chapter 4 withholding rate pool of U.S.
1099 and backup withholding responsibility.
payees (described in Regulations section 1.6049-4(c)(4)(iii))
Because the QI is a U.S. payor, it is not permitted, under
or when the alternative procedure is used. The pools are
Regulations section 1.6049-4(c)(4)(i) and (iii), to include A
based on valid documentation that you obtain or, if a
and B in a chapter 4 withholding rate pool of U.S. payees.
payment cannot be reliably associated with valid
The QI must provide a withholding statement allocating $5 of
documentation, the applicable presumption rules.
the payment to A, $5 of the payment to B, $10 of the payment
Example 1. A QI that is a participating FFI receives a
to C, and $20 of the payment to D along with Forms W-9 (or
$100 payment of U.S. source dividends on an account for
name and TIN) for A, B, and D. The QI will provide Form
which it acts as a QI held with the withholding agent for the
W-8IMY and check boxes 14 and 15a.
following recipients:
-11-
Instructions for Form W-8IMY (Rev. 6-2017)