W'8BEN Certificate of Foreign Status of Beneficial Owner for United
'-," States Tax Withholding and Reporting (lndividuals)
(Rev. July 201 7) Þ For use by individuals. Ent¡ti€s must use Form W-8BEN-E. OMB No. 1545-1621
Þ Go to www,irs.govlFo¡mWSBEN lor instructions and the latest information.
Department of the Trsasury
lntemal Revenue Service Þ Give this form to the withholding agent or payer. Do not send to the lRS.
Do NOT use this form if: lnstead, use Form:
. You are NOT an individual W-8BEN-E
. You are a U.S. citizen or other U.S. person, including a r€sident alien individual w-9
. You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) W-8EC|
. You are a beneficial ownerwho is receiving compensation for personal services performed in the United States 8233 or W-4
. You are a person acting as an intermediary . W-8|MY
Note: lf you are resident in a FATCA partner jurisdiction (i.e., a Model 'l IGA jurisdiction with reciprocity), certain tax account information may be
provided to your jurisdiction of residence.
ldentification of Owner
Name of individual who is the owner 2 Country of citizenship
no., or route), not use a P.O. box or in-care-of address.
ortown, state or province.
or town, state postal code appropriate.
taxpayer number (SSN or lTlN), if required instrucl number
Reference numbe(s) (see instructions) I Date of birth (MM-DD-YYYT (see instructions)
Claim of Tax Treatv Benefits instruction
I certify that the beneficial owner is a resident of within the meaning of the income tax
treaty between the United States and that country.
l0 Special rates and conditions (if applicable-see instructions): The beneficial owner is claiming the provisions of Article and paragraph
of the treaty identified on line 9 above to claim a % rate of withholding on (specify type of income):
Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:
Under penalties of perjury, I declare that I have examined the lnformation 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:
I am the individualthat is the ben€ficial owner (or am authoriz€d to sign for the indiv¡dual that is the beneficlalowner) of all the incom€ to which this lorm relates or
am using thls lorm to document myself for chapter 4 purposes,
The person named on line 1 of this form ¡s not a U.S. person,
The income to which this form relates is:
(a) not effectively connect€d with thê conduct of a trade or business ln the Unlted States,
(b) effectively connected but ls not sublect to tax under an applicable income tax treaty, or
(c) lhe partner's share of a parlnêrship's effectively connected income,
The person named on line 1 of this form is a resident of the treaty country listed on line I of the form (if any) within the mêan¡ng ôf the income tax treaty between
the Unlt€d States and that country, and
For broker transactlons or barter exchanges, the beneficial owner is an exempt forelgn person as defined in the instructions,
Furlhermore, I authorize thls form to be prov¡ded to any withholdlng agent that has control, receipt, or custody of the lncome of which I am the bêneficial owner or
any w¡thholding agent that can disburse or make payments of the income of which I am the beneflcial owner. I agrêe that I w¡ll subm¡t a new fqrm w¡thin 30 days
lf any certlfloation made on lhis form becomes ¡ncorrect.
sisn Here
) Date (MM-DD-YYYY)
Signature of b€n€fic¡al own€r (or indiv¡dual aulhorized to sign for bensficial owner)
Print name of s¡gner Capaclty in which acting (if form ls not signed by benelicial owne{
For Papenvork Reduction Act Notice, see separate instructions. Cat. No.250472 rorm W-8BEN (Rev. 7-2017¡
