Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United
States Tax Withholding and Reporting (Individuals)
(Rev. January 2017) ▶ For use by individuals. Entities must use Form W-8BEN-E. OMB No. 1545-1621
Department of the Treasury
▶ Information about Form W-8BEN and its separate instructions is at www.irs.gov/formw8ben.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.
Internal Revenue Service
Do NOT use this form if: Instead, use Form:
• You are NOT an individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN-E
• You are a U.S. citizen or other U.S. person, including a resident 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-8ECI
• You are a beneficial owner who is receiving compensation for personal services performed in the United States . . . . . . . 8233 or W-4
• You are a person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8IMY
Note: If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be
provided to your jurisdiction of residence.
Part I Identification of Beneficial Owner (see instructions)
1 Name of individual who is the beneficial owner 2 Country of citizenship
Greifer Omar Andrade Chourio Venezuela
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
Jardines el valle calle 15 casa #156, Distrito Capital Venezuela
City or town, state or province. Include postal code where appropriate. Country
caracas venezuela
4 Mailing address (if different from above)
4815 Westgrove Dr Addison TX 75001, Bent tree oaks building 17 Apto 1706
City or town, state or province. Include postal code where appropriate. Country
westgrove eeuu
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions)
447719602
7 Reference number(s) (see instructions) 8 Date of birth (MM-DD-YYYY) (see instructions)
+58 412-9124410 06/27/1997
Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 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.
10 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:
Part III Certification
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:
• I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or
am using this form to document myself for chapter 4 purposes,
• The person named on line 1 of this form is not a U.S. person,
• The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or
(c) the partner’s share of a partnership's effectively connected income,
• The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between
the United States and that country, 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. I agree that I will submit a new form within 30 days
if any certification made on this form becomes incorrect.
▲
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY)
Greifer Omar Andrade Chourio
Print name of signer Capacity in which acting (if form is not signed by beneficial owner)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 1-2017)
