W-8BEN (Rev July 2017)
Certificate of Foreign Status of Beneficial Owner for
United States Tax Withholding and Reporting (Individuals)


Click on any of the following for help with this form:
IRS W-8 instructions, IRS W-8BEN instructions

Instructions:
1. Complete Part 1 below.
2. Complete Part 2, where applicable.
3. Complete Part 3 to electronically sign and date the form.
When complete, send the completed form by clicking on the "Submit W-8" button.


W-8BEN:
For use by individuals. Entities must use Form W-8BEN-E.
Part I: Identification of Beneficial Owner
1. Name of individual:
2. Country of citizenship:
3. Permanent residence address:
City or town, state or province:
Country:
4. Mailing address:
City or town, state or province:
Country:
5. U.S. taxpayer ID (SSN/ITIN):
6. Foreign TIN:
7. Reference number(s):
8. Date of Birth (MM/DD/YYYY): / /

Part II: Claim of Tax Treaty Benefits (for chapter 3 purposes only)

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:

Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:


Part III: Certification/Signature: (all fields required)

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.

Signature and name below of beneficial owner or individual authorized to sign for beneficial owner certifies that I have the capacity to sign for the individual identified on line 1 of this form.

Name:
Email Address:
Verify Email Address:
Title/Capacity:
Phone:
Signature:
Date: May 12, 2021
Message:

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