W-8BEN-E Rev. October 2021
Certificate of Foreign Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)


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

Instructions:
1. Complete Part 1 below.
2. Complete Part 2 if you are a disreguarded entity or branch receiving payment.
3. Complete all additional parts as displayed based upon your chapter 3 & chapter 4 status.
4. Complete Part XXX to electronically sign and date the form.
When complete, send the completed form by clicking on the "Submit W-8" button.


W-8BEN-E: For use by entities. Individuals must use Form W-8BEN.
Part I: Identification of Beneficial Owner
1. Name of organization:
2. Country of incorporation:
3. Name of disregarded entity:
4. Chapter 3 Status (entity type):

If you entered disregarded entity, partnership, simple trust or grantor trust above, is the entity a hybrid making a treaty claim? If yes, complete Part III  Yes       No

5. Chapter 4 Status (FATCA status)(See instructions for details and complete the certification below for the entity's applicable status).

Not Required.

Nonparticipating FFI (including an FFI related to a Reporting IGA FFI other than a deemed-compliant FFI, participating FFI, or exempt beneficial owner).

Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.

Registered deemed-compliant FFI (other than a reporting Model 1 FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII). See instructions.

Sponsored FFI. Complete Part IV.

Certified deemed-compliant nonregistering local bank. Complete Part V.

Certified deemed-compliant FFI with only low-value accounts. Complete Part VI.

Certified deemed-compliant sponsored, closely held investment vehicle. Complete Part VII.

Certified deemed-compliant limited life debt investment entity. Complete Part VIII.

Certain investment entities that do not maintain financial accounts. Complete Part IX.

Owner-documented FFI. Complete Part X.

Restricted distributor. Complete Part XI.

Nonreporting IGA FFI. Complete Part XII.

Foreign government, government of a U.S. possession, or foreign central bank of issue. Complete Part XIII.

International organization. Complete Part XIV.

Exempt retirement plans. Complete Part XV.

Entity wholly owned by exempt beneficial owners. Complete Part XVI.

Territory financial institution. Complete Part XVII.

Excepted nonfinancial group entity. Complete Part XVIII.

Excepted nonfinancial start-up company. Complete Part XIX.

Excepted nonfinancial entity in liquidation or bankruptcy. Complete Part XX.

501(c) organization. Complete Part XXI.

Nonprofit organization. Complete Part XXII.

Publicly traded NFFE or NFFE affiliate of a publicly traded corporation. Complete Part XXIII.

Excepted territory NFFE. Complete Part XXIV.

Active NFFE. Complete Part XXV.

Passive NFFE. Complete Part XXVI.

Excepted inter-affiliate FFI. Complete Part XXVII.

Direct reporting NFFE.

Sponsored direct reporting NFFE. Complete Part XXVIII.

Account that is not a financial account.

6. Permanent residence address Street, apt. or suite no., or rural route. Do not use a P.O. box or in-care-of address (other than a registered address).

City or town, state or province:
Country:
7. Mailing address:
City or town, state or province:
Country:

8. U.S. taxpayer ID (TIN), if required:

-
9a GIIN:
9b Foreign TIN:
9c. Check if FTIN not legally required
10. Reference number(s):
Note: Please complete the remainder of the form including signing the form in Part XXX.


Part II: Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a branch of an FFI in a country other than the FFI's country of residence. See instructions.)

11. Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment

  Branch treated as nonparticipating FFI.
  Participating FFI.
  Reporting Model 1 FFI.
  Reporting Model 2 FFI.
  U.S. Branch.
12. Address of disregarded entity or branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
City or town, state or province:
Country:
13 GIIN (if any):

Part III: Claim of Tax Treaty Benefits (if applicable). (for chapter 3 purposes only.)

14. I certify that (check all that apply):

a.  The beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country.

b.  The beneficial owner derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits. The following are types of limitation on benefits provisions that may be included in an applicable tax treaty (check only one; see instructions):

Government
Tax exempt pension trust or pension fund
Other tax exempt organization
Publicly traded corporation
Subsidiary of a publicly traded corporation
Other 

Company that meets the ownership and base erosion test

Company that meets the derivative benefits test

Company with an item of income that meets active trade or business test

Favorable discretionary determination by the U.S. competent authority received

No LOB article in treaty

c.  The beneficial owner is claiming treaty benefits for U.S. source dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation and meets qualified resident status (see instructions).

15. 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 14a above to claim a % rate of withholding on:

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


Part XXX: 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:

- The entity identified on line 1 of this form is the beneficial owner of all the income or proceeds to which this form relates, is using this form to certify its status for chapter 4 purposes, or is submitting this form for purposes of section 6050W or 6050Y;

- The entity identified on line 1 of this form is not a U.S. person;

- This form relates to: (a) income not effectively connected with the conduct of a trade or business in the United States, (b) income effectively connected with the conduct of a trade or business in the United States but is not subject to tax under an income tax treaty, (c) the partner's share of the partnership's effectively connected taxable income, or (d) the partner's amount realized from the transfer of a partnership interest subject to withholding under section 1446(f); 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 the entity on line 1 is the beneficial owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner.

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

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

Name:
Email Address:
Verify Email Address:
Title:
Phone:
I certify that I have the capacity to sign for the person identified on line 1 of this form.
Signature:
Date: June 25, 2022
Message:

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Validation Code:

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