W-8BEN-E Rev. July 2017
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):
Is the entity a hybrid making a treaty claim?  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:
City or town, state or province:
Country:
7. Mailing address:
City or town, state or province:
Country:
8. U.S. taxpayer ID (TIN): -
9a GIIN:
9b Foreign TIN:
10. Reference number(s):


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:
City or town, state or province:
Country:
13 GIIN (if any):


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 to which this form relates, is using this form to certify its status for chapter 4 purposes, or is a merchant submitting this form for purposes of section 6050W,

• The entity identified 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 income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, 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:
Signature:
Date: May 12, 2021
Message:

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