W-8IMY Rev. June 2017
Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain
U.S. Branches for United States Tax Withholding and Reporting


Click on any of the following for help with this form:
IRS W-8 instructions, IRS W-8IMY 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 XXIX to electronically sign and date the form and add attachments.
When complete, send the completed form by clicking on the "Submit W-8" button.


Part I: Identification of Entity
1. Name of organization:
2. Country of incorporation:
3. Name of disregarded entity:
4. Chapter 3 Status (entity type):

5. Chapter 4 Status (FATCA status)(See instructions for details and complete the certification below for the entity's applicable status.)(Must check one box only.):.

Nonparticipating foreign financial institution (FFI) (including an FFI related to a Reporting IGA FFI other than a deemed-compliant FFI, participating FFI, or exempt beneficial owner). Complete Part IX (if applicable).

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 XIX).

Territory financial institution. Complete Part V.

Sponsored FFI (other than a certified deemed-compliant sponsored, closely held investment vehicle). Complete Part X.

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

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

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

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

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

Owner-documented FFI. Complete Part XI.

Restricted distributor. Complete Part XVII.

Foreign central bank of issue. Complete Part XVIII.

Nonreporting IGA FFI. Complete Part XIX.

Exempt retirement plans. Complete Part XX.

Excepted nonfinancial group entity. Complete Part XXI.

Excepted nonfinancial start-up company. Complete Part XXII.

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

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

Excepted territory NFFE. Complete Part XXV.

Active NFFE. Complete Part XXVI.

Passive NFFE. Complete Part XXVII.

Direct reporting NFFE.

Sponsored direct reporting NFFE. Complete Part XXVIII.

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): (if required)
QI-EIN   WP-EIN   WT-EIN   EIN
9. GIIN:
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. Do not complete Part II for QDD branches. 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 branch:
City or town, state or province:
Country:
13 GIIN (if any):

Chapter 3 Status Certifications


Chapter 4 Status Certifications


Part XXIX: Attachments/Certification/Signature: (all fields required)

Please select and attach any required documentation per instructions.
Not including these documents may cause a delay in your setup.

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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. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any withholding agent that can disburse or make payments of the amounts for which I am providing this form.

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

Signature and name of authorized official below 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: December 8, 2021
Message:

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