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Form Name:   W8BEN
Tags:   tax USA stocks
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Date:   12/6/2010
Size:   43KB
Type:   .PDF
     
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FormW-8BEN(Rev. December 2000)Department of the TreasuryInternal Revenue ServiceCertificate of Foreign Status of Beneficial Ownerfor United States Tax WithholdingSee separate instructions.Give this form to the withholding agent or payer. Do not send to the IRS.OMB No. 1545-1621Do not use this form for:Instead, use Form:A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions)W-8ECI or W-8IMYA foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization,foreign private foundation, or government of a U.S. possession that received effectively connected income or that isclaiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)W-8ECI or W-8EXPA person acting as an intermediaryW-8IMYA person claiming an exemption from U.S. withholding on income effectively connected with the conductof a trade or business in the United StatesW-8ECIPart IPart IIIdentification of Beneficial Owner (See instructions.)13245678Name of individual or organization that is the beneficial ownerType of beneficial owner:Country of incorporation or organizationPermanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.City or town, state or province. Include postal code where appropriate.Country (do not abbreviate)U.S. taxpayer identification number, if required (see instructions)Foreign tax identifying number, if any (optional)Reference number(s) (see instructions)IndividualCorporationPartnershipSimple trustMailing address (if different from above)City or town, state or province. Include postal code where appropriate.Country (do not abbreviate)Claim of Tax Treaty Benefits (if applicable)I certify that (check all that apply):The beneficial owner is a resident ofwithin the meaning of the income tax treaty between the United States and that country.If required, the U.S. taxpayer identification number is stated on line 6 (see instructions).The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, ifapplicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions).The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from aU.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions).The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will fileForm 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000.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. Ifurther certify under penalties of perjury that:I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates,The beneficial owner is not a U.S. person,The income to which this form relates is not effectively connected with the conduct of a trade or business in the United States or is effectively connected but isnot subject to tax under an income tax treaty, andFor broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.Sign HereSignature of beneficial owner (or individual authorized to sign for beneficial owner)Date (MM-DD-YYYY)For Paperwork Reduction Act Notice, see separate instructions.Cat. No. 25047ZFormW-8BEN(Rev. 12-2000)Section references are to the Internal Revenue Code.abcdeSSN or ITINEINCapacity in which actingDisregarded entityCertification9Special rates and conditions (if applicableƑseeinstructions): The beneficial owner is claiming the provisions of Articleof thetreaty identified on line 9a above to claim a% rate of withholding on (specify type of income):.Explain the reasons the beneficial owner meets the terms of the treaty article:10GovernmentInternational organizationCentral bank of issueTax-exempt organizationPart IVPart IIINotional Principal Contracts11I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectivelyconnected with the conduct of a trade or business in the United States. I agree to update this statement as required.A U.S. citizen or other U.S. person, including a resident alien individualW-9Private foundationNote: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only toclaim they are a foreign person exempt from backup withholding.Note: See instructions for additional exceptions.Grantor trustEstateComplex trustFurthermore, 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 orany withholding agent that can disburse or make payments of the income of which I am the beneficial owner.