Do NOT use this form if:
• You are NOT an individual
• You are a U.S. citizen or other U.S. person, including a resident alien individual
• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the United States (other than personal services)
• You are a beneficial owner who is receiving compensation for personal services performed in the United States
• You are a person acting as an intermediary
Note: If you are resident in a FATCA partner jurisdiction (that is, a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be provided to your jurisdiction of residence.
1) Name of individual who is the beneficial owner:
2) Country of citizenship:
3) Permanent residence address: Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate:
4) Mailing address (if different from above):
City or town, state or province: Include postal code where appropriate.
5) Date of birth (MM-DD-YYYY):
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:
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.
I certify that I have the capacity to sign for the person identified on line 1 of this form.
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: W-8BEN
Agree & Sign