(Rev. October 2021)
OMB No. 1545-1621
Do NOT use this form if:
• You are NOT an individual. . . . . . . (Instead, use Form: W-8BEN-E)
• You are a U.S. citizen or other U.S. person, including a resident alien individual . . . . . . (Instead, use Form: W-9)
• 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) . . . . . . (Instead, use Form: W-8ECI)
• You are a beneficial owner who is receiving compensation for personal services performed in the United States . . . . . . (Instead, use Form: 8233 or W-4)
• You are a person acting as an intermediary . . . . . . (Instead, use Form: W-8IMY)
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)
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) Not applicable
6a Foreign tax identifying number (see instructions)
6b Check if FTIN not legally required Not required
7 Reference number(s) (see instructions)
8 Date of birth (MM-DD-YYYY) (see instructions) Date of birth
9 I certify that the beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country.
10 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 9 above to claim a % rate of withholding on (specify type of income):
Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:
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:
(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 applicable income tax treaty; (c) the partner’s share of a 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);
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)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 10-2021)
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