Forms W 8BEN and W 9 Compliance

Transcription

1 Presenting a live 110 minute teleconference with interactive Q&A Forms W 8BEN and W 9 Compliance in Foreign and US U.S. Business Transactions Meeting the Demands of a Substantially Overhauled W 8BEN Under FATCA WEDNESDAY, AUGUST 15, pm Eastern 12pm Central 11am Mountain 10am Pacific Today s faculty features: Johnny Ragheb, Senior, Ernst & Young, New York Marianne Couch, Principal, COKALA Tax Information Reporting Solutions, Ann Arbor, Mich. For this program, attendees must listen to the audio over the telephone. Please refer to the instructions ed to the registrant for the dial-in information. Attendees can still view the presentation slides online. If you have any questions, please contact Customer Service at ext. 10.

2 Form W-8BEN (Rev. December 2012) Department of the Treasury Internal Revenue Service Do NOT use this form if: Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding (Individual) For use by individuals. Entities must use Form W-8BEN-E. Information about Form W-8BEN and its separate instructions is at Give this form to the withholding agent or payer. Do not send to the IRS. Version A, Cycle 3 OMB No Instead, use Form: You are NOT an individual W-8BEN-E You are a U.S. citizen or other U.S. person, including a resident alien individual W-9 You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal services) W-8ECI You are a beneficial owner who is receiving compensation for personal services performed in the United States or W-4 A person acting as an intermediary W-8IMY Part I Identification of Beneficial Owner (see instructions) 1 Name of individual who is the beneficial owner 2 Country of citizenship (do not abbreviate) 3 Permanent 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) 4 Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country (do not abbreviate) 5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions) 7 Reference number(s) (see instructions) DRAFT AS OF between the United States and that country. 9 Special rates and conditions May (if applicable see instructions): 31, The beneficial owner 2012 is claiming the provisions of Article of the treaty identified on line 8 above to claim a % rate of withholding on (specify type of income):. Part II Claim of Tax Treaty Benefits (if applicable) 8 I certify that the beneficial owner is a resident of Explain the reasons the beneficial owner meets the terms of the treaty article: within the meaning of the income tax treaty Part III Certification 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: 1 I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or am using this form to document myself as an individual that is an owner of a foreign financial institution, 2 The person named on line 1 of this form is not a U.S. person, 3 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, 4 The person named on line 1 of this form is a resident of the treaty country listed on line 8 of the form (if any) within the meaning of the income tax treaty between the United States and that country, and 5 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 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 if any certification made on this form becomes incorrect. Sign Here Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Print name of signer Capacity in which acting (if form is not signed by beneficial owner) For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev )

3 Form W-8BEN-E (Rev. December 2012) Department of the Treasury Internal Revenue Service Certificate of Status of Beneficial Owner for United States Tax Withholding (Entities) For use by entities. Individuals must use Form W-8BEN. Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS. 4 Chapter 4 Status (Must check one box only unless otherwise indicated) (see instructions for details) DRAFT Certified deemed-compliant FFI with only low-value accounts. Complete Part IX. MAY 31, 2012 Version A, Cycle 3 OMB No XXXX Do NOT use this form for: Instead use Form: U.S. entity or U.S. citizen or resident W-9 Any foreign individual W-8BEN (Individual) A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S..... W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) W-8IMY A 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 U.S. income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions) W-8ECI or W-8EXP Note: These entities should use Form W8-BEN-E if they are claiming treaty benefits. Any person acting as an intermediary W-8IMY Part I Identification of Beneficial Owner (see instructions) 1 Name of organization that is the beneficial owner 2 Country of incorporation or organization (do not abbreviate) 3 Chapter 3 Status (Must check one box only): Corporation Disregarded entity Partnership Simple Trust Grantor trust Complex trust Estate Government Central Bank of Issue Tax-exempt organization Private foundation If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty claim? Yes No Nonparticipating FFI (including limited branch or affiliate of participating FFI) Participating FFI. Complete Part IV. Registered deemed-compliant FFI. Complete Part IV. Owner-documented FFI. Complete Part V. Certified deemed-compliant nonregistering local bank. Complete Part VI. Certified deemed-compliant non-profit organization. Complete Part VIII. Foreign government or government of U.S. possession. Foreign central bank of issue. Complete Part X. Entity wholly owned by exempt beneficial owners. Complete Part XII. Excepted nonfinancial holding company. Complete Part XIII. Excepted start-up company. Complete Part XIV. Excepted nonfinancial entity in liquidation or bankruptcy. Complete Part XV. Excepted hedging/financing center of non-financial group. Complete Part XVI. Restricted distributor. Complete Part XVII. Territory financial institution. Complete Part XVIII. Publicly traded NFFE. Complete Part XIX. Affiliate of publicly traded NFFE. Complete Part XX. Excepted Territory NFFE. Complete Part XXI. Active NFFE. Complete Part XXII. Passive NFFE. Complete Part XXIII. Not applicable (merchant submitting this form solely for purposes of Section 6050W) May check one or both of the following: Certified deemed-compliant retirement plan. Complete Part VII. Exempt retirement funds. Complete Part XI. 5 Permanent 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) 6 Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country (do not abbreviate) 7 U.S. taxpayer identification number, if required (see instructions) FFI-EIN QI-EIN EIN 9 Reference number(s) (see instructions) 8 Foreign tax identifying number (see instructions) For Paperwork Reduction Act Notice, see separate instructions. Cat. No N Form W-8BEN-E (Rev )

4 Version A, Cycle 3 Form W-8BEN-E (Rev ) Page 2 Part II Claim of Tax Treaty Benefits (if applicable) 10 I certify that (check all that apply) a The beneficial owner is a resident of within the meaning of the income tax b c treaty between the United States and that country. The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, 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 a U.S. trade or business of a foreign corporation and meets qualified resident status (see instructions). 11 Special rates and conditions (if applicable see instructions): The beneficial owner is claiming the provisions of Article of the treaty identified on line 10a above to claim a % rate of withholding on (specify type of income):. Part III Explain the reasons the beneficial owner meets the terms of the treaty article: Notional Principal Contracts 12 I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Participating FFI or Registered Deemed-Compliant FFI (see instructions) 13 I certify that the entity identified in Part I: Has the following active FATCA ID ; and Is not submitting this form for payments or an account belonging to a limited branch of an FFI. Part V Owner Documented FFI (see instructions) Note. This status only applies if the U.S. financial institution or participating FFI to which this form is given has agreed that it will treat the FFI as an owner-documented FFI. In addition, the FFI must make the certifications below. DRAFT 14a (All owner documented FFIs check here) I certify that the FFI identified in Part I: Does not act as an intermediary; Does not accept deposits in the ordinary course of a banking or similar business; Does not hold, as a substantial portion of its business, financial assets for the account of others; Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a financial account; Is not affiliated with an entity that accepts deposits in the ordinary course of a banking or similar business, holds, as a substantial portion of its business, financial assets for the account of others, or is an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a financial account; MAY 31, 2012 Does not maintain a financial account for any nonparticipating FFI; and Does not issue debt which constitutes a financial account to any person in excess of $50,000. Check box 14b or 14c, whichever applies: b I certify that the FFI identified in Part I: Has provided, or will provide, valid documentation (including waivers), as required, associated with each individual, specified U.S. person, owner-documented FFI, exempt beneficial owner, or NFFE that holds, directly or indirectly, an interest in the FFI identified in Part I; and Has provided, or will provide, an FFI owner reporting statement that contains the name, address, TIN (if any), entity tax classification, and the type of documentation provided (when required) for every person that owns an equity interest in the owner documented FFI, each person's Chapter 4 status, the percentage that each owner owns of the owner documented FFI, and any other information the withholding agent requests to fulfill its obligations. c I certify that the FFI identified in Part I: Has provided, or will provide, an auditor's letter, signed within one year of the date of payment, from an independent accounting firm or legal representative with a location in the United States stating that the firm or representative has reviewed the FFI's documentation with respect to all of its owners, that the FFI meets all the requirements to be an owner-documented FFI, and that no owner that owns a direct or indirect interest in the payee is a nonparticipating FFI, specified U.S. person, or passive NFFE with any substantial U.S. owners. Part VI Certified Deemed-Compliant Nonregistering Local Bank (see instructions) 15 I certify that the FFI identified in Part I: Operates and is licensed solely as a bank in its country of incorporation or organization; Engages primarily in the business of making loans and taking deposits from unrelated retail customers; Is licensed to conduct business in its country of incorporation or organization and has no fixed place of business outside such country; Does not solicit account holders outside its country of organization; Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more than $500 million in total assets on its consolidated or combined balance sheets; Is required under the tax laws of the country in which it is organized to perform either information reporting or withholding of tax with respect to resident accounts (unless all accounts maintained by the bank and the affiliates in its expanded affiliated group have a value or account balance of $50,000 or less (as determined after applying applicable account aggregation rules)); Form W-8BEN-E (Rev )

5 Version A, Cycle 3 Form W-8BEN-E (Rev ) Page 3 Part VI Certified Deemed-Compliant Nonregistering Local Bank (see instructions) (continued) Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that is incorporated or organized in the same country as the bank identified in Part I and that meets the requirements set forth in this Part VI; and Has provided the withholding agent with either a current audited financial statement or, if the bank has no such statement, an unaudited financial statement or other similar financial document that supports the claim that it operates solely as a bank and does not contradict the certifications made in this Part VI. Part VII Certified Deemed-Compliant Retirement Plan (see instructions) 16a (All certified deemed-compliant retirement funds check here) I certify that the FFI identified in Part I: Is organized for the provision of retirement or pension benefits under the law of the country in which it is established or in which it operates; and Has provided the withholding agent with an organizational document that generally supports the certifications made in this Part VII. Check box 16b or 16c, whichever applies: b I further certify that with respect to the FFI identified in Part I: All contributions to the FFI (other than transfers of assets from accounts described in (b)(2)(i)(A) or funds described in this Part VII or Part XI) are employer, government, or employee contributions that are limited by reference to earned income; No single beneficiary has a right to more than 5% of the FFI's assets; and Contributions to the FFI that would otherwise be subject to tax under the laws of the jurisdiction where the FFI is established or operates are deductible or excluded from gross income attributable to the beneficiary, the taxation of investment income attributable to the beneficiary is deferred under the laws of such jurisdiction, or 50% or more of the total contributions to the FFIs (other than transfers from plans described in this Part VII or Part XI) are from the government and/or an employer. c I further certify that with respect to the FFI identified in Part I: The FFI has fewer than 20 participants; The FFI is sponsored by an employer that is not an FFI engaged primarily in the business of investing, reinvesting, or trading in securities, partnership DRAFT interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest (including a futures or forward contract or option) in such security, partnership interest, commodity, notional principal contract, insurance contract or annuity contract, and is not a passive NFFE described in Part XXIII; Part VIII MAY 31, 2012 Contributions to the FFI (other than transfers from plans described in this Part VII or Part XI) are limited by reference to earned income; Participants who are not residents of the country in which the FFI is organized are not entitled to more than 20% of the FFI's assets; and No participant that is not a resident of the country in which the FFI is organized is entitled to more than $250,000 of the FFI's assets. Certified Deemed-Compliant Non-Profit Organization (see instructions) 17 I certify that the FFI identified in Part I is a non-profit organization and has provided a letter from counsel concluding that it meets the following requirements: The FFI is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes; The FFI is exempt from income tax in its country of residence; The FFI has no shareholders or members who have a proprietary or beneficial interest in its income or assets; The applicable laws of the FFI's country of residence or the FFI's formation documents do not permit any income or assets of the FFI to be distributed to, or applied for the benefit of, a private person or non-charitable FFI other than pursuant to the conduct of the FFI's charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property which the FFI has purchased; and The applicable laws of the FFI's country of residence or the FFI's formation documents require that, upon the FFI's liquidation or dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled entity of a foreign government, or another organization that is described in this Part VIII or escheats to the government of the FFI's country of residence or any political subdivision thereof. Part IX Certified Deemed-Compliant FFI with Only Low-Value Accounts (see instructions) 18 I certify that the FFI identified in Part I: Accepts deposits in the ordinary course of a banking or similar business and/or holds, as a substantial portion of its business, financial assets for the account of others; Is not engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest (including a futures or forward contract or option) in such security, partnership interest, commodity, notional principal contract, insurance contract or annuity contract; Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a financial account; No financial account maintained by the FFI or any member of its expanded affiliated group, if any, has a balance or value in excess of $50,000 (as determined after applying applicable account aggregation rules); Neither the FFI nor the entire expanded affiliated group, if any, of the FFI, have more than $50 million in assets on its consolidated or combined balance sheet as of the end of its most recent accounting year; Has provided an organizational document supporting the claim that it accepts deposits in the ordinary course of a banking or similar business and/or holds as a substantial portion of its business financial assets for the account of others; and Has provided a current audited financial statement (or if such statement is not available, an unaudited financial statement or similar financial document) for the FFI and all members of its expanded affiliated group, if any, supporting the claim that the FFI and all members of the expanded affiliated group in total, have $50 million or less in total assets and that does not contradict the claim that the FFI has only low-value accounts. Form W-8BEN-E (Rev )

6 Version A, Cycle 3 Form W-8BEN-E (Rev ) Page 4 Part X Central Bank (see instructions) 19 I certify that the entity identified in Part I is the beneficial owner of the payment and is submitting this form only for transactions in which it fulfills its role as a central bank of issue and not for those in which it functions as a commercial bank. Part XI Exempt Retirement Fund (see instructions) 20a (All exempt retirement plans check here) I certify that the entity identified in Part I: Is the beneficial owner of the payment; and Has either made a valid claim for treaty benefits under the pension plan article of a treaty or has provided an organizational document that generally supports the claim of status as an exempt retirement plan. Check box 20b or 20c, whichever applies: b I certify that the entity identified in Part I: Is established in a country with which the United States has an income tax treaty in force and is generally exempt from income taxation in that country; Is operated principally to administer or provide pension or retirement benefits; and Is entitled to benefits under the treaty on income that the fund derives from U.S. sources as a resident of the other country that satisfies any applicable limitation on benefits requirement. c I certify that the entity identified in Part I: Is formed for the provision of retirement or pension benefits under the law of the country in which it is established; Receives all of its contributions (other than transfers of assets from accounts described in (b)(2)(i)(A) or funds described in this Part XI or Part VII) from government, employer, or employee contributions that are limited by reference to earned income; Does not have a single beneficiary with a right to more than 5% of the entity's assets; and Is exempt from tax on investment income under the laws of the country in which it is established or in which it operates due to its status as a retirement or pension plan, or receives 50% or more of its total contributions (other than transfers of assets from accounts described in (b)(2)(i)(A) or funds described in this Part VII or Part XI) from the government and/or the employer. Part XII Entity Wholly Owned by Exempt Beneficial Owners (see instructions) DRAFT 21 I certify that the entity identified in Part I: Is the beneficial owner of the payment; MAY 31, 2012 Is engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest in such security, partnership interest, commodity, notional principal contract, insurance contract or annuity contract; Is wholly owned by entities described in (b), (c), (d), (e), and/or (f); Has provided an owner reporting statement, as required; and Has provided documentation for every owner of the entity establishing that every owner of the entity is an entity described in (b), (c), (d), (e), and/or (f), without regard to whether such owners are beneficial owners. Part XIII Excepted Nonfinancial Holding Company (see instructions) 22 I certify that the entity identified in Part I: Operates as a holding company, substantially all of the activities of which are to own (in whole or in part) the outstanding stock of one or more subsidiaries that engage in trades or businesses; Has no subsidiary that is a financial institution; and Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund or any investment vehicle the purpose of which is to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes. Part XIV Excepted Start-Up Company (see instructions) 23 I certify that the entity identified in Part I: Was formed on (date must be less than 24 months prior to date of payment); Is not yet operating a business and has no prior operating history; Is investing capital into assets with the intent to operate a business other than that of a financial institution; and Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes. Part XV Excepted Nonfinancial Entity in Liquidation or Bankruptcy (see instructions) 24 I certify that the entity identified in Part I: Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on During the past 5 years has not been engaged in business as a financial institution; Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a nonfinancial entity; and Has, or will provide, documentary evidence such as a bankruptcy filing or other public documentation that supports its claim if it remains in bankruptcy or liquidation for more than three years. Form W-8BEN-E (Rev )

7 Version A, Cycle 3 Form W-8BEN-E (Rev ) Page 5 Part XVI Excepted Hedging / Financing Center of a Nonfinancial Group (see instructions) 25 I certify that the entity identified in Part I: Engages primarily in financing and hedging transactions with or for members of its expanded affiliated group that are not financial institutions; Does not provide financing or hedging services to non-affiliates; and Is a member of an expanded affiliated group that is primarily engaged in a business other than that of a financial institution. Part XVII Restricted Distributor (see instructions) 26a (All restricted distributors check here) I certify that the entity identified in Part I: Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished; Provides investment services to at least 30 unrelated customers and no more than half of its customers are related persons; Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is a FATF-compliant country); Operates solely in its country of incorporation or organization, has no fixed place of business outside of that country, and has the same country of incorporation or organization as all members of its affiliated group, if any; Does not solicit customers outside its country of incorporation or organization; Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement for the most recent accounting year; Is not a member of an expanded affiliated group that has more than $500 million in total assets under management or more than $20 million in gross revenue for its most recent accounting year on a combined or consolidated income statement; Does not distribute any securities to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs. Check box 26b or 26c, whichever applies: I further certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made after December 31, 2011, the entity identified in Part I: b c DRAFT accounts related to such sales in accordance with the procedures identified in Treas. Reg (c) applicable to preexisting accounts Has been bound by a distribution agreement that contained a prohibition on the sale of securities to U.S. entities and U.S. resident individuals. Is currently bound by a distribution agreement that contained a prohibition on the sale of securities to U.S. entities and U.S. resident individuals and, for all sales made prior to the time that such a restriction was included in its distribution agreement, has reviewed all and has redeemed any securities which were sold to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs. Part XVIII Territory Financial Institution (see instructions) MAY 31, I certify that the entity identified in Part I: Is a financial institution that is incorporated or organized under the laws of a possession of the United States; and Either: Accepts deposits in the ordinary course of a banking or similar business; Holds, as a substantial portion of its business, financial assets for the account of others; or Is an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a financial account. Part XIX Publicly Traded NFFE (see instructions) 28 I certify that: The entity identified in Part I is a foreign corporation that is not a financial institution; and The stock of such corporation is regularly traded on one or more established securities markets, including (name one securities exchange upon which the stock is regularly traded). Part XX Affiliate of a Publicly Traded NFFE (see instructions) 29 I certify that: The entity identified in Part I is a foreign corporation that is not a financial institution; The entity identified in Part I is an affiliate of an entity the stock of which is regularly traded on an established exchange; The name of the affiliate, the stock of which is regularly traded on an established exchange, is ; and The name of the exchange on which the stock is regularly traded is. Part XXI Excepted Territory NFFE (see instructions) 30 I certify that: The entity identified in Part I is an entity that is organized in a possession of the United States; The entity identified in Part I: Does not accept deposits in the ordinary course of a banking or similar business, Does not hold, as a substantial portion of its business, financial assets for the account of others, or Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a financial account; and All of the owners of the entity identified in Part I are bona fide residents of the possession in which the NFFE was organized or incorporated. Form W-8BEN-E (Rev )

8 Version A, Cycle 3 Form W-8BEN-E (Rev ) Page 6 Part XXII Active NFFE (see instructions) 31 I certify that: The entity identified in Part I is a foreign entity that is not a financial institution; Less than 50% of such entity's gross income for the preceding calendar year is passive income; and Less than 50% of the assets held by such entity at any time during the preceding calendar year are assets that produce or are held for the production of passive income. See the instructions for the definition of passive income. Part XXIII Passive NFFE (see instructions) 32 I certify that the entity identified in Part I: Is a foreign entity that is not a financial institution (this category includes an entity organized in a possession of the United States that engages (or holds itself out as being engaged) primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest in such security, partnership interest, commodity, notional principal contract, insurance contract or annuity contract); and Is not an excepted NFFE. Check box 32b or 32c, whichever applies: b I further certify that the entity identified in Part I has no substantial U.S. owners, or c I further certify that the entity identified in Part I has provided the name, address, and TIN of each substantial U.S. owner of the NFFE in Part XXV. Part XXIV Certification 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: 1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates or am using this form to document myself as an owner of a foreign financial institution or as a merchant submitting this form for purposes of section 6050W, 2 The person identified on line 1 of this form is not a U.S. person, DRAFT 3 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 4 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 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 if any certification made on this form becomes incorrect. Sign Here MAY 31, 2012 Part XXV Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Capacity in which acting Substantial U.S. Owners of Passive NFFE As required by Part XXIII, provide the name, address, TIN, and percentage ownership of each substantial U.S. owner of the NFFE. Please see instructions for definition of substantial U.S. owner. Name Address TIN Percentage Ownership Form W-8BEN-E (Rev )

9 Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding (Rev. February 2006) OMB No Department of the Treasury Section references are to the Internal Revenue Code. See separate instructions. Internal Revenue Service Give this form to the withholding agent or payer. Do not send to the IRS. Do not use this form for: Instead, use Form: A U.S. citizen or other U.S. person, including a resident alien individual W-9 A person claiming that income is effectively connected with the conduct of a trade or business in the United States W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) W-8ECI or W-8IMY A 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 is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions) W-8ECI or W-8EXP Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A person acting as an intermediary W-8IMY Note: See instructions for additional exceptions. Part I Identification of Beneficial Owner (See instructions.) 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 4 Type of beneficial owner: Individual Corporation Disregarded entity Partnership Simple trust Grantor trust Complex trust Estate Government International organization Central bank of issue Tax-exempt organization Private foundation Permanent 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) 5 Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country (do not abbreviate) 6 U.S. taxpayer identification number, if required (see instructions) 7 SSN or ITIN EIN 8 Reference number(s) (see instructions) Foreign tax identifying number, if any (optional) Part II Claim of Tax Treaty Benefits (if applicable) 9 I certify that (check all that apply): a The beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country. b If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). c The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions). d The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions). e 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 file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500, Special rates and conditions (if applicable see instructions): The beneficial owner is claiming the provisions of Article of the treaty 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: Part III Notional Principal Contracts 11 I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Certification 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: 1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, 2 The beneficial owner is not a U.S. person, 3 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 4 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 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. Sign Here Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Capacity in which acting For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev ) Printed on Recycled Paper

10 Instructions for Form W-8BEN (Rev. February 2006) Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding Department of the Treasury Internal Revenue Service If applicable, claim a reduced rate of, or exemption General Instructions from, withholding as a resident of a foreign country with Section references are to the Internal Revenue Code which the United States has an income tax treaty. unless otherwise noted. You may also be required to submit Form W-8BEN to For definitions of terms used throughout these claim an exception from domestic information reporting instructions, see Definitions on pages 3 and 4. and backup withholding for certain types of income that are not subject to foreign-person withholding. Such Purpose of form. Foreign persons are subject to U.S. income includes: tax at a 30% rate on income they receive from U.S. Broker proceeds. sources that consists of: Short-term (183 days or less) original issue discount Interest (including certain original issue discount (OID). (OID)); Bank deposit interest. Dividends; Foreign source interest, dividends, rents, or royalties. Rents; Proceeds from a wager placed by a nonresident alien Royalties; individual in the games of blackjack, baccarat, craps, Premiums; roulette, or big-6 wheel. Annuities; You may also use Form W-8BEN to certify that income Compensation for, or in expectation of, services from a notional principal contract is not effectively performed; connected with the conduct of a trade or business in the Substitute payments in a securities lending transaction; United States. or A withholding agent or payer of the income may rely Other fixed or determinable annual or periodical gains, on a properly completed Form W-8BEN to treat a profits, or income. payment associated with the Form W-8BEN as a This tax is imposed on the gross amount paid and is payment to a foreign person who beneficially owns the generally collected by withholding under section 1441 or amounts paid. If applicable, the withholding agent may 1442 on that amount. A payment is considered to have rely on the Form W-8BEN to apply a reduced rate of been made whether it is made directly to the beneficial withholding at source. owner or to another person, such as an intermediary, Provide Form W-8BEN to the withholding agent or agent, or partnership, for the benefit of the beneficial payer before income is paid or credited to you. Failure to owner. provide a Form W-8BEN when requested may lead to In addition, section 1446 requires a partnership withholding at a 30% rate (foreign-person withholding) or conducting a trade or business in the United States to the backup withholding rate. withhold tax on a foreign partner s distributive share of Additional information. For additional information and the partnership s effectively connected taxable income. instructions for the withholding agent, see the Instructions Generally, a foreign person that is a partner in a for the Requester of Forms W-8BEN, W-8ECI, W-8EXP, partnership that submits a Form W-8 for purposes of and W-8IMY. section 1441 or 1442 will satisfy the documentation Who must file. You must give Form W-8BEN to the requirements under section 1446 as well. However, in withholding agent or payer if you are a foreign person some cases the documentation requirements of sections and you are the beneficial owner of an amount subject to 1441 and 1442 do not match the documentation withholding. Submit Form W-8BEN when requested by requirements of section See Regulations sections the withholding agent or payer whether or not you are through Further, the owner of a claiming a reduced rate of, or exemption from, disregarded entity, rather than the disregarded entity withholding. itself, shall submit the appropriate Form W-8 for purposes of section Do not use Form W-8BEN if: You are a U.S. citizen (even if you reside outside the If you receive certain types of income, you must United States) or other U.S. person (including a resident provide Form W-8BEN to: alien individual). Instead, use Form W-9, Request for Establish that you are not a U.S. person; Taxpayer Identification Number and Certification. Claim that you are the beneficial owner of the income You are a disregarded entity with a single owner that is for which Form W-8BEN is being provided or a partner in a U.S. person and you are not a hybrid entity claiming a partnership subject to section 1446; and treaty benefits. Instead, provide Form W-9. Cat. No H

11 You are a nonresident alien individual who claims W-8IMY and accompanying documentation. See exemption from withholding on compensation for Regulations sections through independent or dependent personal services performed Giving Form W-8BEN to the withholding agent. Do in the United States. Instead, provide Form 8233, not send Form W-8BEN to the IRS. Instead, give it to the Exemption from Withholding on Compensation for person who is requesting it from you. Generally, this will Independent (and Certain Dependent) Personal Services be the person from whom you receive the payment, who of a Nonresident Alien Individual, or Form W-4, credits your account, or a partnership that allocates Employee s Withholding Allowance Certificate. income to you. Give Form W-8BEN to the person You are receiving income that is effectively connected requesting it before the payment is made to you, credited with the conduct of a trade or business in the United to your account or allocated. If you do not provide this States, unless it is allocable to you through a partnership. form, the withholding agent may have to withhold at the Instead, provide Form W-8ECI, Certificate of Foreign 30% rate, backup withholding rate, or the rate applicable Person s Claim That Income Is Effectively Connected under section If you receive more than one type of With the Conduct of a Trade or Business in the United income from a single withholding agent for which you States. If any of the income for which you have provided claim different benefits, the withholding agent may, at its a Form W-8BEN becomes effectively connected, this is a option, require you to submit a Form W-8BEN for each change in circumstances and Form W-8BEN is no longer different type of income. Generally, a separate Form valid. You must file Form W-8ECI. See Change in W-8BEN must be given to each withholding agent. circumstances on this page. Note. If you own the income or account jointly with You are filing for a foreign government, international one or more other persons, the income or account will be organization, foreign central bank of issue, foreign treated by the withholding agent as owned by a foreign tax-exempt organization, foreign private foundation, or person if Forms W-8BEN are provided by all of the government of a U.S. possession claiming the owners. If the withholding agent receives a Form W-9 applicability of section 115(2), 501(c), 892, 895, or from any of the joint owners, the payment must be 1443(b). Instead, provide Form W-8EXP, Certificate of treated as made to a U.S. person. Foreign Government or Other Foreign Organization for Change in circumstances. If a change in United States Tax Withholding. However, you should use circumstances makes any information on the Form Form W-8BEN if you are claiming treaty benefits or are W-8BEN you have submitted incorrect, you must notify providing the form only to claim you are a foreign person the withholding agent or payer within 30 days of the exempt from backup withholding. You should use Form change in circumstances and you must file a new Form W-8ECI if you received effectively connected income (for W-8BEN or other appropriate form. example, income from commercial activities). If you use Form W-8BEN to certify that you are a You are a foreign flow-through entity, other than a foreign person, a change of address to an address in the hybrid entity, claiming treaty benefits. Instead, provide United States is a change in circumstances. Generally, a Form W-8IMY, Certificate of Foreign Intermediary, change of address within the same foreign country or to Foreign Flow-Through Entity, or Certain U.S. Branches another foreign country is not a change in circumstances. for United States Tax Withholding. However, if you are a However, if you use Form W-8BEN to claim treaty partner, beneficiary, or owner of a flow-through entity and benefits, a move to the United States or outside the you are not yourself a flow-through entity, you may be country where you have been claiming treaty benefits is a required to furnish a Form W-8BEN to the flow-through change in circumstances. In that case, you must notify entity. the withholding agent or payer within 30 days of the You are a disregarded entity for purposes of section move Instead, the owner of the entity must submit the If you become a U.S. citizen or resident alien after you form. submit Form W-8BEN, you are no longer subject to the You are a reverse hybrid entity transmitting beneficial 30% withholding rate or the withholding tax on a foreign owner documentation provided by your interest holders to partner s share of effectively connected income. You claim treaty benefits on their behalf. Instead, provide must notify the withholding agent or payer within 30 days Form W-8IMY. of becoming a U.S. citizen or resident alien. You may be You are a withholding foreign partnership or a required to provide a Form W-9. For more information, withholding foreign trust within the meaning of sections see Form W-9 and instructions and 1442 and the accompanying regulations. A Expiration of Form W-8BEN. Generally, a Form withholding foreign partnership or a withholding foreign W-8BEN provided without a U.S. taxpayer identification trust is a foreign partnership or trust that has entered into number (TIN) will remain in effect for a period starting on a withholding agreement with the IRS under which it the date the form is signed and ending on the last day of agrees to assume primary withholding responsibility for the third succeeding calendar year, unless a change in each partner s, beneficiary s, or owner s distributive share circumstances makes any information on the form of income subject to withholding that is paid to the incorrect. For example, a Form W-8BEN signed on partnership or trust. Instead, provide Form W-8IMY. September 30, 2005, remains valid through December You are acting as an intermediary (that is, acting not 31, A Form W-8BEN furnished with a U.S. TIN will for your own account, but for the account of others as an remain in effect until a change in circumstances makes agent, nominee, or custodian). Instead, provide Form any information on the form incorrect, provided that the W-8IMY. withholding agent reports on Form 1042-S at least one You are a foreign partnership or foreign grantor trust payment annually to the beneficial owner who provided for purposes of section Instead, provide Form the Form W-8BEN. See the instructions for line 6-2-