Explanatin f a U.S. Address and/r U.S. Phne Number (S3) Custmer Name Custmer Number By cmpleting yur IRS Frm W-8 yu are affirming that yu are nt a citizen r resident f the United States r ther U.S. persn fr the purpses f U.S. tax law. Yur accunt recrds, hwever, indicate that yu have a mailing address/permanent residence address in the U.S. and / r a U.S. phne number. Because a U.S. address / Phne Number is an indicatin that yu may be a U.S. resident fr U.S. tax law purpses, we wuld be grateful if yu wuld please: 1. Prvide an explanatin fr the address and / r phne number in Part A belw; and 2. Cmplete the substantial presence test table in Part B belw (if applicable); and 3. As apprpriate, cmplete the declaratin in Part C OR Part D belw. 4. Hand ver the declaratin t the clsest HSBC branch r mail the cmpleted declaratin r ther required dcuments t the address belw: HSBC SD-Banking Operatins N.525, Unin Place Clmb 2
PART A U.S. ADDRESS / U.S. PHONE NUMBER EXPLANATION (Select ne) 1. I nly have a U.S. Phne Number and d nt have any U.S. addresses. 2. The US address is a secndary residence address (e.g. a vacatin hme) 3. The US address is that f my/ur financial r legal advisr 4. Other (please explain): If yu selected #1 (I nly have a U.S. Phne Number) abve, please prceed t Part C, therwise prceed t Part B. PART B SUBSTANTIAL PRESENCE TEST One factr that must be cnsidered when determining a persn s U.S. tax status is the number f days that persn has been present in the U.S. S, if it is pssible that yu may spend r have spent significant time in the U.S, yu may be cnsidered a U.S. persn. Because yur accunt recrds indicate that yu have a mailing address/permanent residence in the U.S. we need yu t prvide infrmatin t demnstrate that yu have nt spent significant time in the U.S. by asking if yu meet the Substantial Presence Test described belw. Subject t certain exceptins (see Appendix 2 f the frm), a persn is cnsidered t be substantially present in the U.S. if he r she is: 1. Physically present in the U.S. fr at least 31 days during the current calendar year, and 2. Physically present in the U.S. fr at least 183 days during the 3 year perid that includes the current calendar year and the 2 years immediately befre that, cunting: a. all the days the individual was present in the U.S. in the, and b. 1/3 f the days the individual was present in the U.S. in the 1st year befre the, and 1/6 f the days the individual was present in the U.S. in the 2nd year befre the. Please cmplete the fllwing table based n yur days f presence in the U.S. (See Instructins and Example in Appendix 1 f this frm befre cmpleting) Current year befre the Secnd year befre the Ttal days f present (Bx D) Ttal days Calculatin (If yu have spent r intend t spend less than 31 ttal days in the US in the current calendar year, enter 0 in bx D belw and sign in Sectin (Divide ttal days by 3) (Divide ttal days by 6) Days t be cunted Disclaimer: The details requested in this Part B are required fr infrmatinal purpses nly. Yu shuld nt rely upn it as a statement f applicable law. HSBC des nt prvide legal r tax advice and n parts f this frm (including the Appendices) shuld be cnstrued r cnsidered as advice. Yu shuld seek guidance frm an independent legal and/r tax adviser regarding yur persnal tax situatin. 2
PART C DECLARATION OF NON-US STATUS (if bx D is less than 183) I certify that althugh I have the cnnectin(s) indicated abve with the United States, fr the reasn(s) indicated n this frm, I am nt a U.S. Persn fr U.S. tax purpses. If I am signing n behalf f the accunt hlder/payee identified n page 1 f this frm, I further certify that I am authrized t sign fr that persn I acknwledge that I must infrm yu within 30 days in the event f a change in circumstance impacting my status as a nn-u.s. Persn and I agree t prvide yu with any dcument requested by yu t supprt my status as nn-u.s. Persn fr U.S. tax purpses. If my status changes t that f a U.S. persn, I will ntify yu within 30 days f that change, and I agree t prvide yu with an IRS Frm W-9 and any ther dcument requested by yu relating t that status. By signing this frm, I als acknwledge and agree that HSBC has n liability in respect f any f my tax bligatins and/r any legal and/r tax advice prvided t me by third parties. Please print name, sign and date belw. Print Name Signature Date (MM//DD/YYYY) Capacity in which acting (if frm is nt signed by accunt hlder/payee) Part D - US SUBSTANITAL PRESENCE (If Bx D is greater than r equal t 183) In the event that the value frm Bx D in Part B is equal t r greater than 183 days, please submit the fllwing dcumentatin t HSBC within 30 days frm the date n this letter: IRS Frm W-9 and Secrecy Waiver (can be btained frm any HSBC branch) Hand ver the declaratin t the clsest HSBC branch r mail the cmpleted declaratin r ther required dcuments t the address belw: HSBC SD-Banking Operatins N.525, Unin Place Clmb 2 3
APPENDIX 1 INSTRUCTIONS TO PART B 1. Please cmplete the table in Part B by adding the number f days yu were present in the U.S. in each f the years and inserting the ttal days in clumn A 2. Apply the calculatin shwn in clumn B 3. Recrd the number f days t be cunted fr each year in clumn C 4. Calculate the sum f values in clumn C and recrd in the ttal days present bx D Befre cmpleting the table, please refer t the guidance in Appendix 2 fr infrmatin abut the days n which yu wuld NOT be cnsidered present in the United States (ptential excluded days). Current year befre the current year Secnd year befre the Ttal days A1 Calculatin (If yu have spent r intend t spend less than 31 ttal days in the US in the current calendar year, enter 0 in bx D belw and sign in Sectin Days t be cunted A1 = C1 A2 (Divide ttal days by 3) A2 3 = C2 A3 (Divide ttal days by 6) A3 6 = C3 Ttal days present ( Bx D) D = C1 + C2 + C3 EXAMPLE (Substantial Presence Test calculatin) If Jhn De were physically present in the United States fr 120 days in this year and 90 days in the previus year and 60 days 2 years prir t the, t determine if he met the Substantial Presence Test fr this year, cunt: all 120 days f presence in this year, 30 days fr the year befre the (1/3 f 90), and, 10 days in the secnd year befre the (1/6 f 60) In this example, because the cuntable ttal days fr the 3-year perid is 160 (120 + 30 +10) days, Mr. X wuld nt be cnsidered a U.S. resident under the Substantial Presence Test fr this year. Custmer Name: Jhn X Custmer Number: 123456789 Ttal days Calculatin Days t be cunted Current year 120 120 / 1 120 befre the current year Secnd year befre the 90 90 / 3 30 60 60 / 6 10 Ttal days present (Bx D) 160 4
Appendix 2 Days f Presence in the United States: Yu are treated as present in the United States n any day yu were physically present in the cuntry, at any pint during the day. Hwever there are exceptins t this rule. D nt cunt the fllwing as days f presence in the United States fr the purpses f the Substantial Presence Test: Days yu cmmute t wrk in the.u.s frm a residence in Canada r Mexic, if yu regularly cmmute frm Canada r Mexic Days yu are in the U.S. fr less than 24 hurs, when yu are in transit between tw places utside the U.S. Days yu are in the U.S. as a crew member f a freign vessel Days yu are unable t leave the U.S. because f a medical cnditin that develps while yu are in the U.S. Days yu are temprarily in the U.S. as a prfessinal athlete t cmpete in a charitable sprts event Days yu are an exempt individual (see belw) Exempt Individual D nt cunt days fr which yu are an exempt individual. The term exempt individual des nt refer t smene exempt frm U.S. tax, but t anyne in the fllwing categries wh is exempt frm cunting days f presence in the U.S: 1. Freign Gvernment Related Individual r Internatinal Organizatin Emplyee present in U.S. Emplyee f Freign Gvernment; Emplyee f Internatinal Organizatin; Usually in U.S. n A r G visa; Exempt Individual status applies als t immediate family members (i.e., spuse and unmarried children under age 21 years residing in the hme). 2. Teacher, Prfessr, Trainee, Researcher in U.S. n J r Q visa Des NOT include students n J r Q visas; Des include any alien n a J r Q visa wh is nt a student (physicians, au pairs, summer camp wrkers, etc.); If yu were a teacher, prfessr, trainee r researcher in a year prir t the, see IRS Publicatin 519 regarding hw yu shuld apply the Substantial Presence Test Exempt Individual status applies als t immediate family members with J-2 r Q-3 visa. 3. Student in U.S. n F, J, M r Q visa If yu were a student in a year prir t the, see IRS Publicatin 519 regarding hw yu shuld apply the Substantial Presence Test Exempt Individual status applies als t spuse and child n F-2, J-2, M-2, r Q-3 visa. Fr details n days excluded frm the Substantial Presence Test (including fr exempt individuals) described abve, please refer t IRS Publicatin 519, U.S. Tax Guide fr Aliens, r infrmatin abut the Substantial Presence Test n the IRS website at http://www.irs.gv/individuals/internatinal-taxpayers/substantial-presence-test 5