# Fоrm W-8BEN

#### **Form W-8BEN**

**Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting**\
**Purpose**: To establish the account holder's foreign status, claim tax treaty benefits (if applicable), and ensure proper withholding of U.S. taxes on relevant transactions.

***

**1. Identification of Beneficial Owner**

* **Full Name of Individual or Entity (Beneficial Owner)**:
* **Country of Citizenship (Individual)** or **Country of Incorporation (Entity)**:
* **Permanent Residence Address (Do not use a P.O. Box)**:
  * Address Line 1: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Address Line 2 (if applicable): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * City/Town: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * State/Province (if applicable): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Country: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Postal Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* **Mailing Address (if different from above)**:
  * Address Line 1: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Address Line 2 (if applicable): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * City/Town: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * State/Province (if applicable): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Country: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  * Postal Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***

**2. U.S. Taxpayer Identification Number (TIN)**

* **Foreign Tax Identification Number (FTIN)**:
* **U.S. Taxpayer Identification Number (if applicable)**:

***

**3. Claim of Tax Treaty Benefits (if applicable)**

* **Country of Residence for Tax Purposes**:
* **Treaty Article** (applicable to reduced withholding rate):
* **Explain Conditions of Treaty Benefit**:
* **Special Rates or Exemptions Claimed**:\
  ☐ Dividends: \_\_\_\_\_\_\_ %\
  ☐ Interest: \_\_\_\_\_\_\_ %\
  ☐ Royalties: \_\_\_\_\_\_\_ %\
  ☐ Other (specify): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***

**4. 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 person named on 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 exempt from tax under a tax treaty, or\
   c. The partner’s share of a partnership’s effectively connected income.
4. I am a resident of the treaty country listed above (if applicable) within the meaning of the income tax treaty between that country and the United States.
5. For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

***

* **Signature of Beneficial Owner (or Authorized Representative)**:
* **Printed Name of Signatory**:
* **Date**:
* **Capacity in Which Acting (if applicable)**:

***

**5. Terms and Conditions**

* ☐ I acknowledge that failure to complete this form accurately may result in incorrect tax withholding.
* ☐ I understand that the information provided on this form may be reported to the U.S. Internal Revenue Service (IRS) and tax authorities in my country of residence.

***

**6. For Internal Use Only**

* **Form Received By (Name and Employee ID)**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* **Date/Time of Submission**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* **Review Status**:\
  ☐ Verified\
  ☐ Incomplete – Requires Additional Information\
  ☐ Rejected
* **Comments**:

***


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