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Statement of Claim for Death Benefit |
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Mailing Address: |
Courier Address: |
Telephone Inquiries |
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John Hancock |
John Hancock |
Customers before 1/1/2005 |
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Attn: Life Claims Services R-03 |
Life Claims Services R-03 |
1-800-732-5543 |
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1 John Hancock Way Suite 1105 |
27 Drydock Ave Suite 3 |
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Originally a Manulife Customer or Customer after 12/31/2004 |
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Boston MA 02217-1105 |
Boston MA 02210-2382 |
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1-800-387-2747 |
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A message to our John Hancock beneficiaries
On behalf of John Hancock, please accept our condolences for your loss. We realize that this is a difficult time for you and your family and we will make every effort to process your claim promptly. We take pride in assisting our beneficiaries.
To expedite the processing of your claim, it is important that it contain all of the necessary information as requested in the Claimant's Statement attached.
Please review this checklist prior to submitting your claim:
Complete and sign all applicable sections of the Claimant's Statement and return all pages. If there is more than one beneficiary, please ensure each claimant completes a separate Statement of Claim for Death Benefit. Please sign page 5, where applicable.
Obtain a certified copy of the insured's death certificate. The funeral director often provides one or assists in this area. Note: Only one certified death certificate is required per insured with multiple claimants and/or policies.
The Death Certificate will not be returned.
Include the original policy, if available. If the policy is not available, be sure to complete Section E - STATEMENT OF LOST OR DESTROYED POLICY.
If the claim form is being completed by an Administrator, Executor, or a Legal Guardian, a Court Certificate of Appointment must be submitted with this Claimant's Statement.
If death occurred outside the United States or Canada, please submit the official death certificate issued in the country where the death
occurred and:
•A completed Report of a Death of a U.S. Citizen Abroad, and
•A Physician's Statement, completed and signed by the local doctor who certified the death.
Generation-Skipping Transfer Tax - Complete Section H.
If the proceeds are greater than $250,000 and are subject to the Generation-Skipping Transfer Tax, please submit a Schedule R-1 of
IRS Form 706 with this Statement of Claim for Death Benefit. Schedule R-1, which is to be completed by the executor, is usually required if any part of the death benefit is payable either directly or through a trust to an individual beneficiary who is either (i) a relative two or more generations younger than the insured (a grandchild, for example) or (ii) at least 37-1/2 years younger than the insured and not related to the insured
(a godchild, for example).
Review the "Fraud Warning Notices" for your state and sign Section J or K.
Please include any funeral home assignments and copy of bill.
If death of the insured occurred within two years of the issue date or reinstatement of the policy or supplementary benefit or if the manner of death was accidental, further investigation will be made in order to confirm information provided at the time the application for life insurance was completed. We will send you an Authorization to Release Information for Death Benefit form.
Also included with the Statement of Claim for Death Benefit form is a W9 Request For Taxpayer Identification Number and Certification form that must be completed by the claimant(s) of the death benefit proceeds. Please submit the W9 with the Statement of Claim for Death Benefit form.
If the claimant(s) is a U.S. person, including a U.S. citizen, U.S. resident alien, or other U.S. person, they must complete the enclosed Form W-9. Please see the instructions for the Form W-9 for more information. However, if the claimant(s) is not a U.S. person, they should not complete the Form W-9. Instead, they should complete the appropriate Form W-8 which is available on the IRS website http://www.irs.gov/Forms-&-Pubs
Although every effort is made to ensure prompt payment of benefits, your claim may be delayed if additional information is required to comply with the John Hancock's claim procedures for Federal and State Law. We will notify you immediately if we need additional information.
We're here to help. Should you need assistance in completing this claim, your local John Hancock representative is ready to assist you. If one is not available in your area, you may call our Customer Service toll-free number at one of the numbers listed above.
Please note that we reserve the right to make further inquiries.
PS5119US (08/2013) |
Page 1 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
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Statement of Claim for Death Benefit |
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Mailing Address: |
Courier Address: |
Telephone Inquiries |
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John Hancock |
John Hancock |
Customers before 1/1/2005 |
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Attn: Life Claims Services R-03 |
Life Claims Services R-03 |
1-800-732-5543 |
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1 John Hancock Way Suite 1105 |
27 Drydock Ave Suite 3 |
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Originally a Manulife Customer or Customer after 12/31/2004 |
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Boston MA 02217-1105 |
Boston MA 02210-2382 |
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1-800-387-2747 |
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Settlement Options and Payment of Proceeds
If the policyowner previously elected a settlement option
•John Hancock is required to carry out the policyowner's instructions. We will provide the beneficiary with complete details when the claim is processed.
Payment Options for Lump-Sum Payments
•Total proceeds from one or more policies or contracts of less than $7,500 will be paid directly to the beneficiary(ies) by check or electronic funds transfer. Available on policies issued after December 31, 2004 - please complete the Electronic Funds Transfer Information on page 7.
•Total proceeds of $7,500 or more from one or more policies or contracts will be placed in a John Hancock Safe Access Account in the beneficiary’s name. The John Hancock Safe Access Account also assures our beneficiary(ies) of immediate access to the claim proceeds. Please read the section below entitled “Safe Access Account” for more information.
•If the claim is payable to a corporation, partnership, multiple trustees or estate, the total proceeds will be paid by check or electronic funds transfer. Available on policies issued after December 31, 2004 - please complete the Electronic Funds Transfer Information on page 7.
Safe Access Account
•The total claim proceeds will be deposited in a John Hancock Safe Access Account in the beneficiary's name.
The Safe Access Account gives beneficiaries added peace of mind in knowing that while they take the time to make well planned financial decisions, they are immediately earning interest on the claim proceeds.
•For more information about John Hancock’s Safe Access Account, please see the terms and conditions set forth in the Supplemental Contract.
Safe Access Account offers you
Safety John Hancock guarantees the entire account balance*.
Convenience You can access the funds in your account at any time simply by writing a check.
Value There are no monthly service charges or check fees.
Growth Your account earns an attractive interest rate.
Time Take the time you need to make well planned financial decisions.
Additional payment options
•You have the right to receive a lump sum payment by check. Certain life insurance policies may provide for other methods of payment.
A description of available options can be found in the policy. To receive a lump sum payment by check or to inquire whether other settlement options are available, please contact your local John Hancock Representative or call our Customer Service toll-free number listed on page 1.
*A John Hancock Safe Access Account is not a bank account and is not insured by the FDIC; however, protection is afforded by the State Guaranty Associations. For information about coverage limitations in your state, you may contact the National Organization of Life and Health Insurance Guaranty Associations at www.nohlga.com. Guarantees are dependent upon the claims-paying ability of the issuing company. Safe Access Account balances remain in John Hancock's general account and are subject to the claims of our creditors.
PS5119US (08/2013) |
Page 2 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
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Statement of Claim for Death Benefit |
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John Hancock Life Insurance Company (U.S.A.) |
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(hereinafter referred to as The Company) |
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Mailing Address: |
Courier Address: |
Telephone Inquiries |
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John Hancock |
John Hancock |
Customers before 1/1/2005 |
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Attn: Life Claims Services R-03 |
Life Claims Services R-03 |
1-800-732-5543 |
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1 John Hancock Way Suite 1105 |
27 Drydock Ave Suite 3 |
Originally a Manulife Customer or Customer after 12/31/2004 |
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Boston MA 02217-1105 |
Boston MA 02210-2382 |
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1-800-387-2747 |
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Complete, sign and return the form together with the insurance policy and a certified death certificate, which indicates the cause and manner of death of the insured person. Additional requirements may also be requested depending on the circumstances.
You, your and yourself refer to the person(s), Trustee(s) or Entity claiming the death benefit, whichever is applicable to the policy(ies).
A - LIST ALL POLICY NUMBERS IF YOU ARE CLAIMING THE DEATH BENEFIT FOR MORE THAN ONE POLICY
B - TELL US ABOUT THE PERSON INSURED BY THE POLICY(IES)
a) Name |
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as Name |
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f)Date of Death
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j)Employer's Name
k)Employer's Address
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C - READ THIS SECTION CAREFULLY IF THE NAMED BENEFICIARY(IES) IS NOT ALIVE
If the last known beneficiary(ies) of the policy(ies) has died, please send us a copy of the beneficiary's death certificate.
D - TELL US ABOUT THE CLAIMANT OF THE DEATH BENEFIT PROCEEDS
i.e., individual, company, executor or trustee, whichever is applicable for this policy(ies).
a) Name |
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(if different than Street Address) |
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e) Date of Birth |
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f) Relationship to Insured |
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h) E-mail Address |
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j)In what capacity are you claiming the death benefit?
Named Beneficiary - Please complete one form for each named beneficiary and if a beneficiary is former spouse, include copy of divorce settlement.
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Executor or Administrator - Please send a court certificate of appointment. |
Trustee |
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Legal Guardian - Please send a court certificate of appointment. |
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PS5119US (08/2013) |
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Page 3 of 7 |
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Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
E - STATEMENT OF LOST OR DESTROYED POLICY
Check this box if the policy is lost or destroyed:
The undersigned hereby represents that the above numbered policy was lost or destroyed. This policy is not now assigned, nor has it been otherwise transferred or encumbered in any manner. No person, firm or corporation has or claims the right to possession of this policy.
F - FORM 712 (LIFE INSURANCE STATEMENT)
If you require an IRS Form 712 (Life Insurance Statement) for estate tax purposes, please check this box.
G - READ THIS SECTION CAREFULLY AND COMPLETE IT ONLY IF YOU ARE A TRUSTEE OF THE TRUST THAT IS CLAIMING THE PROCEEDS OF THIS POLICY(IES).
a) Name |
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b) Date |
of Trust |
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of Trust |
c) Name of Trustees
If more than one trustee, all trustees must complete and sign this form
Certification
If you have completed this section, you are making the following commitments when you sign this form:
•You certify that you are the trustee(s) of the trust named above.
•You certify that you have the right under the trust to act as the claimant for the policies named in this form.
•You agree that John Hancock doesn't have to determine the original terms of the trust or any revisions to them. You also agree that John Hancock shall not be charged with the knowledge of the trust's provisions. You confirm that neither John Hancock nor its representatives are responsible for inquiring into or shall be charged with the knowledge of the terms of the trust.
•You agree that John Hancock may discharge its obligations under the policies named in this form by relying solely on the signature of the trustee(s) or successor trustee(s) on this form.
•You agree that proof of payment to the trustee(s) of the death claim proceeds will be final and conclusive evidence that payment was made and that all claims and demands of the trustee(s) against John Hancock will have been satisfied.
H - GENERATION-SKIPPING TRANSFER TAX
Are the death benefit proceeds subject to the Generation-Skipping Transfer Tax? |
Yes |
No |
If you answered ‘Yes’ above, and the proceeds are greater than $250,000, please submit a Schedule R-1 of IRS Form 706.
I - ADDITIONAL INFORMATION
Complete if any family members are covered under the insurance being claimed.
Please list the names and birth dates of all children born of the marriage of the insured and the insured's Spouse, or of children acquired by the insured as stepchildren or legally adopted children. Please list only living children who have not reached their 25th birthday.
Full Name of Child/Spouse
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Is there any possibility of a posthumous child (a child born after the death of the father)? |
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PS5119US (08/2013) |
Page 4 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
J - ALL INDIVIDUAL CLAIMANTS OR TRUSTEES OR EXECUTORS MUST SIGN HERE AND HAVE THEIR SIGNATURE WITNESSED BY A DISINTERESTED THIRD PARTY.
Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, is subject to criminal prosecution and/or civil penalties. By signing below, you agree under penalties of perjury that the information in this statement is complete and true to the best of your knowledge (please sign as you would sign a check). Refer to "Fraud Warning Notices" insert for your state.
To the extent proceeds are settled by lump sum into a John Hancock Safe Access Account, you further agree to the terms and conditions set forth in the
John Hancock Safe Access Account Supplemental Contract, which together with this Statement of Claim forms the entire agreement between you and John Hancock.
Signed at |
City |
State |
This |
Day of |
Year |
Signature of Claimant, Trustee(s), Executor or Signing Officer
X
Signature of Witness
X
K - SIGNATURES - ALL CORPORATE CLAIMANTS MUST SIGN HERE AND HAVE THEIR SIGNATURE WITNESSED BY A DISINTERESTED THIRD PARTY
Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, is subject to criminal prosecution and/or civil penalties. By signing below, you agree under penalties of perjury that the information in this statement is complete and true to the best of your knowledge (please sign as you would sign a check). Refer to "Fraud Warning Notices" insert for your state.
Corporations making a claim must provide either:
•The title and signature of one signing officer along with the corporate seal, or
•Signatures of two signing officers with their titles and the Corporation Name.
Signed at |
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Signature of the First Signing Officer |
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Name and Title of the First Signing Officer and the Name of Corporation |
X
Signature of Witness
X
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Signature of the Second Signing Officer |
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X
Signature of Witness
X
By providing this form or other claim forms for the convenience of the claimant, John Hancock does not admit any liability or waive any of its rights.
PS5119US (08/2013) |
Page 5 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
FRAUD WARNING NOTICES - PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
CALIFORNIA: For your protection California law requires the
following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
INDIANA: A person who knowingly and with the intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the Company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OREGON: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or deceptive information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison
TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and/or civil penalties.
PS5119US (08/2013) |
Page 6 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
Electronic Funds Transfer Information - Disbursement
•The information below needs to be completed if you wish to have your disbursement electronically wired to your bank.
IMPORTANT: In order to expedite your request, please also provide a void check in addition to completing this form.
This form and the void check need to be provided in addition to the other forms in the package you have received. The funds will only be released if all requirements have been met.
Insured Name
Policyowner’s Name
Policy No.
Name of Bank
Name of Account Holder
Owner’s Account No.
Address of Bank
City, State, Zip Code
Bank Telephone No. (include area code)
Bank ABA/Routing (9 digits)
(ABA number must be specific for a Wire transfer)
Attention/Re:
For Credit to the Account of
Date
Signature of Owner/Trustee
Signature of Collateral AssigneeName - please print
Title
PS5119US (08/2013) |
Page 7 of 7 |
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.
Form W-9
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the requester. Do not send to the IRS.
Print or type See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification: |
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Exemptions (see instructions): |
Individual/sole proprietor |
C Corporation |
S Corporation |
Partnership |
Trust/estate |
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Exempt payee code (if any) |
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Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶ |
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Exemption from FATCA reporting |
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code (if any) |
Other (see instructions) ▶ |
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Address (number, street, and apt. or suite no.) |
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Requester’s name and address (optional) |
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City, state, and ZIP code |
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List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.
Employer identification number
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Part II Certification
Under penalties of perjury, I certify that:
1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3.I am a U.S. citizen or other U.S. person (defined below), and
4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Signature of |
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U.S. person ▶ |
Date ▶ |
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at www.irs.gov/w9. Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
1.Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2.Certify that you are not subject to backup withholding, or
3.Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners’ share of effectively connected income, and
4.Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct.
Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
•An individual who is a U.S. citizen or U.S. resident alien,
•A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
•An estate (other than a foreign estate), or
•A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.
Cat. No. 10231X |
Form W-9 (Rev. 8-2013) |
Form W-9 (Rev. 8-2013) |
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In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:
•In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity,
•In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust, and
•In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:
1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
2.The treaty article addressing the income.
3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
4.The type and amount of income that qualifies for the exemption from tax.
5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.
What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1.You do not furnish your TIN to the requester,
2.You do not certify your TIN when required (see the Part II instructions on page 3 for details),
3.The IRS tells the requester that you furnished an incorrect TIN,
4.The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or
5.You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.
Also see Special rules for partnerships on page 1.
What is FATCA reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.
If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.
Sole proprietor. Enter your individual name as shown on your income tax return on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name/disregarded entity name” line.
Partnership, C Corporation, or S Corporation. Enter the entity's name on the “Name” line and any business, trade, or “doing business as (DBA) name” on the “Business name/disregarded entity name” line.
Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulation section 301.7701-2(c)(2)(iii). Enter the owner's name on the “Name” line. The name of the entity entered on the “Name” line should never be a disregarded entity. The name on the “Name” line must be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on the “Name” line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the “Business name/disregarded entity name” line. If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.
Note. Check the appropriate box for the U.S. federal tax classification of the person whose name is entered on the “Name” line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Limited Liability Company (LLC). If the person identified on the “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the U.S. federal tax classification in the space provided. If you are an LLC that is treated as a partnership for U.S. federal tax purposes, enter “P” for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for C corporation or “S” for S corporation, as appropriate. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701-3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the “Name” line) is another LLC that is not disregarded for U.S. federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the “Name” line.
Other entities. Enter your business name as shown on required U.S. federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name/disregarded entity name” line.
Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and Exemption from FATCA reporting code on page 3.
Form W-9 (Rev. 8-2013) |
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Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)
2—The United States or any of its agencies or instrumentalities
3—A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies, or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States
7—A futures commission merchant registered with the Commodity Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a) 11—A financial institution
12—A middleman known in the investment community as a nominee or custodian
13—A trust exempt from tax under section 664 or described in section 4947
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
IF the payment is for . . . |
THEN the payment is exempt for . . . |
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Interest and dividend payments |
All exempt payees except |
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for 7 |
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Broker transactions |
Exempt payees 1 through 4 and 6 |
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through 11 and all C corporations. S |
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corporations must not enter an exempt |
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payee code because they are exempt |
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only for sales of noncovered securities |
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acquired prior to 2012. |
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Barter exchange transactions and |
Exempt payees 1 through 4 |
patronage dividends |
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Payments over $600 required to be |
Generally, exempt payees |
reported and direct sales over $5,0001 |
1 through 52 |
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Payments made in settlement of |
Exempt payees 1 through 4 |
payment card or third party network |
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transactions |
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1See Form 1099-MISC, Miscellaneous Income, and its instructions.
2However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements.
A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I—A common trust fund as defined in section 584(a) J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.
If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800- TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.
Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see Exempt payee code earlier.
Signature requirements. Complete the certification as indicated in items 1 through 5 below.
1.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.
2.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
3.Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
4.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
5.Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.
Form W-9 (Rev. 8-2013) |
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What Name and Number To Give the Requester
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For this type of account: |
Give name and SSN of: |
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1. |
Individual |
The individual |
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2. |
Two or more individuals (joint |
The actual owner of the account or, |
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account) |
if combined funds, the first |
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individual on the account 1 |
3. Custodian account of a minor |
The minor 2 |
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(Uniform Gift to Minors Act) |
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4. a. The usual revocable savings |
The grantor-trustee 1 |
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trust (grantor is also trustee) |
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b. So-called trust account that is |
The actual owner |
1 |
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not a legal or valid trust under |
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state law |
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5. |
Sole proprietorship or disregarded |
The owner 3 |
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entity owned by an individual |
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6. |
Grantor trust filing under Optional |
The grantor* |
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Form 1099 Filing Method 1 (see |
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Regulation section 1.671-4(b)(2)(i)(A)) |
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For this type of account: |
Give name and EIN of: |
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7. |
Disregarded entity not owned by an |
The owner |
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individual |
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8. |
A valid trust, estate, or pension trust |
Legal entity 4 |
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9. |
Corporation or LLC electing |
The corporation |
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corporate status on Form 8832 or |
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Form 2553 |
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10. |
Association, club, religious, |
The organization |
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charitable, educational, or other |
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tax-exempt organization |
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11. |
Partnership or multi-member LLC |
The partnership |
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12. |
A broker or registered nominee |
The broker or nominee |
13. |
Account with the Department of |
The public entity |
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Agriculture in the name of a public |
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entity (such as a state or local |
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government, school district, or |
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prison) that receives agricultural |
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program payments |
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14. |
Grantor trust filing under the Form |
The trust |
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1041 Filing Method or the Optional |
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Form 1099 Filing Method 2 (see |
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Regulation section 1.671-4(b)(2)(i)(B)) |
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1List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.
2Circle the minor’s name and furnish the minor’s SSN.
3You must show your individual name and you may also enter your business or “DBA” name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.
4List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1.
*Note. Grantor also must provide a Form W-9 to trustee of trust.
Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
•Protect your SSN,
•Ensure your employer is protecting your SSN, and
•Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.
For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.
Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or 1-877- IDTHEFT (1-877-438-4338).
Visit IRS.gov to learn more about identity theft and how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
