In the realm of tax compliance, the complexity of dealing with missing or incorrect Taxpayer Identification Numbers (TINs) poses a significant challenge for businesses and financial institutions. Publication 1281, crafted by the Department of the Treasury and the Internal Revenue Service, serves as an essential guide for navigating the intricacies of backup withholding requirements under these circumstances. This publication delineates the steps to be taken, including the deployment of the CP2100 notice and the initiation of corrective actions when payers encounter discrepancies in TINs or the combination of names and TINs on information returns. It meticulously outlines the backup withholding rate, currently set at 24% for payments made after December 31, 2017, and presents a comprehensive overview covering frequently asked questions, assistance channels, and procedural flowcharts. Furthermore, the publication furnishes detailed instructions for reading data from tape cartridges and CD/DVD formats and incorporates vital forms such as Form W-9 and the Form W-8 series, accompanied by the relevant instructions. This guidance is aimed at payers of income reported on Forms 1099 and others who might fall into the predicament of dealing with missing or incorrect TIN information, offering a structured approach to ensure compliance with federal tax obligations, thus underscoring its importance in the arsenal of financial reporting tools. To cap it off, the inclusion of electronic service applications and TIN matching programs showcases the IRS's commitment to leveraging technology in facilitating tax compliance, highlighting the publication's role as a bridge between complex tax regulations and the entities striving to adhere to them.
Question | Answer |
---|---|
Form Name | Publication 1281 Form |
Form Length | 81 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 20 min 15 sec |
Other names | 1281, uannnn tin pub online, form publication 1281, payer record solicit |
BACKUP WITHHOLDING FOR MISSING AND INCORRECT NAME/TIN(S)
(Including instructions for reading tape cartridges and CD/DVD Formats)
Publication 1281 (Rev.
BACKUP WITHHOLDING FOR MISSING AND INCORRECT NAME/TIN(S)
(Including instructions for reading tape cartridges and CD/DVD Formats)
TABLE OF CONTENTS |
PAGE |
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Part 1 |
Introduction |
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• |
Backup Withholding Rate |
3 |
Part 2 |
Frequently Asked Questions |
4 |
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Part 3 |
Where to Call for Help |
10 |
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Part 4 |
Actions for Missing TINs and Incorrect Name/TIN Combinations |
10 |
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• |
CP2100 Notice |
10 |
|
• |
Missing TIN(s) |
10 |
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• |
Incorrect Name/TIN Combinations |
10 |
|
• |
First “B” Notice |
11 |
|
• |
Second “B” Notice |
12 |
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• Third and Subsequent Notices |
12 |
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Part 5 |
The IRS Matching Process/ Name Controls |
13 |
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Part 6 |
Flow Charts |
19 |
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• First “B” Notice Copy |
19 |
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• Second “B” Notice Copy |
20 |
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Part 7 |
Name Compression Specifications for “B” Notice Tape Cartridges |
21 |
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Part 8 |
Instructions for Reading Tape Cartridges |
22 |
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Part 9 |
Instructions for Reading CD/DVD media |
25 |
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Part 10 |
Other Forms |
29 |
•Instructions for the Requester of Form
•Form
•Form
2
PART 1. INTRODUCTION
This publication contains information about the backup withholding
E- Services provide various electronic and interactive applications. See the IRS web site at, https://la.www4.irs.
Backup Withholding
Rate/Percentage is 24%, effective for all subject payments after December 31, 2017.
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PART 2. FREQUENTLY ASKED QUESTIONS
1.Q… What is backup withholding?
A… Persons (payers) making certain payments to payees must withhold and pay to the IRS a specified percentage (see “BWH Rate” on page 3) of those payments under certain conditions. Payments that may be subject to backup withholding include interest, dividends, rents, royalties, commissions,
2.Q… What is a Taxpayer Identification Number (TIN)?
A… A TIN is a Social Security Number (SSN) issued by the Social Security Administration (SSA) or an
Employer Identification Number (EIN) issued by the IRS. A TIN can have only nine (9) numbers. It cannot have more or less than nine numbers nor can it have letters. See Question #3 for information on ITINs and ATINs.
3.Q… What is an Individual Taxpayer Identification Number (ITIN)/Adoption Taxpayer Identification
Number (ATIN)?
A… An ITIN is an individual Taxpayer Identification Number (ITIN) issued by the IRS and may be used as a TIN to meet federal tax obligations only. Resident aliens and nonresident aliens, who are not eligible for SSNs, use ITINs. An ITIN has nine numbers in the same format as an SSN and always begins with the number 9. The fourth and fifth digits are always within the range of 70 through 88. An ATIN is an Adoption Taxpayer Identification Number issued by the IRS and can be used as a TIN. An ATIN is only a temporary taxpayer identification number issued for a child born, and adopted, in the United States. An ATIN contains nine numbers in the same format as an SSN. An ATIN should be requested when an SSN cannot be obtained in time to file your tax return. Once the adoptive parent obtains an SSN for the adopted child, the ATIN becomes obsolete.
4.Q… What payments are subject to backup withholding?
a)Rents and commissions,
b)Commissions, fees, or other payments for work performed as an independent contractor on Form
c)Interest reportable on Form
d)Dividends reportable on Form
e)Patronage dividends paid in money or qualified check reportable on Form
f)Original issue discount reportable on Form
g)Gross proceeds reportable on Form
h)Gambling winnings reportable on Form
i)Gross payments reportable on Form
j)Form
4
5.Q… Can a payee claim he or she is exempt from backup withholding?
A… Yes. Payees who may be exempt are listed in the “Instructions for the Requester of Form
6.Q… Is a payee an exempt corporation if it uses the term “Company” or “Co.” in its name? A… A payer cannot treat a payee as an exempt organization merely because the business name
contains the word “Company” or “Co.” A payer may treat a payee as exempt if:
•the name contains the term insurance company, indemnity company, reinsurance company or assurance company. Requirement one is also met if the entities name indicates that it is an entity listed as a corporation under IRS Regulations, section
•the payer has on file a corporate resolution or similar document clearly indicating corporate status,
•the payer receives a Form
•the payer receives a withholding certificate described in Section
7.Q… When is a TIN considered missing or incorrect?
A… Missing TIN - We consider a TIN to be missing if it is not provided, has more or less than nine numbers, or it has an alpha character as one of the nine positions.
Example: Missing SSN:
Example: Missing SSN:
Example: Missing EIN: 12- 345678P
Incorrect TIN - We consider a TIN incorrect if it is in the proper format but the Name/TIN combination does not match or cannot be found on IRS or SSA files.
Examples of Proper Format:
Correct
Correct EIN:
8.Q… What files do the IRS use in the matching process?
A… The
The
9.Q… What should I do if a payee refuses or neglects to provide a TIN?
A… Begin backup withholding immediately on any reportable payments. Do the required annual solicitation (request) for the TIN. Question 19 has information about the solicitation requirements for missing and incorrect TINs. Backup withhold until you receive a TIN.
10.Q… How do I know if a TIN on my account is incorrect?
A… After the submission of Form 1099 information returns, the IRS will send you a CP2100 or a
CP2100A Notice and a listing of incorrect Name/TIN(s) reported on those forms.
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11.Q… What is a CP2100 or CP2100A Notice?
A… It is a notice that tells a payer that he or she may be responsible for backup withholding. It is accompanied by a listing of missing, incorrect, and/or not currently issued payee TINs. Large volume filers will receive a CD or DVD data file CP2100,
Large Filer …………. 250 or more error documents; Mid Size Filer ……… Between 50 and 249 documents. Small Filer …............ Less than 50 error documents.
12.Q… What should I do if I receive a CP2100 or CP2100A Notice?
A… Compare the listing(s) with your records. For missing TINs: If you have not started backup withholding, begin to do so immediately and continue until you receive a TIN. You must make up to three solicitations for the TIN (initial, first annual, second annual), as described in Question 19, to avoid a penalty for failing to include a TIN on the information return.
For incorrect TINs: Compare the accounts on the listing with your business records. See Question 19 for the solicitation requirements in order to avoid a penalty for failure to include the correct TIN on an Information Return. If they agree, send the appropriate “B” Notice to the payee. If an account does not agree, this could be the result of a recent update to SSA records, an error in the information you submitted, or an IRS processing error. If this type of error occurred, the only thing you should do is correct or update your records, if necessary.
Remember: You do not have to call or write to the IRS to say that you made the correction or update to your records.
13.Q… What should I do if I receive a CP2100, CP2100A, or 972CG and do not recognize a TCC
provided on the notice?
A… The TCC belongs to the business who transmitted the information returns listed on the notice. The
TCC may belong to the payer; however, the TCC may belong to a
14.Q… What is a “B” Notice?
A… A “B” Notice is a backup withholding notice. There are two “B” Notices
Second “B” Notice. You must send the First “B” Notice and a Form
of their name/TIN combinations in accordance with the procedures described in Part 4. Generally, you do not have to send a “B” Notice more than two times within three calendar years to the same account.
15.Q… When do I send a “B” Notice to a payee?
A… You have 15 business days from the date of the CP2100A or CP2100 Notice, or the date you received it (whichever is later), to send a “B” Notice to a payee. For incorrect TINS you only have to
send a “B” Notice to a payee whose Name/TIN combination and account number on your records agrees with the combination that IRS identified as incorrect.
16.Q… How do I know which “B” Notice to send?
A… If this is the first CP2100 or CP2100A Notice you have received with respect to this account, you must provide the payee with (1) the First “B” Notice and (2) a copy of Form
6
substitute). You may also provide an optional reply envelope. Your outside mailing envelope must be clearly marked “IMPORTANT TAX INFORMATION ENCLOSED” or “IMPORTANT TAX RETURN DOCUMENT ENCLOSED.”
If this is the second CP2100 or CP2100A Notice you have received within three calendar years with respect to this account, you must provide the payee with the Second “B” Notice. Do not include a Form
17.Q… Do I have to mail a Second “B” Notice if I receive the second CP2100 or CP2100A Notice in
the same calendar year as the first notice?
A… No. You may disregard the second CP2100 or CP2100A notice, even if it relates to a different tax year than the first notice. You also have no obligation to mail a second ‘B’ Notice if you receive the second CP2100 or CP2100A Notice in a different calendar year than the first, but both of the CP notices relate to the same payee’s account for the same calendar year.
18.Q… What should I do if a “B” Notice is returned as “undeliverable”?
A… You must begin backup withholding. However, try to get the correct address for the payee and re- mail the notice. If you cannot find the correct address, keep the undelivered notice with your records for a period of three years, in order to track the
19.Q… After I receive a CP2100 or CP2100A Notice, when do I start and stop backup withholding?
A… You must begin backup withholding on all reportable payments to the payee no later than 30 business days after you have received the CP2100 or CP2100A Notice. You must stop backup withholding on payments within 30 calendar days after you have received the required certification (Form
20.Q… What are the first and second annual solicitation requirements?
A… A solicitation is a request for a payee’s correct TIN. You must make the request to satisfy the backup withholding requirements and to avoid a penalty for filing another information return with a missing or an incorrect TIN. The payee must furnish a certified TIN (initial solicitation) on Form
For missing TINs: For all payees you must make the initial solicitation when the payee opens the account or when the transaction occurs. If the payee does not provide a TIN when you initially ask for it, you must begin backup withholding. In addition, to avoid a penalty for filing an incorrect information return, you must make a first annual solicitation by December 31 of the year in which
the account is opened (for accounts opened before December) or January 31 of the following year
(for accounts opened during the preceding December). If the payee does not provide a TIN after the first annual solicitation, you must make the second annual solicitation by December 31 of the year following the calendar year in which the account was opened.
For incorrect TINs: You must make up to two annual solicitations in response to the CP2100 or CP2100A Notice. You must send a B Notice within 15 business days after you receive a CP2100 or CP2100A Notice. If you receive a Proposed Penalty Notice (972CG) but not a CP2100 or CP2100A Notice, your annual solicitation must be made by December 31st of the year you received the Proposed Penalty Notice (972CG).
However, if you already sent a B Notice in the calendar year in response to a CP2100 or CP2100A
7
Notice, you do not have to send another solicitation in response to the proposed penalty notice. If the IRS notifies you in the next calendar year that a TIN is still incorrect, you must make a second annual solicitation within 15 business days after you receive the second CP2100 or CP2100A Notice.
21.Q… Does a CP2100 or CP2100A Notice indicate whether it is the first or second notification of an
incorrect TIN for a specific account?
A… No. The backup withholding regulations require that payers be responsible for tracking the status of the notices they receive.
22.Q… What is the relationship between the requirements to make an annual solicitation for a
payee’s TIN and the requirements to send a “B” Notice?
A… Sending a “B” Notice to a payee in response to a CP2100A or CP2100 Notice satisfies the annual solicitation requirement in order to avoid a penalty for filing an information return with an incorrect TIN.
23.Q… Why are accounts I corrected still on the listing of missing or incorrect TIN(s)?
A… Due to processing
24.Q… What should I do if a TIN was actually on file but was omitted from the Form 1099 or reported
incorrectly?
A… Make any required change to your records and use the correct information on future filings. Do not send a “B” Notice to the payee.
25.Q… What should I do if this is the first notification and the Form
incorrect information?
A… Keep the Form
26.Q… If I don’t do business anymore with a payee, or if it was only a
should I do with the “B” Notice?
A… Send it and try to get the correct TIN. Also, note your records to track the notice for the
Note: A “B” Notice is not required if no payments have been made to an account and no return is required for the account for one year.
27.Q… Can a sole proprietor have an SSN or does he or she need an EIN?
A… A sole proprietor may have an SSN or an EIN. However, he or she must always furnish his or her individual name (on Name Line 1), regardless of whether he or she uses a SSN or an EIN. A sole proprietor may also provide a business name or Doing Business As (DBA) (on Name Line 2), but he or she must list his or her individual name first on the account with you.
28.Q… Should I backup withhold on a payee who is a nonresident alien?
A… Yes. A nonresident alien is subject to backup withholding unless you have a signed Form
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding, on file for him or her.
29.Q… Can a Form
A… Yes, if the payer required a payee to file only one Form
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30.Q… Can a payee be subject to backup withholding for more than one reason? A… Yes. However, backup withhold for only one reason at a time.
31.Q… How do I get an EIN?
A… Complete Form
32.Q… What form do I use to report backup withholding?
A… Report backup withholding on Form 945, Annual Return of Withheld Federal Income Tax. For more information, including the deposit requirements for Form 945, see the instructions for Form 945, or Pub. 15, (Circular E), Employer’s Tax Guide.
33.Q… How is a Name/TIN mismatch identified?
A… A Name/TIN combination is incorrect if it does not match, or cannot be found, on IRS or SSA files.
For example, a Name/TIN mismatch occurs when an individual name is submitted with a TIN not associated with the individual name provided. A TIN is not interchangeable with different names. A business EIN must be used for a partnership, corporation, or
34.Q… What amount is subject to backup withholding with respect to security sales made through
margin accounts?
A… The amount subject to backup withholding in the case of a security sale made through a margin account is limited to the amount of cash available for withdrawal by the customer immediately after the settlement of the sale. The amount available for withdrawal by the customer does not include amounts required to satisfy margin account maintenance. If a margin call forces a customer into a sell - off, such proceeds are not subject to backup withholding.
35.Q… In what manner should a payer treat erroneously withheld tax?
A… If a payer withholds from a payee in error or withholds more than the correct amount of tax, the payer may refund the amount improperly withheld. The refund must be made prior to the end of the calendar year and prior to the time the payer issues a Form 1099. If the payer has not deposited the amount of the tax prior to the time that the refund is made to the payee, the payer should not deposit the improperly withheld tax. If the improperly withheld tax has been deposited prior to the time the refund is made to the payee, the payer may adjust any subsequent deposit of tax collected, which the payer is required to make, by the amount of the tax which has been refunded to the payee. Payers may use refund alternatives only when backup withholding is the result of an error by the payer. The timely submission of requested TIN information including any verifications and/or certifications by the payee does not establish an error by the payer.
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PART 3. WHERE TO CALL FOR HELP
If you have any questions about backup withholding, information reporting, Forms 1099, or the CP2100 or CP2100A Notice(s) and listing(s), you may call:
Technical Services |
Operation Customer Service Section |
|
Telephone |
(866) |
|
Hours |
8:30 am to 4:30 pm Monday through Friday, ET |
Access this publication
PART 4. ACTIONS FOR MISSING TIN(S) AND INCORRECT NAME/TIN COMBINATIONS
The CP2100 or CP2100A Notice includes a listing(s) of the information returns you filed that had missing, incorrect, and/or not currently issued TIN(s). You should compare the listing(s) to your records to determine which of the following required actions you must take.
Missing TIN(s)
We consider a TIN to be missing if it is not provided or if it is obviously incorrect. Examples are a TIN with more or less than nine digits, or with a mixture of digits and letters. For accounts with missing TIN(s), make sure backup withholding has begun and continue backup withholding until you receive a TIN. If you have not begun backup withholding, generally you must:
1.Begin backup withholding on any reportable payment you make and continue backup withholding until you receive a TIN. Remember that in some cases, the TIN must be certified.
2.Do not send a first or second “B” Notice in response to the CP2100 or CP2100A Notice. However, in order to avoid a penalty for filing an information return that omitted the payee’s TIN, you
must make a first annual solicitation for the TIN (generally by December 31 of the year in which the account is opened) and if a TIN is still not received make a second annual solicitation by December 31 of the following year. No annual solicitations are required in the years in which no reported payments are made.
3.Report amounts withheld on Form 945, Annual Return of Withheld Federal Income Tax, and make the required deposits.
Note: Generally, you must obtain a TIN from a payee even for a
Note: If you inadvertently did not include the TIN on the information return, do not contact the payee. Include the TIN on any future information returns filed.
Incorrect Name/TIN Combinations (including not currently issued TINs)
A Name/TIN combination is incorrect if it does not match or cannot be found on IRS or SSA files. You must
follow different procedures depending on whether information on the listing(s) agrees or disagrees with your business records. Compare the listing(s) with your records and take the following actions:
For account information that does not agree, check to see if you put the incorrect information on the return, if the information changed after you filed the return, or if the IRS misprinted the information when processing the return. In these situations, do not write to the IRS. However:
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1.If you reported the incorrect information on the return, correct your records and include that information on any future information returns you file. Do not send a “B” Notice to the payee. Do not send the correction to the IRS.
2.If the information changed after you filed the return, include that information on any future information returns you file. Do not send a “B” Notice to the payee. Do not send the correction to the IRS.
3.If the IRS misprinted your information, make a note of it in your records and do not take any action.
Do not send the correction to the IRS.
For account information that agrees with your records, determine whether this is the first or second time, within three calendar years, that we have notified you about an incorrect Name/TIN combination. Your first notification of an incorrect Name/TIN combination occurs when the payee TIN appears for the first time on the listing we send you. The second notification of an incorrect Name/TIN combination is when the same payee TIN appears for the second time within three calendar years on the listing.
Note: The
First “B” Notice
1.Send the First “B” Notice, Form
DOCUMENT ENCLOSED.”
2.Make sure that necessary information such as the date, account number, and BWH rate are on the “B” Notice before mailing it to the payee. If you do not include the optional reply envelope be sure to provide return address information in your mailing.
3.Update your records with the corrected information you receive from the payee and include it on any future information returns you file. Do not send the signed Form
4.Begin backup withholding on payments made to payees who do not return a signed Form
Note: Do not file a corrected Information Return unless you are also making a change to the dollar amount reported on a Form 1099.
Note: It is your responsibility to send the appropriate “B” Notice to the payee, when required, to obtain the correct Name/TIN. This information may not be solicited by telephone. You need a TIN that the payee certifies as correct on Form
11
Second “B” Notice
1.Send the Second “B” Notice and an optional reply envelope to the payee within 15 business days after the date of the CP2100/CP2100A Notice or the date you received it (whichever is later). Date the “B” notice no later than 30 business days after the date of the CP2100/CP2100A Notice or the date you received it (whichever is later). Do not send a Form
RETURN DOCUMENT ENCLOSED.”
2.An individual payee must provide the payor with a copy of a Social Security card with his or her correct name and SSN. Payors may rely upon a Social Security card as being correct only if the name and SSN combination appearing on the card differ from the name and SSN combination appearing on the second B notice, or if there is a date appearing on the Social Security card that is no earlier than six months prior to the date of the second B notice. If the TIN is an EIN, the payee must contact the IRS to get his or her employer identification number validated on the IRS Letter 147C. A “Letter 685C” is requested from the IRS by the payee to validate an ITIN. The payee then sends a copy of the “Letter 685C” received from the IRS to the Payer. A “Letter 096C” is requested by the payee from the IRS to validate an ATIN. The payee then sends a copy of the “Letter 096C” received from the IRS to the payer.
3.Allow 30 business days after the date of the Second “B” Notice to receive a copy of a Social Security card described in paragraph 2 or Letter 147C from the payee. Begin backup withholding on payments made to the payee if you do not receive a copy of a Social Security card or Letter 147C by the 30th business day. You may, at your option, begin backup withholding anytime during the 30 business day period. You must continue to backup withhold until you receive the validation. Stop backup withholding no later than 30 days after you receive the required validation. You may stop backup withholding anytime within the 30 calendar day period after receiving validation.
Note: You are not required to file a corrected Information Return unless you are also making a change to the dollar amount reported on Form 1099.
Note: It is your responsibility to send the appropriate “B” notice to the payee, when required, to solicit the correct Name/TIN. This information may not be solicited by telephone. You need a TIN validation (IRS Letter 147C or a copy of a Social Security cardas appropriate) in order to stop current backup withholding or prevent backup withholding from starting.
Third and Subsequent Notices
Generally, you may ignore a third or subsequent notice of missing or incorrect TIN(s) if you completed the actions for the First and Second “B” Notices and the incorrect payee name and TIN combination and account number remain the same. However, if the CP2100/CP2100A Notice and listing(s) relate to the same payee, but with a different Name/TIN combination than on the “first” and “second” notice, you must treat the notice as a “first” notice.
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PART 5. THE IRS MATCHING PROCESS
This section provides an overview of the IRS matching process and the development of name controls.
The information returns you file must include a correct Name/TIN combination to allow us to match the information reported against the income included on the payee’s income tax return. We check whether a Name/TIN combination is correct by matching it against a file containing all social security numbers (SSNs) issued by SSA or against a file containing all employer identification numbers (EINs) issued by IRS. Then we compare the name control on the payee document (if provided) to the name control on file. If a name control is not provided, we develop it from the name(s) provided on the first two name lines (up to 40 characters for each name line including spaces) of the information return. If we can match a provided name or a developed name control to the name control in our records, we consider it correct. If no match is found using this process, we consider the Name/TIN combination to be incorrect. The chart on the back of Form
Name Controls
A name control consists of up to four characters. To help ensure that the Name/TIN combination for an account matches the Name/TIN combination on IRS and SSA files, use the following information when you open an account for a payee.
Individuals
We develop a name control for an individual from the last name on the information return. For example:
Ralph Teak; Dorothy Willow; Joe McCedar
If an individual has a hyphenated last name, we develop the name control from the first of the two last names. For example:
Joan
For joint accounts, regardless of whether the payees use the same or different last names, we develop the name control from the primary payee’s last name. For example:
Joseph Ash & Linda Birch; Edward & Joan Maple
Reminder: If a payee has changed his or her last name, for instance, due to marriage, he or she needs to inform the Social Security Administration (SSA) of the name change.
Hint: On name line one of the Form 1099, a payer should enter the payee’s first name and new last name (if the change has been made with SSA), or the payee’s first name, former last name, and new last name (if the change has not been made with SSA).
Sole Proprietors
We generally develop the name control (first name line) from the last name on the information return. For example:
Mark Hemlock; The Sunshine Cafe; Karen Birch; Ace Computer Co.
Hint: Payers may enter a sole proprietor’s business, trade, or “doing business as” name on the second name line of the information return. However, the individual name must be provided on the first name line. When individual name is provided on the first name line as shown above, the Sole Proprietor can provide either SSN or EIN (TIN) information.
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Estates
We develop the name control for a decedent’s estate from the decedent’s name on the first name line on the information return. The decedent’s name may be followed by the word “Estate.” (The TIN should be the one that was assigned to the estate.) For example:
Frank White Estate
Alan Greene, Exec
Estate of Frank White
John Black, Exec
Trusts and Fiduciaries
We generally develop the name control for a trust or fiduciary account from the name of the person in whose name the trust or fiduciary account was established. For example:
Jonathan Periwinkle Irrevocable Trust
FBO Patrick Redwood
Chestnut Bank, Trustee
Memory Church Endowment Trust
John Waxbean, Trustee
Partnerships
We develop the name control for a partnership from the trade or business name of the partnership; if there is not any, we develop the name control from the last name of the first partner listed on the original Form
(The) Oak Tree A.S. Greene, K.L. Black & O.H. Brown, Ptrs.
Bob Orange & Carol Black, et al Ptrs. d.b.a. The Merry Go Round
E.F. Brown, M.S. White & T.J. Green, Ptrs.
The Brown & White Company
Other Organizations
We develop the name control for other organizations from the entity’s name on the original Form
St Bernard’s Methodist Church Building Fund for St. Bernard’s Church
ABC Company
Main Street Store
NOTE: Extraneous words, titles, and special characters (i.e., Mr., Mrs., Dr., and apostrophes, etc.), may be dropped during the development of name controls. For example, we dropped the period in St. Bernard’s Methodist Church.
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First B Notice
IMPORTANT TAX NOTICE ACTION IS REQUIRED
Backup Withholding Warning!
WE NEED A FORM
will begin on
Account Number
Current Name on Account
Current TIN on Account
The Internal Revenue Service (IRS) has notified us that the taxpayer identification number (TIN) on your account with us does not match its records. The IRS considers a TIN as incorrect if either the name or number shown on an account does not match a name and number combination in their files or the files of the Social Security Administration (SSA). If you do not take appropriate action to help us correct this problem before the date shown above, the law requires us to backup withhold on interest, dividends, and certain other payments that we make to your account. The backup withholding rate is: __ [set forth rates/dates] In addition to backup withholding, you may be subject to a $50 penalty by the IRS for failing to give us your correct Name/ TIN combination. This notice tells you how to help us make your account records accurate and how to avoid backup withholding and the penalty.
Why Your TIN May Be Considered As Incorrect.
An individual’s TIN is his or her social security number (SSN). Often a TIN does not match IRS records because a name has changed through marriage, divorce, adoption, etc., and the change has not been reported to SSA, so it has not been recorded in SSA’s files. Sometimes an account or transaction may not contain the correct SSN of the actual owner. For example, an account in a child’s name may reflect a parent’s SSN. (An account should be in the name and SSN of the actual owner.)
What You Need To Do for Individuals
If you have never been assigned a social security number (or if you lost your social security card and do not know your SSN), call your local SSA office and find out how to obtain an original (or a replacement) social security card. Then apply for it. If you already have a social security number: Compare the name and SSN
on your account with us (shown at the beginning of this notice) with the name and SSN shown on your social
security card. Then use the chart on the next page to decide what action to take.
IF |
Then |
1. The last name and SSN on your account |
1. Contact your local SSA office to ascertain |
agree with the last name and SSN on |
whether the information on SSA’s |
your social security card |
records is different from that on your |
|
social security card, and to resolve any |
|
problem. Also, put your name and SSN |
|
on the enclosed Form |
|
instructions on the form. Sign the Form |
|
|
2. The SSN on your account is different |
2. Put your name and SSN, as shown on |
from the SSN on your social security |
your social security card, on the enclosed |
card, but the last name is the same |
Form |
|
the form, sign it, and send it to us. You do |
|
not need to contact SSA. |
15
3. |
The last name on your account is |
3. |
Take one of the following steps (but |
|
different from the last name on your |
|
not both): (a) If the last name on your |
|
social security card, but the SSN is the |
|
account is correct, contact SSA to correct |
|
same on both |
|
the name on your social security card. |
|
|
|
Put your SSN and name shown on your |
|
|
|
account on the enclosed Form |
|
|
|
following the instructions on the form, |
|
|
|
sign it, and send it to us. However, if |
|
|
|
you are not able to contact SSA at this |
|
|
|
time, you can provide us with both last |
|
|
|
names. Put your SSN and the name |
|
|
|
shown on your social security card plus |
|
|
|
the last name shown on your account (in |
|
|
|
that order) on the enclosed Form |
|
|
|
following the instructions on the form, |
|
|
|
sign it, and return it to us. For example, |
|
|
|
if your social security card lists your |
|
|
|
maiden name, give us your SSN and |
|
|
|
your name in the following order: First/ |
|
|
|
maiden/married name. Please note, |
|
|
|
however, that you should contact SSA as |
|
|
|
soon as possible so they can correct their |
|
|
|
records. |
|
|
|
(b) If the last name on your social |
|
|
|
security card is correct, put that name |
|
|
|
and your SSN on the enclosed Form |
|
|
|
following the instructions on the form. |
|
|
|
Sign it, and return it to us. You do not |
|
|
|
need to contact SSA. |
4. |
Both the last name and SSN on your |
4. |
(a) If the last name and SSN on your |
|
account are different from the last name |
|
social security card are correct, put that |
|
and SSN on your social security card |
|
name and SSN on the enclosed Form |
|
|
|
|
|
|
|
form. Sign it, and send it to us. You do |
|
|
|
not need to contact SSA. |
|
|
|
(b) If the last name on your account and |
|
|
|
the SSN on your social security card are |
|
|
|
correct, follow the procedure in section |
|
|
|
3(a) above. Be sure to put the name |
|
|
|
shown on your account and the name |
|
|
|
on your social security card on the Form |
|
|
|
Once you have resolved what your correct name and TIN combination is, you must provide this information to us (and all your other payors) for all of your accounts to avoid a problem in the future. If you are required to visit an SSA office, take this notice, your social security card, and any other related documents with you. Information regarding what documentation is needed to update information with the Social Security Administration is available at ssa.gov.
16
Instructions for
For most
A sole proprietor must furnish his or her individual name and either his or her SSN or the EIN for his or her sole proprietorship. In addition to his or her individual name, the sole proprietor may also furnish the business name for the sole proprietorship, provided his or her individual name is listed before the business name. A sole proprietor must not furnish only the business name. Please put the individual name and SSN or EIN on the enclosed Form
Important Reminder!
You must send us a signed IRS Form
(SSN or EIN) on your account with us match the name and number (SSN or EIN) on your social security card or the document issuing you an EIN. If we do not receive your Form
17
Second B Notice
IMPORTANT TAX NOTICE ACTION IS REQUIRED
Second Backup Withholding Warning!
YOU MUST HAVE THE IRS OR SSA VALIDATE YOUR TAXPAYER IDENTIFICATION NUMBER AND RETURN IT TO US BY: ________________________________. Otherwise, backup withholding will begin.
Account Number
Current Name on Account
Current TIN on Account
We have received notice from the Internal Revenue Service (IRS) twice within 3 years stating that the combination of the name and taxpayer identification number (Name/TIN combination) on your account with us is incorrect. (Your account number, current name on the account, and current taxpayer identification number (TIN) on the account are shown above.) A Name/TIN combination is incorrect if it does not match a Name/TIN combination shown on the records of the Social Security Administration (SSA) or the IRS.
You should follow the instructions below to correct this problem and send the corrected information to us before the date shown above. If we do not have the correct information before that date, the law requires us to backup withhold on interest, dividends, and certain other payments that we make to your account. The backup withholding rate is: __ [set forth rates/dates]
Section 3406 of the Internal Revenue Code requires that we withhold a predetermined percent in tax, called backup withholding, when you do not give us your correct Name/TIN combination. Because of the notices we received from the IRS, we are now required to disregard any future Name/TIN combinations you furnish us for your account (whether or not you certify your TIN under penalties of perjury) unless SSA (or, in the case of an incorrect employer identification number, the IRS) validates your Name/TIN combination. Also, the IRS may charge you a $50 penalty for failing to provide us with your correct Name/TIN combination.
What You Need To Do
Follow the instructions below to correct your account record to avoid backup withholding on your account (or to stop it once it has begun) and to avoid the penalty.
Individuals
Instructions for Incorrect Social Security Numbers
If the incorrect TIN you furnished us is a social security number, you must:
1.Provide us with a copy of your Social Security card. The social security card must show your correct name/SSN combination that differs from the name and SSN combination appearing on this
notice or it must show a date of issuance that is no earlier than six months prior to the date on this notice. Send the copy directly to us with a copy of this notice attached.
2.If you do not have a card meeting the requirement in item 1, you must apply for a Social Security card by submitting SSA Form
3.In addition to the required identifying information for obtaining a Social Security card, give a copy of this notice to the SSA.
4.Allow
5.Once you receive your Social Security card, make a copy of the card and send the copy directly to us with a copy of this notice attached.
18
Non- individuals or Certain Sole Proprietors
Instructions for Incorrect Employer Identification Numbers
If the incorrect TIN you furnished is an employer identification number, you must:
1.Write the Internal Revenue Service Center where you file your income tax return, and ask the IRS to send you a Letter 147C;
2.Enclose a copy of this notice in your letter to the Internal Revenue Service Center; and
3.When the IRS sends you the Letter 147C, send it to us with a copy of this notice attached.
Note: Internal Revenue Service Center address information can be found at www.irs.gov.
19
PART 6. FLOW CHART
FLOWCHARTING FOR INCORRECT NAMES/TINs
|
|
Does the |
|
||
Incorrect |
Name/TIN and the |
YES |
|||
account number on |
|||||
Name/TIN |
|
||||
the notice match |
|
||||
|
|
your records? |
|
||
|
|
|
|
||
|
|
NO |
|
|
|
|
|
|
|
|
Is the mismatch due |
YES |
No action |
to Iocessin |
|
reed. |
NO
to record
|
|
This is the |
|
Is this the first |
NO |
second |
|
notification |
|||
notification? |
|
||
|
within a three |
||
|
|
||
|
|
year period. |
YES
Send the first |
Send the |
second |
|
Form W- |
|
the payee. |
the payee. |
Did the
Is the mismatch
update.
Did the payee |
payee return a copy o
due to an error in your submission?
NO
No action reed.
return a certified |
W- |
business days? |
Sociard
business days?
YES
YES
NO |
YESNO
ect your records i necessary.
records with the certified Name/TIN.
Stop bac withho aeady be
Be |
|
Be |
withho |
|
withho |
within/by |
records |
within/by |
business days. |
|
business days. |
20
FLOWCHARTING FOR MISSING TINs
Missing TIN
|
|
|
|
Continue to |
|
Is the missing TIN |
NO |
Are you backup |
YES |
backup |
|
due to an error in |
withholding on the |
withhold until |
|||
|
|
||||
your submission? |
|
account? |
|
a TIN is |
|
|
|
|
|
received. |
YES |
NO |
|
|
Correct your |
Begin backup |
|||
records if |
||||
withholding. |
||||
necessary. |
||||
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Annual |
|
|
|
|
|
|
solicitation |
|
|
|
|
|
|
request for TIN, |
|
|
|
|
|
|
remit backup |
|
Have you |
|
Did you receive a |
|
|
withholding on |
NO |
YES |
NO |
|||
Form 945. |
|
requested a TIN? |
|
response? |
|
|
Continue to |
|
|
|
|
|
|
backup withhold |
|
|
|
|
|
|
until a TIN is |
|
|
|
|
|
|
received. |
|
|
|
|
|
|
|
|
|
|
|
YES |
|
|
|
|
|
|
|
|
Update your records and STOP backup withholding.
Remit backup withholding on Form 945. Continue to backup withhold until a TIN is received.
Make annual solicitations for TIN as required to avoid penalty.
Note
21
PART 7. NAME COMPRESSION SPECIFICATIONS FOR “B” NOTICE TAPE CARTRIDGES
Use the following information to standardize the entity information on your computer program/system so that it is the same as the entity information on the “B” Notice cartridges we send to you:
Payee Name Line 1
•Blank out or eliminate all special characters on this line except ampersands (&), dashes
•For each position on this line, if a character is not an alpha, numeric, blank, ampersand, dash, or comma, change it to a blank. Exception: apostrophes (‘) should be eliminated (instead of being changed to a blank) i.e. O’Hanlon should be OHanlon
Payee Name Line 2
•Blank out or eliminate all special characters on this line except ampersands, dashes, and percentage symbols (%).
•For each position on this line, if a character is not an alpha, numeric, blank, ampersand, dash, or percentage symbol, change it to a blank. Exception: apostrophes should be eliminated (instead of being changed to a blank).
Street Address
•Blank out all special characters on this line except ampersands, dashes, and percentage symbols.
•For each position on this line, if a character is not an alpha, numeric, blank, ampersand, dash, or percentage symbol, change it to a blank.
City
•Blank out all special characters on this line except ampersands and dashes.
•For each position on this line, if a character is not an alpha, numeric, blank, ampersand or dash, change it to a blank.
We use this command to search for groups of leading blanks and intervening blanks in each payee entity line (payee name lines 1, 2, street address, and city) and remove them. It also
For each entity line:
1)eliminate all leading blanks, 2) if two or more blanks in a row are followed by significant data, eliminate all but one blank and 3) blank fill trailing positions left on the line.
Foreign Addresses Forms 1099 filed on tape cartridge, or electronically, undergo the following processing. If the
•set the STATE CODE to “.” (Note: this code has two positions, the first is a period and the second is a blank) and
•set the ZIP code to “00000”.
22
PART 8. INSTRUCTIONS FOR READING TAPE CARTRIDGES
General
A tape cartridge file will have the following characteristics:
A.18 channel Standard Label/EBCDIC with: (a) odd parity and (b) a density of 1600 BPI.
B.Tape cartridges will be ½
C.Tape cartridges are 3480 compatible (a) Contain 37,871 CPI
D.Tape thickness - 1.0 or 1.5 mils
Record Length
A tape will be blocked in groups of 20 records, subject to the following:
A.a record will be 208 tape positions,
B.all records except the Header and Trailer Labels will be blocked,
C.a block will be 4,160 tape positions, and
D.in the event of a short block (less than 20 records), all remaining positions will be filled in with 9s.
Tape Marking Conventions
Header Label:
1.1. Standard headers will be used. They will be marked VOL1, HDR1, HDR2. 2. The HDR1 record will contain the Data Set Name “O4061211.” 3. This record will be 80 positions long.
Trailer Label:
1.Standard trailer labels will be used. They will begin with EOR1, EOR2, EOF1 or EOF2.
2.This label will be 80 positions long.
Tape Marks:
1.Tape marks are used to signify the physical end of the recording on the tape.
2.They follow the header label, and precede and follow the trailer label.
External Label:
A label marked with the Data Set Name “O4061211” will be put on the cartridge(s).
23
PAYER “A” RECORD |
|
|
|
|
|
|
|
TAPE POSITION |
FIELD TITLE |
LENGTH |
DESCRIPTION AND REMARKS |
1 |
RECORD TYPE |
1 |
AN “A” WILL BE ENTERED |
ACCESS KEY |
15 |
NUMBER USED BY THE IRS TO GROUP |
|
|
|
|
A PAYER’S INFORMATION RETURN |
|
|
|
TRANSMITTALS. |
SERVICE CENTER |
2 |
TWO DIGIT SERVICE CENTER CODES: |
|
|
|
|
BROOKHAVEN 19 |
|
|
|
CINCINNATI 17 |
|
|
|
MEMPHIS 49 |
|
|
|
OGDEN 29 |
|
|
|
PHILADELPHIA 28 |
PAYER’S EIN |
9 |
THE NINE DIGIT NUMBER ASSIGNED BY THE |
|
|
|
|
IRS. |
PAYER’S NAME |
40 |
||
NUMBER OF |
8 |
THE NUMBER OF INFORMATION RETURNS |
|
|
DOCUMENTS |
|
WITH MISSING AND INCORRECT TINS |
|
|
|
ASSOCIATED WITH THIS PAYER. IT WILL BE |
|
|
|
RIGHT JUSTIFIED AND ZERO FILLED. |
BWH TIN STATUS 1 |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE |
|
|
CNT |
|
PAYER WITH A |
|
|
|
TO “1” (SEE PAYER “B” RECORD). IT WILL BE |
|
|
|
RIGHT JUSTIFIED AND ZERO FILLED. |
BWH TIN STATUS 2 |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE |
|
|
CNT |
|
PAYER WITH A |
|
|
|
TO “2” (SEE PAYER “B” RECORD). IT WILL BE |
|
|
|
RIGHT JUSTIFIED AND ZERO FILLED. |
BWH TIN STATUS 3 |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE |
|
|
CNT |
|
PAYER WITH A |
|
|
|
TO “3” (SEE PAYER “B” RECORD). IT WILL BE |
|
|
|
RIGHT JUSTIFIED AND ZERO FILLED. |
100 |
FILLER |
1 |
BLANK FILLED |
TAX YEAR |
4 |
TAX YEAR DOCUMENTS WERE SUBMITTED |
|
FILLER |
104 |
BLANK FILLED |
24
PAYER “B” RECORD |
|
|
|
|
|
|
|
TAPE POSITION |
FIELD TITLE |
LENGTH |
DESCRIPTION AND REMARKS |
1 |
RECORD TYPE |
1 |
A “B” WILL BE ENTERED. |
TIN |
9 |
THE PAYEE’S TIN. |
|
11 |
BWH TIN STATUS |
1 |
“1” MISSING TIN “2” NOT CURRENTLY ISSUED |
|
|
|
TIN “3” INCORRECT NAME/TIN |
TCC |
5 |
TRANSMITTER CONTROL CODE |
|
DOC TYPE |
2 |
“10” = Form |
|
|
|
|
Form |
|
|
|
|
|
|
|
|
|
|
|
“71” = Form |
ACCOUNT NUMBER |
20 |
PAYEE’S ACCOUNT NUMBER FROM PAYER |
|
NAME LINE 1 |
40 |
PAYEE’S NAME LINE 1 |
|
NAME LINE 2 |
40 |
PAYEE’S NAME LINE 2 |
|
STREET ADDRESS |
40 |
PAYEE’S STREET ADDRESS |
|
CITY |
30 |
PAYEE’S CITY |
|
STATE CODE |
2 |
PAYEE’S STATE CODE |
|
ZIP CODE |
5 |
PAYEE’S ZIP CODE |
|
196 |
TIN INDICATOR |
1 |
“1” = payer indicated EIN |
|
|
|
“2” = payer indicated SSN |
|
|
|
“0” = no TIN indicated |
PAYER OFFICE CODE |
4 |
ALPHANUMERIC |
|
SEQUENCE NUMBER |
8 |
SEQUENCE NUMBER WITHIN PAYER |
|
PAYER “C” RECORD |
|
|
|
|
|
|
|
TAPE POSITION |
FIELD TITLE |
LENGTH |
DESCRIPTION AND REMARKS |
1 |
RECORD TYPE |
1 |
A “C” WILL BE ENTERED |
RECORD COUNTS |
32 |
COUNTS AS DESCRIBED IN POSITIONS |
|
|
|
|
OF THE PAYER “A” RECORD |
FILLER |
175 |
BLANK FILLED |
25
PART 9
CD/DVD Information
If you have 250 to 100,000 incorrect payee “B” records, your data will be on a CD. If you have over 100,000 payee “B” records then your data will be delivered on a DVD. Please make sure you have the correct type of reader. Many older readers only read CDs.
The enclosed CD/DVD is encrypted. You should be able to read it by putting it into a CD/DVD reader on your computer. If you have the
If you do not have
7438 to receive your encryption key. International callers may dial
When you view the CD/DVD there should be one file named “UDnnnn”**. This file will be an .exe file. When you
On the CD/DVD please find the files described below:
I40642.UAnnnn ** is the Payer
A Copy of Publication 1281. ** nnnn is the CD/DVD transmittal number. Each file record layout is described below.
These files are .txt files; So if you read them with Note Pad, word processing software, etc. you will see the Pipe Codes “|” as separate characters between each field. If you open the file with Excel, you can read it as a delimited file set the delimiters as pipes “|”. You then will see the file laid out without the Pipe Codes “|”, just like Cartridges of past years. Be careful to set or convert fields to text so that leading zeros are not truncated or blanked out.
The IRS hopes this new delivery method meets most of your requests to move away from the tape cartridges.
PAYER “A” RECORD FILE |
|
|
|
|
|
|
|
POSITION |
FIELD TITLE |
LENGTH |
DESCRIPTION AND REMARKS |
1 |
RECORD TYPE |
1 |
AN “A” WILL BE ENTERED |
2 |
Pipe Code |
1 |
“|” |
ACCESS KEY |
15 |
NUMBER USED BY THE IRS TO GROUP A PAYER’S |
|
|
|
|
INFORMATION RETURN TRANSMITTAL |
18 |
Pipe Code |
1 |
“|” |
26
SERVICE CAMPUS |
|
2 |
|
TWO DIGIT SERVICE CAMPUS CODE |
|
|
|
|
|
|
BROOKHAVEN=19 |
|
|
|
|
|
CINCINNATI = 17 |
|
|
|
|
|
MEMPHIS = 49 |
|
|
|
|
|
OGDEN = 29 |
|
|
|
|
|
PHILADELPHIA = 28 |
21 |
Pipe Code |
|
1 |
|
“|” |
PAYER’S TIN |
|
9 |
|
THE NINE DIGIT NUMBER ASSIGNED BY THE IRS |
|
31 |
Pipe Code |
|
1 |
|
“|” |
|
|
|
|
|
|
PAYER’S NAME |
|
40 |
|
||
72 |
Pipe Code |
|
1 |
|
“|” |
NUMBER OF |
|
8 |
|
THE NUMBER OF INFORMATION RETURNS WITH |
|
|
DOCUMENTS |
|
|
|
MISSING AND INCORRECT TINS ASSOCIATED WITH |
|
|
|
|
|
THIS PAYER. IT WILL BE RIGHT JUSTIFIED AND |
|
|
|
|
|
ZERO FILLED |
81 |
Pipe Code |
|
1 |
|
“|” |
BWH TIN STATUS 1 CNT |
8 |
|
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
||
|
|
|
|
|
WITH A |
|
|
|
|
|
PAYER “B” RECORD). IT WILL BE RIGHT JUSTIFIED |
|
|
|
|
|
AND ZERO FILLED |
90 |
Pipe Code |
|
1 |
|
“|” |
BWH TIN STATUS 2 CNT |
8 |
|
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
||
|
|
|
|
|
WITH A |
|
|
|
|
|
PAYER “B” RECORD) IT WILL BE RIGHT JUSTIFIED |
|
|
|
|
|
AND ZERO FILLED. |
99 |
Pipe Code |
|
1 |
|
“|” |
BWH TIN STATUS 3 CNT |
8 |
|
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
||
|
|
|
|
|
WITH A |
|
|
|
|
|
PAYER “B” RECORD) IT WILL BE RIGHT JUSTIFIED |
|
|
|
|
|
AND ZERO FILLED. |
108 |
Pipe Code |
|
1 |
|
“|” |
|
|
|
|
|
|
109 |
FILLER |
|
1 |
|
BLANK FILLED |
110 |
Pipe Code |
|
1 |
|
“|” |
|
|
|
|
|
|
TAX YEAR |
|
4 |
|
TAX YEAR DOCUMENTS WERE SUBMITTED |
|
PAYEE “B” RECORD FILE |
|
|
|
|
|
|
|
|
|
||
POSITION |
FIELD TITLE |
LENGTH |
DESCRIPTION AND REMARKS |
||
1 |
RECORD TYPE |
1 |
|
A “B” WILL BE ENTERED |
|
2 |
Pipe Code |
1 |
|
“|” |
|
|
|
|
|
|
|
TIN |
9 |
|
THE PAYEE’S TIN |
||
12 |
Pipe Code |
1 |
|
“|” |
|
|
|
|
|
|
|
13 |
BWH TIN STATUS |
1 |
|
“1” MISSING TIN “2” NOT CURRENTLY ISSUED “3” INCORRECT NAME/ |
|
|
|
|
|
TIN |
|
|
|
|
|
|
|
14 |
Pipe Code |
1 |
|
“|” |
|
TCC |
5 |
|
TRANSMITTER CONTROL CODE |
||
20 |
Pipe Code |
1 |
|
“|” |
|
|
|
|
|
|
|
27
DOC TYPE |
2 |
“02” = Form |
|
|
|
|
“10” = Form |
|
|
|
“21” = Form |
|
|
|
“27” = Form 5498S |
|
|
|
“28” = Form 5498S |
|
|
|
“31” = Form |
|
|
|
“32” = Form |
|
|
|
“71” = Form |
|
|
|
“71” = Form |
|
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“72” = Form |
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“73” = Form |
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“75” = Form |
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“79” = Form |
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“80” = Form |
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“81” = Form 1098 |
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“83” = Form |
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“84” = Form |
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“85” = Form |
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“86” = Form |
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“91” = Form |
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“92” = Form |
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“93” = Form |
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“94” = Form |
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“95” = Form |
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“96” = Form |
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“97” = Form |
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“98” = Form |
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23 |
Pipe Code |
1 |
“|” |
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ACCOUNT NUMBER |
20 |
PAYEE’S ACCOUNT NUMBER FROM PAYER |
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44 |
Pipe Code |
1 |
“|” |
NAME LINE |
40 |
PAYEE’S NAME LINE 1 |
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85 |
Pipe Code |
1 |
“|” |
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NAME LINE |
40 |
PAYEE’S NAME LINE 2 |
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126 |
Pipe Code |
1 |
“|” |
STR. ADDRESS |
40 |
PAYEE’S STREET ADDRESS |
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167 |
Pipe Code |
1 |
“|” |
CITY |
30 |
PAYEE’S CITY |
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198 |
Pipe Code |
1 |
“|” |
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STATE CODE |
2 |
PAYEE’S STATE CODE |
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201 |
Pipe Code |
1 |
“|” |
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ZIP CODE |
5 |
PAYEE’S ZIP CODE |
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207 |
Pipe Code |
1 |
“|” |
208 |
TIN INDICATOR |
1 |
“1” = Payer indicated EIN “2” = Payer indicated SSN “0” = no TIN indicated |
209 |
Pipe Code |
1 |
“|” |
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PAYER OFFICE CODE |
4 |
BLANK FILLED |
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214 |
Pipe Code |
1 |
“|” |
SEQUENCE |
8 |
NUMBER OF THE RECORD AS IT APPEARED IN YOUR FILE |
28
PAYER “C” RECORD FILE |
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POSITION |
RECORD FILE FIELD |
LENGTH |
DESCRIPTION AND REMARKS |
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1 |
RECORD TYPE |
1 |
A “C” WILL BE ENTERED |
2 |
Pipe Code |
1 |
“|” |
NUMBER OF |
8 |
THE NUMBER OF INFORMATION RETURNS WITH |
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DOCUMENTS |
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MISSING AND INCORRECT TINS ASSOCIATED WITH |
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THIS PAYER. IT WILL BE RIGHT JUSTIFIED AND |
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ZERO FILLED |
11 |
Pipe Code |
1 |
“|” |
BWH TIN STATUS |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
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WITH A |
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PAYER “B” RECORD). IT WILL BE RIGHT JUSTIFIED |
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AND ZERO FILLED |
20 |
1 CNT |
1 |
“|” |
Pipe Code BWH TIN |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
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STATUS 2 CNT |
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WITH A |
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PAYER “B” RECORD) IT WILL BE RIGHT JUSTIFIED |
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AND ZERO FILLED |
29 |
Pipe Code |
1 |
“|” |
BWH TIN STATUS 3 CNT |
8 |
THE NUMBER OF DOCUMENTS SENT TO THE PAYER |
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WITH A |
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PAYER “B” RECORD) IT WILL BE RIGHT JUSTIFIED |
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AND ZERO FILLED. |
PART 10. OTHER FORMS
Instructions for the Requester of Form
•Form
•Instructions for the Requester of Forms
•Form
•Form
(Entities)
•Form
•Form
Tax Withholding
•Form
Branches for United States Tax Withholding
29
Instructions for the Requester of Form
(Rev. November 2017)
Request for Taxpayer Identification Number and Certification
Department of the Treasury
Internal Revenue Service
Section references are to the Internal Revenue Code unless otherwise noted.
Future Developments
For the latest developments related to Form
Reminders
FATCA and backup withholding exemptions. FATCA requires a participating foreign financial institution to report all U.S. account holders that are specified U.S. persons. Form
The Certification section in Part II of Form
Backup withholding rate. The backup withholding rate is 28% for reportable payments.
Backup withholding liability. If you do not collect backup withholding from affected payees as required, you may become liable for any uncollected amount.
TIN matching
How Do I Know When To Use Form
Use Form
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;
Any estate (other than a foreign estate); or
A domestic trust (as defined in Regulations section
A partnership may require a signed Form
A participating foreign financial institution (PFFI) should request Form
Advise foreign persons to use the appropriate Form
Electronic Submission of Forms
Requesters may establish a system for payees and payees' agents to submit Forms
Payee's agent. A payee's agent can be an investment advisor (corporation, partnership, or individual) or an introducing broker. An investment advisor must be registered with the Securities and Exchange Commission (SEC) under the Investment Advisers Act of 1940. The introducing broker is a
Electronic system. Generally, the electronic system must:
Ensure the information received is the information sent, and document all occasions of user access that result in the submission;
Make reasonably certain that the person accessing the system and submitting the form is the person identified on Form
Provide the same information as the paper Form
Be able to supply a hard copy of the electronic Form
Require as the final entry in the submission an electronic signature by the payee whose name is on Form
For Forms
signature or a perjury statement.
For more details, see the following.
Announcement
Announcement
Individual Taxpayer Identification Number (ITIN)
Form
However, in some cases, individuals who become U.S. resident aliens for federal tax purposes are not eligible to obtain an SSN. This includes certain resident aliens who must receive information returns but who cannot obtain an SSN.
These individuals must apply for an ITIN on Form
Note. ITINs that haven’t been included on a U.S. federal tax return at least once in the last three consecutive tax years will expire. Expired ITINs must be renewed in order to avoid delays in processing the ITIN holder’s tax return. If the IRS deactivates the ITIN because it has expired, the ITIN may still be used on Form
“The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.”
If you use a substitute form, you are required to provide the Form
TIN Applied For
For interest and dividend payments and certain payments with respect to readily tradable instruments, the payee may return a properly completed, signed Form
Substitute Form
You may develop and use your own Form
You may incorporate a substitute Form
1.The payee's TIN is correct,
2.The payee is not subject to backup withholding due to failure to report interest and dividend income,
3.The payee is a U.S. person, and
4.The FATCA code entered on this form (if any) indicating that the payee is exempt from FATCA reporting is correct.
You may provide certification instructions on a substitute Form
Exempt From FATCA Reporting, later), you may notify the payee that item 4 does not apply.
You may not:
1.Use a substitute Form
2.Imply that a payee may be subject to backup withholding unless the payee agrees to provisions on the substitute form that are unrelated to the required certifications.
A substitute Form
If a single signature line is used for the required certifications and other provisions, the certifications must be highlighted, boxed, printed in
Reserve rule. You must backup withhold on any reportable payments made during the
Alternative rule. You also may elect to backup withhold during this
Option 1. Backup withhold on any reportable payments if the payee makes a withdrawal from the account after the close of 7 business days after you receive the
Treat as reportable payments all cash withdrawals in an amount up to the reportable payments made from the day after you receive the
Option 2. Backup withhold on any reportable payments made to the payee's account, regardless of whether the payee makes any withdrawals, beginning no later than 7 business days after you receive the
The
!not apply to any payment other than interest, dividends, CAUTION and certain payments relating to readily tradable instruments. Any other reportable payment, such as nonemployee compensation, is subject to backup withholding immediately, even if the payee has applied for and is awaiting a TIN.
Even if the payee gives you an
If you do not collect backup withholding from affected payees as required, you may become liable for any uncollected amount.
Payees Exempt From Backup
Withholding
The following payees are exempt from backup withholding with respect to the payments below, and should enter the corresponding exempt payee code on Form
Instr. for Req. of Form |
In that case, you may rely on the Form
If the payee is not exempt, you are required to backup withhold on reportable payments if the payee does not provide a TIN in the manner required or does not sign the certification, if required.
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 U.S. commonwealth or possession, or any of their political subdivisions, agencies, or instrumentalities;
4.A foreign government or any of its political subdivisions, agencies, or instrumentalities; or
5.A corporation;
6.A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession;
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; or
13.A trust exempt from tax under section 664 or described in section 4947.
The following types of payments are exempt from backup withholding as indicated for payees listed in 1 through 13, above.
Interest and dividend payments. All listed payees are exempt except the payee in item 7.
Broker transactions. All payees listed in items 1 through 4 and 6 through 11 are exempt. Also, C corporations are exempt. A person registered under the Investment Advisers Act of 1940 who regularly acts as a broker also is exempt.
Barter exchange transactions and patronage dividends.
Only payees listed in items 1 through 4 are exempt.
Payments reportable under sections 6041 and 6041A.
Payees listed in items 1 through 5 generally are exempt.
However, the following payments made to a corporation and reportable on Form
Medical and health care payments.
Attorneys' fees (also gross proceeds paid to an attorney, reportable under section 6045(f)).
Payments for services paid by a federal executive agency. (See Rev. Rul.
Payments made in settlement of payment card or third par- ty network transactions. Only payees listed in items 1 through 4 are exempt.
Payments Exempt From Backup Withholding
Payments that are not subject to information reporting also are not subject to backup withholding. For details, see sections 6041, 6041A, 6042, 6044, 6045, 6049, 6050A, 6050N, and 6050W and their regulations. The following payments generally are exempt from backup withholding.
Dividends and patronage dividends.
Payments to nonresident aliens subject to withholding under section 1441.
Payments to partnerships not engaged in a trade or business in the United States and that have at least one nonresident alien partner.
Payments of patronage dividends not paid in money.
Payments made by certain foreign organizations. Section 404(k) distributions made by an ESOP.
Interest payments.
Payments of interest on obligations issued by individuals. However, if you pay $600 or more of interest in the course of your trade or business to a payee, you must report the payment. Backup withholding applies to the reportable payment if the payee has not provided a TIN or has provided an incorrect TIN. Payments described in section 6049(b)(5) to nonresident aliens.
Payments on
Payments made by certain foreign organizations. Mortgage or student loan interest paid to you.
Other types of payment.
Wages.
Distributions from a pension, annuity,
Distributions from a medical or health savings account and
Certain surrenders of life insurance contracts.
Distribution from qualified tuition programs or Coverdell ESAs.
Gambling winnings if regular gambling winnings withholding is required under section 3402(q). However, if regular gambling winnings withholding is not required under section 3402(q), backup withholding applies if the payee fails to furnish a TIN.
Real estate transactions reportable under section 6045(e).
Cancelled debts reportable under section 6050P. Fish purchases for cash reportable under
section 6050R.
Payees and Account Holders Exempt From FATCA Reporting
Reporting under chapter 4 (FATCA) with respect to U.S. persons generally applies only to foreign financial institutions (FFI) (including a branch of a U.S. financial institution that is treated as an FFI under an applicable intergovernmental agreement (IGA)). Thus, for example, a U.S. financial institution maintaining an account in the United States does not need to collect an exemption code for FATCA reporting. If you are providing a Form
Instr. for Req. of Form |
requirements, including specific information regarding which financial institutions are required to report, see sections 1471 to 1474 and related regulations. See Regulations section
If you receive a Form
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 U.S. commonwealth or possession, or any of their political subdivisions, agencies, or instrumentalities;
D.A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section
E.A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section
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; or
M.A
Joint Foreign Payees
If the first payee listed on an account gives you a
Form
1.Every joint payee provides the statement regarding foreign status, or
2.Any one of the joint payees who has not established foreign status gives you a TIN.
If any one of the joint payees who has not established foreign status gives you a TIN, use that number for purposes of backup withholding and information reporting.
For more information on foreign payees, see the Instructions for the Requester of Forms
Names and TINs To Use for Information Reporting
Show the full name and address as provided on Form
For more information on the names and TINs to use for TIP information reporting, see section J of the General
Instructions for Certain Information Returns.
Notices From the IRS
The IRS will send you a notice if the payee's name and TIN on the information return you filed do not match the IRS's records. (See Taxpayer Identification Number (TIN) Matching.) If you receive a backup withholding notice, you may have to send a “B” notice to the payee to solicit another TIN. Pub. 1281, Backup Withholding for Missing and Incorrect Name/TIN(s), contains copies of the two types of “B” notices. If you receive a penalty notice, you also may have to send a solicitation to the payee. See Pub. 1586, Reasonable Cause Regulations and Requirements for Missing and Incorrect Name/TINs.
Taxpayer Identification Number (TIN) Matching
TIN Matching allows a payer or authorized agent who is required to file Forms
Additional Information
For more information on backup withholding, see Pub. 1281.
Instr. for Req. of Form |
Form
(Rev. November 2017)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the requester. Do not send to the IRS.
Print or type. See Specific Instructions on page 3.
1Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2Business name/disregarded entity name, if different from above
3 |
Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the |
4 Exemptions (codes apply only to |
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certain entities, not individuals; see |
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instructions on page 3): |
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Individual/sole proprietor or |
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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Note: Check the appropriate box in the line above for the tax classification of the |
Exemption from FATCA reporting |
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LLC if the LLC is classified as a |
code (if any) |
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another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a |
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is disregarded from the owner should check the appropriate box for the tax classification of its owner. |
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Other (see instructions) |
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5 |
Address (number, street, and apt. or suite no.) See instructions. |
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Requester’s name and address (optional) |
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6 |
City, state, and ZIP code |
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7List 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 line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number
– |
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– |
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or
Employer identification number
–
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 for Part II, later.
Sign Here
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. For the latest information about developments related to Form
•Form
•Form
•Form
•Form
Purpose of Form
An individual or entity (Form
• Form
•Form
•Form 1098 (home mortgage interest),
•Form
•Form
Use Form
If you do not return Form
Cat. No. 10231X |
Form |
Form |
Page 2 |
|
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By signing the
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. See What is FATCA reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other than Form
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
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
In the cases below, the following person must give Form
•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
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
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
If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form
Backup Withholding
What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest,
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 instructions for Part II 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, later, and the separate Instructions for the Requester of Form
Also see Special rules for partnerships, earlier.
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, later, and the Instructions for the Requester of Form
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
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.
Form |
Page 3 |
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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
Line 1
You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.
If this Form
a.Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on your Form
b.Sole proprietor or
c.Partnership, LLC that is not a
d.Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. 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 line 2.
e.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 Regulations section
Line 2
If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.
IF the entity/person on line 1 is |
THEN check the box for . . . |
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a(n) . . . |
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• |
Corporation |
Corporation |
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Individual |
Individual/sole proprietor or single- |
• |
Sole proprietorship, or |
member LLC |
• |
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company (LLC) owned by an |
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individual and disregarded for U.S. |
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federal tax purposes. |
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LLC treated as a partnership for |
Limited liability company and enter |
U.S. federal tax purposes, |
the appropriate tax classification. |
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• |
LLC that has filed Form 8832 or |
(P= Partnership; C= C corporation; |
2553 to be taxed as a corporation, |
or S= S corporation) |
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or |
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• |
LLC that is disregarded as an |
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entity separate from its owner but |
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the owner is another LLC that is |
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not disregarded for U.S. federal tax |
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purposes. |
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• |
Partnership |
Partnership |
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• |
Trust/estate |
Trust/estate |
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.
Exempt payee code.
•Generally, individuals (including sole proprietors) are not exempt from backup withholding.
•Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.
•Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.
•Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form
The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.
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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 |
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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. |
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S corporations must not enter an |
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exempt payee code because they |
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are exempt only for sales of |
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noncovered securities acquired |
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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 |
1 through 52 |
$5,0001 |
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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
2However, the following payments made to a corporation and reportable on Form
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 requester may indicate that a code is not required by providing you with a Form
Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number). This is where the requester of this Form
Line 6
Enter your city, state, and ZIP code.
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.
If you are a
Note: See What Name and Number To Give the Requester, later, 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
If you are asked to complete Form
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
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form
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 line 1 must sign. Exempt payees, see Exempt payee code, earlier.
Signature requirements. Complete the certification as indicated in items 1 through 5 below.
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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), ABLE accounts (under section 529A), 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.
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, if |
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account) other than an account |
combined funds, the first individual on |
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maintained by an FFI |
the account |
1 |
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3. |
Two or more U.S. persons |
Each holder of the account |
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(joint account maintained by an FFI) |
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4. |
Custodial account of a minor |
The minor² |
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(Uniform Gift to Minors Act) |
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5. a. The usual revocable savings trust |
The |
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(grantor is also trustee) |
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b. |
The actual owner1 |
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a legal or valid trust under state law |
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6. |
Sole proprietorship or disregarded |
The owner³ |
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entity owned by an individual |
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7. |
Grantor trust filing under Optional |
The grantor* |
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Form 1099 Filing Method 1 (see |
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Regulations section |
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(A)) |
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For this type of account: |
Give name and EIN of: |
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8. |
Disregarded entity not owned by an |
The owner |
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individual |
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9. |
A valid trust, estate, or pension trust |
Legal entity4 |
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10. |
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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11. |
Association, club, religious, |
The organization |
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charitable, educational, or other tax- |
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exempt organization |
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12. |
Partnership or |
The partnership |
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13. |
A broker or registered nominee |
The broker or nominee |
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For this type of account: |
Give name and EIN of: |
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14. Account with the Department of |
The public entity |
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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15. Grantor trust filing under the Form |
The trust |
1041 Filing Method or the Optional |
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Form 1099 Filing Method 2 (see |
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Regulations section |
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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, earlier.
*Note: The grantor also must provide a Form
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, 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
For more information, see Pub. 5027, Identity Theft Information for Taxpayers.
Victims of identity theft who are experiencing economic harm or a systemic 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
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.
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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 (TIGTA) at
Visit www.irs.gov/IdentityTheft 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.
Printed on recycled paper
Instructions for the Requester of Forms
(Rev. April 2018)
Department of the Treasury
Internal Revenue Service
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. For the latest information about developments related to the Forms
What's New
On January 6, 2017, the Treasury Department and the IRS finalized certain regulations under chapter 3 (TD 9808) and chapter 4 (TD 9809) and published temporary regulations under chapters 3 and 4 to supplement certain provisions of those final regulations. Among other things, the final and temporary regulations under chapters 3 and 4 modified certain requirements with respect to the collection of Forms
On January 24, 2017, the Treasury Department and the IRS finalized certain regulations under sections 871(m) and 1441 (TD 9815) and published temporary regulations under section 871(m) to supplement certain provisions of those final regulations. Among other things, the final and temporary regulations under sections 871(m) and 1441 modified the rules for withholding and reporting certain payments made to qualified derivative dealers (QDDs). The Treasury Department and the IRS also issued Notice
The transition rules related to the Qualified Securities Lender (QSL) regime described in Notice
In addition, on September 25, 2017, the Treasury Department and the IRS released Notice
Purpose of Instructions
These instructions supplement the instructions for the forms listed below and provide notes to assist withholding agents and foreign financial institutions (FFIs) in validating the forms for chapters 3 and 4 purposes. These instructions also outline the due diligence requirements applicable to withholding agents for establishing a beneficial owner’s foreign status and claim for reduced withholding under an income tax treaty. These instructions are not inclusive of all requirements that may apply to a withholding agent for validating Forms
Form
Form
Form
Form
Form
For definitions of terms not defined in these instructions, see the Forms
Throughout these instructions, a reference to or TIP mention of “Form
Apr 18, 2018 |
Cat. No. 26698G |
These instructions reflect the regulatory changes described earlier that are relevant to Forms
Who Is a Withholding Agent?
Any person, U.S. or foreign, in whatever capacity acting, that has control, receipt, custody, disposal, or payment of an amount subject to withholding for chapter 3 purposes or a withholdable payment for chapter 4 purposes is a withholding agent. The withholding agent may be an individual, corporation, partnership, trust, association, or any other entity, including (but not limited to) any foreign intermediary, foreign partnership, or U.S. branch of certain foreign banks and insurance companies. If several persons qualify as withholding agents for a single payment, the tax required to be withheld must only be withheld once. Generally, the person who pays (or causes to be paid) an amount subject to withholding under chapter 3 or a withholdable payment to the foreign person (or to its agent) must withhold. See the Instructions for Form 1042, Annual Withholding Tax Return for U.S. Source Income of Foreign Persons, and Form
For effectively connected taxable income (ECTI) allocable to a foreign partner, the partnership is generally the withholding agent and must file Form 8804, Annual Return for Partnership Withholding Tax (Section 1446); Form 8805, Foreign Partner's Information Statement of Section 1446 Withholding Tax; and Form 8813, Partnership Withholding Tax Payment Voucher (Section 1446).
Responsibilities of a Withholding Agent To Obtain Form
Chapter 3 Responsibilities
(Other Than Section 1446)
Generally, an amount is subject to withholding for purposes of chapter 3 if it is an amount from sources within the United States that is fixed or determinable annual or periodical (FDAP) income. FDAP income is all income included in gross income, including interest (and original issue discount (OID)), dividends, rents, royalties, and compensation. FDAP income does not include most gains from the sale of property (including market discount and option premiums) or items of income excluded from gross income without regard to the U.S. or foreign status of the owner of the income, such as interest under section 103(a). Amounts subject to chapter 3 withholding do not
include amounts that are not FDAP as well as other specific items of income described in Regulations section
For purposes of sections 1441 and 1442, if you are a
withholding agent, you must withhold 30% of any payment of an amount subject to chapter 3 withholding made to a payee that is a foreign person unless you can reliably associate the payment with documentation (for example, Form
However, a withholding agent making a payment to a foreign person need not withhold under chapter 3 if the foreign person assumes responsibility for withholding on the payment as a qualified intermediary (QI) (other than a QI that is acting as a QDD for payments with respect to underlying securities that are subject to withholding), or if the foreign person is a withholding foreign partnership (WP), or a withholding foreign trust (WT) that has provided a valid Form
Chapter 4 Responsibilities
For purposes of chapter 4, if you are a withholding agent, you must withhold 30% of any payment that is a withholdable payment (as defined in Regulations section
You must determine if a payment is a withholdable payment without regard to any exceptions from withholding applicable under chapter 3. For each such withholdable payment, you must obtain a Form
Section 1446 Responsibilities
Generally, under section 1446, a partnership that allocates ECTI to a foreign partner must withhold at the highest tax rate applicable to that person for the type of income allocated (for example, ordinary income or capital gains) in accordance with the provisions of Regulations sections
Other Uses of Form
Chapter 61 and section 3406. The Form
Inst. for the Requester of Forms
FFI documenting account holders. If you are an FFI maintaining a financial account, you may be required to perform due diligence procedures to identify and document the account holder under the chapter 4 regulations or an applicable intergovernmental agreement (IGA) even if you are not making a payment to the account holder that is subject to withholding. You may use Form
If you are an FFI documenting an account holder of an account that you determine is excepted as a financial account under Regulations section
Requesting Form
Generally, if you are making a payment of an amount subject to chapter 3 withholding or a withholdable payment, you must withhold as required at the 30% rate under chapter 3 or 4 unless you can reliably associate the payment with a Form
You should request a Form
A withholding agent or payor that fails to obtain a valid Form
withheld. In addition, you may be liable for interest, penalties, and additions to the tax even if there is no underlying tax liability due from a foreign partner on its allocable share of the partnership’s ECTI.
If you are a withholding agent making a payment of an amount subject to chapter 3 withholding or a withholdable payment and you make the payment to an intermediary, you must obtain documentation from such intermediary (including the intermediary’s chapter 4 status if the payment is a withholdable payment), as well as any required documentation for the beneficial owner(s) of the payment to the extent required under the chapter 3 or 4 regulations.
Do not send Forms
Form
You may also rely on an otherwise valid Form
(E)for the complete requirements for relying on a withholding certificate from a
If you are a withholding agent that maintains a system for furnishing Forms
(B). You may otherwise accept a Form
Requesting Prior Versions of Form
If the IRS issues an updated version of a Form
Due Diligence
Requirements in General
When you receive a completed Form
Reason to know. In general, you have reason to know that a Form
The form is incomplete with respect to any item that is relevant to the claims made;
The form contains any information that is inconsistent with the claims made;
The form lacks information necessary to establish that the beneficial owner is entitled to a reduced rate of withholding; or
You have other account information that is inconsistent with the claims made, or you have knowledge of relevant facts or statements contained in the withholding certificate or other documentation that would cause a reasonably prudent person in your position to question the claims made. For example, if you have information in your records that contradicts information provided on the form, you may not rely on the form.
With respect to a claim for benefits under an income tax treaty, your reason to know requirement that the treaty claim is unreliable or incorrect includes when the beneficial owner claims benefits under a treaty that does not exist or is not in force. For this purpose, you may use the list maintained at IRS.gov/businesses/international-
If you are a financial institution (as defined in Regulations section
payment, and you make a payment of U.S. source FDAP income to the direct account holder, you have reason to know that a Form
1.You have classified the account holder claiming foreign status as a U.S. person in your account information, the Form
a.An individual who has provided a Form
i.You have in your possession or obtain documentary evidence establishing foreign status (as described in Regulations section
ii.For a payment made outside the U.S. with respect to an offshore obligation (as defined in Regulations section
iii.For a payment made with respect to an offshore obligation (as defined in Regulations section
iv.For a case in which you have classified the account holder as a U.S. person in your account information, you have in your possession or obtain documentary evidence (as described in Regulations section
b.You may treat an entity that has provided you with a Form
i.You have in your possession or obtain documentation establishing foreign status that substantiates that the entity is actually organized or created under the laws of a foreign country; or
ii.For a payment made with respect to an offshore obligation (as defined in Regulations section
(1)), you classify the entity as a resident of the country in which the account is maintained, you are required to report a payment made to the entity annually on a tax information statement that is filed with the tax authority of the country in which the obligation is maintained, and that country has an income tax treaty or tax information exchange agreement in effect with the United States.
2.The form is provided with respect to an offshore obligation (as defined in Regulations section
3.The Form
a.A copy of the individual’s Certificate of Loss of Nationality of the United States, or
b.A reasonable written explanation of the account holder’s renunciation of U.S. citizenship or the reason the account holder did not obtain U.S. citizenship at birth.
4.The Form
a.The permanent residence address on the form is not in the treaty country or the direct account holder notifies you of a new permanent residence address that is not in the treaty country, unless the direct account holder provides a reasonable explanation for the permanent residence address outside the treaty country or you have in your possession, or obtain, documentary evidence (described in Regulations section
b.The permanent residence address is in the treaty country, but the mailing address on the form is not in the treaty country or you have a current mailing address that is not in the treaty country as part of your account information for the direct account holder, unless:
i.You have in your possession, or obtain, documentary evidence (as described in Regulations section
ii.You have in your possession, or obtain, documentation that establishes that the direct account holder is an entity organized in a treaty country (or an entity managed and controlled in a treaty country, if required by the applicable treaty);
Inst. for the Requester of Forms |
iii.You know that the address outside the treaty country (other than a P.O. box or
iv.The direct account holder provides a written statement that reasonably establishes entitlement to treaty benefits.
c.The direct account holder has standing instructions for you to pay amounts from the account to an address or account outside the treaty country unless the account holder provides a reasonable explanation, in writing, establishing the account holder's residence in the applicable treaty country or you have in your possession or obtain documentary evidence (described in Regulations section
Where required, a reasonable explanation supporting an individual’s claim of foreign status means a written statement prepared by the individual, or, in the alternative, a checklist provided by you and completed by the individual stating that the individual meets one of the requirements listed in Regulations section
Hold mail instruction. An address that is provided subject to an instruction to hold all mail to that address is not a permanent residence address, such that you may not rely upon the Form
For additional information on the standards of knowledge for chapter 3 purposes for relying on a claim of foreign status or a claim of residency in a treaty country, see Regulations section
Dual claims under a tax treaty. If you are making payments to a foreign entity that is simultaneously claiming a reduced rate of tax under a tax treaty on its own behalf and a separate treaty claim on behalf of its interest holders for different payments or for different portions of the same payment, you may accept the dual claims even though you hold different withholding certificates that require you to treat the entity inconsistently. Alternatively, you may choose to apply only the claim made by the entity, provided that the entity may be treated as the beneficial owner of the income. If, however, inconsistent claims are made for the same portion of a payment, you may either reject both claims and request consistent claims for that portion of the payment, or you may choose which reduction in rate to apply.
Requirements for Obtaining and Verifying a Global Intermediary Identification Number (GIIN)
If you receive a Form
Participating FFIs (including reporting Model 2 FFIs),
Registered
Direct reporting NFFEs,
Sponsored direct reporting NFFEs, and
Certain nonreporting IGA FFIs (as described below).
If you receive a Form
If you receive a Form
For an entity claiming status as a certified
If you receive a Form
payee that does not include a GIIN, or includes a GIIN that does not appear on the published IRS FFI list, will be invalid for purposes of chapter 4 beginning on the date that is 90 days after the date the form is provided. See Regulations section
You may only accept a Form
Presumption Rules
If you do not receive a valid Form
When To Request a New Form
Request a new Form
Before the expiration of the validity period of an existing Form
If the existing form does not support a claim of reduced rate or is incomplete with respect to any claim made on the form (such as may result, for example, from a new regulatory requirement relevant to the Form
If you know or have reason to know of a change in circumstances that makes any information on the current form unreliable or incorrect for purposes of chapter 3 or 4 (to the extent applicable) based on the claims made on the form.
Example. A foreign individual investor opens an account with a broker to purchase U.S. Treasury bonds and provides Form
Inst. for the Requester of Forms
Changes in circumstances for chapter 4 purposes. For chapter 4 purposes, a change in circumstances generally occurs when there is a change in a person’s chapter 4 status. You must treat a Form
You are not considered to have reason to know of a change in circumstances if an FFI’s chapter 4 status changes solely because the jurisdiction where the FFI is resident, organized, or located is treated as having an IGA in effect or if the jurisdiction had a Model 2 IGA in effect and is later treated as having a Model 1 IGA in effect. If such change in circumstances occurs, the FFI may provide you with oral or written confirmation (including by email) of its new chapter 4 status rather than providing a new Form
If an FFI is resident, organized, or located in a jurisdiction that is treated as having an IGA in effect, and the jurisdiction’s status on the Treasury Department’s IGA list (located at
Period of Validity
Generally, a Form
treaty benefits) that are received by a withholding agent before the validity period of either the form or the documentary evidence would otherwise expire are indefinitely valid. A Form
Forms Received That Are Not Dated or That Contain Inconsequential Errors or Omissions
If a Form
Foreign TINs
If you are a U.S. office or branch of a depository institution, custodial institution, investment entity, or specified insurance company (each as defined in Regulations section
The account holder is resident of a jurisdiction that is not listed in section 3 of Revenue Procedure
The account holder is resident in a jurisdiction that has been identified by the IRS on a list of jurisdictions for which witholding agents are not required to obtain foreign TINs;
The account holder is a government, international organization, foreign central bank of issue, or resident of a U.S. territory; or
You obtain a reasonable explanation for why the account holder has not been issued a foreign TIN.
A reasonable explanation that an account holder does not have a foreign TIN must address why the account holder was not issued a foreign TIN only to the extent provided in the instructions for the applicable Form
See Notice
Alternative Certifications
Under an Applicable IGA
If you are an FFI subject to a Model 1 or Model 2 IGA using Form
If you are a withholding agent (including an FFI), you may also request and rely upon an alternative certification from an entity account holder to establish that the account holder is a NFFE (rather than a financial institution) under an applicable IGA. An entity providing such a certification will still be required, however, to provide its chapter 4 status (that is, the type of NFFE) in Part I, line 5, as determined under the regulations if you are a withholding agent other than an FFI documenting an account holder under Annex 1 of an applicable IGA. For example, if you are a U.S. withholding agent that receives a Form
financial institution as defined under the IGA applicable to the entity and document it under the regulations by obtaining the NFFE's certification of its chapter 4 status in Part I, line 5. In the case of an FFI documenting an account holder under Annex 1 of an applicable IGA however, a nonprofit organization treated as an active NFFE under the Annex may provide an FFI with an alternative certification that it is an NFFE that qualifies as a nonprofit organization under an applicable IGA. In such a case, the nonprofit organization will not be required to check a box in Part I, line 5, and the FFI may treat the entity as an excepted NFFE.
If you receive an alternative certification under an applicable IGA described in the preceding paragraphs, you may rely on such certification unless you know or have reason to know the certification is incorrect.
Rules for Specific Types of Forms W– 8
Line 10 (Special rates and conditions). If the beneficial owner is required to explain the additional conditions in the treaty that it meets to be eligible for the rate of withholding on line 10, you may accept a brief explanation for this purpose. You may accept a treaty claim without this explanation under an interest or dividends (other than dividends subject to a preferential rate based on ownership) article of a treaty or other income article, unless such article requires additional representations.
Form
You should request Form
Form
You should request Form
Notes for Validating Form
Line 6 (Foreign TIN). If you do not obtain a foreign TIN (or a reasonable explanation for why the account holder has not been issued a foreign TIN) on line 6 (or on a separate statement) when required (see Foreign TINs, earlier), you must treat the form as invalid for payments of U.S. source income reportable on Form
Line 8 (Date of birth). If you are a U.S. office or branch of a depository institution, custodial institution, investment entity, or specified insurance company (each as defined in Regulations section
Inst. for the Requester of Forms
Notes for Validating Form
Part I, Line 4 (Chapter 3 status). If you receive a Form
Part I, Line 9b (Foreign TIN). If you do not obtain a foreign TIN (or a reasonable explanation for why the account holder has not been issued a foreign TIN) on line 9b (or on a separate statement) when required (see Foreign TINs, earlier), you must treat the form as invalid for payments of U.S. source income reportable on Form
Part II (Disregarded Entity or Branch Receiving Pay- ment). If you are making payments to multiple branches/ disregarded entities that would be completing Part II, and the Part I information for each branch/disregarded entity is the same, instead of obtaining separate Forms
Part III (Claim of Tax Treaty Benefits), Line 14(b). For a Form
an entity claiming a reduced rate of withholding under an income tax treaty that contains a limitation on benefits article must identify the limitation on benefits provision that it satisfies by checking one of the boxes in line 14(b). In general, the entity is only required to check one box, even if it satisfies more than one provision. If the applicable treaty has no limitation on benefits article, the entity must check the box for “Other” and enter “N/A” in the line provided. You may rely on the entity’s claim in line 14(b) unless you have actual knowledge that the claim is incorrect.
Part III, Line 15 (Special rates and conditions). If the beneficial owner is required to explain the additional conditions in the treaty that it meets to be eligible for the rate of withholding on line 15, you may accept a brief explanation. You may accept a treaty claim without this explanation under an interest or dividends (other than dividends subject to a preferential rate based on ownership) article of a treaty or other income article, unless such article requires additional representations.
Part IX, Line 24
Form
You should request Form
If you receive a Form
Your receipt of Form
items of income identified on line 11 are effectively connected with the conduct of a trade or business within the United States. Therefore, if a beneficial owner provides you with a Form
If you pay items of income that are not identified on line 11 by the beneficial owner as effectively connected with the conduct of a trade or business within the United States, generally you are required to obtain another type of Form
Generally, you may not treat an amount as income effectively connected with the conduct of a trade or business within the United States unless the beneficial owner gives you a valid Form
Notional principal contracts reportable on Form
Payments to certain U.S. branches treated as effec- tively connected income. If you make a payment to a U.S. branch of a foreign bank or insurance company that does not provide a withholding certificate but has provided an EIN, the payment is presumed to be effectively connected with the conduct of a trade or business within the United States even if the foreign person (or its U.S. branch) does not give you a Form
obtain a Form
Form
You should request Form
If you are an FFI documenting an account holder that is a
A Form
You may treat a payee as an international organization without requiring a Form
A U.S. TIN is required if the beneficial owner is claiming an exemption or reduced rate of withholding based solely on a claim of
If you receive a Form
Form
You should request Form
You may accept multiple Forms
The chapter 4 status of an intermediary or
Generally, for purposes of both chapters 3 and 4, except to the extent otherwise provided in the Regulations under sections 1441 or 1471, a Form
Inst. for the Requester of Forms |
pool of payees, where permitted, as described later), provide the rate of withholding for each payee (or pool of payees), and provide certain identification information on each payee that is not included in a pool. See Regulations section
If you are a participating FFI or registered
Notes for Validating Form
QIs, WPs, and WTs (in general). A QI, WP, or WT acting in its capacity as such must provide the EIN that was issued to the entity in such capacity (that is, its
(ii)(for a QI),
If a QI checks line 15b of Part III of the form to certify that it assumes primary Form 1099 reporting and backup withholding responsibility, you may accept the form even if you do not know if there are any U.S. accounts receiving reportable payments at the time of the certification. If a QI does not check line 15b or 15c of Part III of the form, you must confirm that the QI is not receiving payments for U.S. accounts that are reportable on Form 1099, and the QI must provide an updated Form
IIIof the form to indicate that it allocates a portion of the payment to a chapter 4 withholding rate pool of U.S. payees that includes account holders of another intermediary or
QIs acting as QDDs. You should only accept a Form
must indicate its entity classification on line 16b of the form. If you are making such payment that is an amount subject to chapter 3 withholding to a QI that is acting as a QDD and the QDD is claiming treaty benefits applicable to the status identified on line 16b on the payment, you may treat the Form
QIs assuming withholding on payments of substitute interest. If a QI represents its status as a QI on a Form
QSLs. If you make payment of a U.S. source substitute dividend to a QSL (prior to January 1, 2020), the QSL is required to provide its U.S. TIN. If you make a payment to a QSL (prior to January 1, 2020) that is a withholdable payment, you must collect a Form
For information on transition rules for 2018 and 2019 for withholding agents to apply with respect to QSLs, see Notice
U.S. branches. If you make a payment to a U.S. branch of a foreign bank or insurance company that represents that it is acting as an intermediary and has agreed to be treated as a U.S. person, you are not required to obtain the GIIN or chapter 4 status of the entity, but you must obtain the U.S. branch’s EIN. If you make a withholdable payment after June 30, 2017, to a U.S. branch of an FFI that is acting as an intermediary and that does not agree to be treated as a U.S. person, the branch must provide its EIN (but does not need to provide a GIIN or chapter 4 status) and certify that the branch is applying the rules described in Regulations section
Territory financial institutions acting as intermedia- ries. If you make a payment to a territory financial institution acting as an intermediary, you must obtain the territory financial institution’s EIN if it agrees to be treated as a U.S. person for chapters 3 and 4. You are not required to obtain a GIIN from a territory financial institution.
Participating FFIs and registered
(B)for standards that apply in such case to determine whether chapter 4 withholding applies. You may rely on documentation that does not include a chapter 4 status for an account holder of an intermediary or
An intermediary or
requirements of (and documentation or information that is publicly available that determines the chapter 4 status of the payee permitted under) an applicable IGA for an account holder, and you may rely upon such status and documentation, provided that you have the information necessary to report on Form
In general, if you make a withholdable payment to an intermediary or
Section 1446 requirements. You should request Form
Inst. for the Requester of Forms |
Requirements for Hybrid and Reverse Hybrid Entities
A hybrid entity is an entity that is treated as fiscally transparent under the Code but is not treated as fiscally transparent under the tax laws of a country with which the United States has an income tax treaty.
If you are making a payment to a foreign hybrid entity that is making a claim for treaty benefits on its own behalf, the hybrid entity should provide a Form
A foreign reverse hybrid entity is an entity that is a corporation for U.S. tax purposes but is fiscally transparent under the tax laws of a country with which the United States has an income tax treaty. If a foreign reverse hybrid entity is receiving a payment for which the entity is claiming a reduced rate of withholding for its owners, you must obtain from the entity a Form
Substitute Forms
You may develop and use your own Form
A form that satisfies these substitute forms requirements may be treated as a similar agreed form for purposes of an applicable IGA unless the partner jurisdiction declines such treatment.
A substitute form does not need to contain all of the provisions contained on the official form, so long as it contains those provisions that are relevant to the transaction for which it is furnished. You may omit the chapter 4 certifications on your substitute form if such certifications are not required based on the payments made to the payees. If you are an FFI documenting the chapter 4 status of your account holders under your chapter 4 requirements or an applicable IGA, however, you may not omit the chapter 4 certifications. If you are making a withholdable payment, you may choose to provide a substitute form that does not include all of the chapter 4 statuses provided on the Form
You may incorporate a substitute Form
1.Use a substitute form that requires the payee, by signing, to agree to provisions unrelated to the required certifications; or
2.Imply that a person may be subject to 30% withholding or backup withholding unless that person agrees to provisions on the substitute form that are unrelated to the required certifications.
A substitute Form
same penalties of perjury statement and certifications as the official forms and the required signature. However, if the substitute form is contained in some other business form, the words “information on this form” may be modified to refer to that portion of the business form containing the substitute form information. The design of the substitute form must be such that the information and certifications that are being attested to by the penalties of perjury statement clearly stand out from any other information contained in the form.
Content of Substitute Form
Substitute Form
The substitute form must contain the penalties of perjury statement identical to the statement on the official Form
incorporated into other business forms, the following statement must be presented in the same manner as the penalties of perjury statement and must appear immediately above the single signature line: “The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a
Substitute Form
If the substitute form is incorporated into other business forms, the following statement must be presented in the same manner as the penalties of perjury statement and must appear immediately above the single signature line: “The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a
Substitute Form
If the substitute form is incorporated into other business forms, the following statement must be presented in the same manner as the penalties of perjury statement and must appear immediately above the single signature line: “The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a
Substitute Form
the form. For example, if a withholding agent is documenting a beneficial owner that is a foreign government for purposes of both chapters 3 and 4, the withholding agent may use a substitute Form
If the substitute form is incorporated into other business forms, the following statement must be presented in the same manner as the penalties of perjury statement and must appear immediately above the single signature line: “The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a foreign government, international organization, foreign central bank of issue, foreign
Substitute Form
Payments, earlier, for when you may omit a chapter 4 certification on a substitute Form
If the substitute form is incorporated into other business forms, the following statement must be presented in the same manner as the penalties of perjury statement and must appear immediately above the single signature line:
Inst. for the Requester of Forms |
“The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish: (1) your status as a qualified intermediary, a nonqualified intermediary, a specific type of U.S. branch, a withholding foreign partnership, a withholding foreign trust, a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust; (2) your chapter 4 status; and/or (3) prior to January 1, 2020, your status as a qualified securities lender.”
Receiving Reportable Amounts
If you are an FFI documenting an account holder that is an individual and you are not making a payment of a reportable amount to such account holder, you may use a
birth. The form may also request other information required for purposes of tax or
Generally, a
This page is blank (do not print)
Form
(Rev. July 2017)
Department of the Treasury Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner for United
States Tax Withholding and Reporting (Individuals)
For use by individuals. Entities must use Form
Go to WWW.IRS.GOV/FORMW8BEN for instructions and the latest information. Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No.
Do NOT use this form if: |
Instead, use Form: |
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• You are NOT an individual |
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• You are a U.S. citizen or other U.S. person, including a resident alien individual |
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• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. |
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(other than personal services) |
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• You are a beneficial owner who is receiving compensation for personal services performed in the United States |
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8233 or |
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• You are a person acting as an intermediary |
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Note: If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be provided to your jurisdiction of residence.
Part I Identification of Beneficial Owner (see instructions)
1Name of individual who is the beneficial owner
2Country of citizenship
3Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
4Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
5U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)
6Foreign tax identifying number (see instructions)
7Reference number(s) (see instructions)
8Date of birth
Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 I certify that the beneficial owner is a resident of treaty between the United States and that country.
10Special rates and conditions (if
of the treaty identified on line 9 above to claim a |
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% rate of withholding on (specify type of income): |
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Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:
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:
•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 for chapter 4 purposes,
•The person named on line 1 of this form is not a U.S. person,
•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 applicable income tax treaty, or
(c)the partner’s share of a partnership's effectively connected income,
•The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the United States and that country, and
•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 within 30 days if any certification made on this form becomes incorrect.
Sign Here
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Signature of beneficial owner (or individual authorized to sign for beneficial owner) |
Date |
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Print name of signer |
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Capacity in which acting (if form is not signed by beneficial owner) |
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For Paperwork Reduction Act Notice, see separate instructions. |
Cat. No. 25047Z |
Form |
Printed on recycled paper
This page is blank (do not print)
Form
(Rev. July 2017)
Department of the Treasury Internal Revenue Service
Certificate of Foreign Person's Claim That Income Is Effectively Connected With the Conduct of a Trade or Business in the United States
Section references are to the Internal Revenue Code.
Go to WWW.IRS.GOV/FORMW8ECI for instructions and the latest information. Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No.
Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively connected with a U.S. trade or business. See instructions.
Do not use this form for: |
Instead, use Form: |
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• |
A beneficial owner solely claiming foreign status or treaty benefits |
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• A foreign |
government, international organization, foreign central bank of issue, foreign |
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foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) |
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Note: These entities should use Form |
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or 4 purposes on Form |
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A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively connected with the |
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conduct of a trade or business in the United States) |
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A person acting as an intermediary |
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Note: See instructions for additional exceptions. |
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Part I |
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Identification of Beneficial Owner (see instructions) |
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1Name of individual or organization that is the beneficial owner
2Country of incorporation or organization
3Name of disregarded entity receiving the payments (if applicable)
4 |
Type of entity (check the appropriate box): |
Individual |
Corporation |
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Partnership |
Simple trust |
Complex trust |
Estate |
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Government |
Grantor trust |
Central bank of issue |
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Private foundation |
International organization |
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5Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
6Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state, and ZIP code
7 |
U.S. taxpayer identification number |
8 Foreign tax identifying number |
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SSN or ITIN |
EIN |
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9 |
Reference number(s) (see instructions) |
10 Date of birth |
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11Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade or business in the United States (attach statement if necessary).
Part II Certification
Sign Here
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:
•I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the payments to which this form relates,
•The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States,
•The income for which this form was provided is includible in my gross income (or the beneficial owner’s gross income) for the taxable year, and
•The beneficial owner is not a U.S. person.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the payments of which I am the beneficial owner or any withholding agent that can disburse or make payments of the amounts of which I am the beneficial owner.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.
Signature of beneficial owner (or individual authorized to sign for the beneficial owner) |
Print name |
Date |
I certify that I have the capacity to sign for the person identified on line 1 of this form.
For Paperwork Reduction Act Notice, see separate instructions. |
Cat. No. 25045D |
Form |
Printed on recycled paper |
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Form
(Rev. July 2017)
Department of the Treasury
Internal Revenue Service
Certificate of Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
▶For use by entities. Individuals must use Form
▶Go to www.irs.gov/FormW8BENE for instructions and the latest information.
▶Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No.
Do NOT use this form for: |
Instead use Form: |
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• U.S. entity or U.S. citizen or resident . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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• A foreign individual |
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• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S. |
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(unless claiming treaty benefits) . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . |
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•A foreign government, international organization, foreign central bank of issue, foreign
501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) |
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• Any person acting as an intermediary (including a qualified intermediary acting as a qualified derivatives dealer) |
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Part I |
Identification of Beneficial Owner |
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1Name of organization that is the beneficial owner
2Country of incorporation or organization
3Name of disregarded entity receiving the payment (if applicable, see instructions)
4 |
Chapter 3 Status (entity type) (Must check one box only): |
Corporation |
Disregarded entity |
Partnership |
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Simple trust |
Grantor trust |
Complex trust |
Estate |
Government |
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Central Bank of Issue |
Private foundation |
International organization |
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If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty |
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claim? If "Yes" complete Part III. |
Yes |
No |
5 |
Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity's applicable status.) |
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Nonparticipating FFI (including an FFI related to a Reporting IGA |
Nonreporting IGA FFI. Complete Part XII. |
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FFI other than a |
Foreign government, government of a U.S. possession, or foreign |
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exempt beneficial owner). |
central bank of issue. Complete Part XIII. |
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Participating FFI. |
International organization. Complete Part XIV. |
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Reporting Model 1 FFI. |
Exempt retirement plans. Complete Part XV. |
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Reporting Model 2 FFI. |
Entity wholly owned by exempt beneficial owners. Complete Part XVI. |
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Registered |
Territory financial institution. Complete Part XVII. |
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FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII). |
Excepted nonfinancial group entity. Complete Part XVIII. |
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See instructions. |
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Excepted nonfinancial |
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Sponsored FFI. Complete Part IV. |
Excepted nonfinancial entity in liquidation or bankruptcy. |
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Certified |
Complete Part XX. |
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Part V. |
501(c) organization. Complete Part XXI. |
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Certified |
Nonprofit organization. Complete Part XXII. |
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Complete Part VI. |
Publicly traded NFFE or NFFE affiliate of a publicly traded |
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Certified |
corporation. Complete Part XXIII. |
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vehicle. Complete Part VII. |
Excepted territory NFFE. Complete Part XXIV. |
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Certified |
Active NFFE. Complete Part XXV. |
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Complete Part VIII. |
Passive NFFE. Complete Part XXVI. |
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Certain investment entities that do not maintain financial accounts. |
Excepted |
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Complete Part IX. |
Direct reporting NFFE. |
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Sponsored direct reporting NFFE. Complete Part XXVIII. |
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Restricted distributor. Complete Part XI. |
Account that is not a financial account. |
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6Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
7Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
8U.S. taxpayer identification number (TIN), if required
9a GIIN
bForeign TIN
10Reference number(s) (see instructions)
Note: Please complete remainder of the form including signing the form in Part XXX.
For Paperwork Reduction Act Notice, see separate instructions. |
Cat. No. 59689N |
Form |
Form |
Page 2 |
Part II Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a branch of an FFI in a country other than the FFI's country of residence. See instructions.)
11Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment
Branch treated as nonparticipating FFI. |
Reporting Model 1 FFI. |
Participating FFI. |
Reporting Model 2 FFI. |
U.S. Branch.
12Address of disregarded entity or branch (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
13GIIN (if any)
Part III Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only.)
14I certify that (check all that apply):
a The beneficial owner is a resident of
treaty between the United States and that country.
b The beneficial owner 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. The following are types of limitation on benefits provisions that may be included in an applicable tax treaty (check only one; see instructions):
Government |
Company that meets the ownership and base erosion test |
Tax exempt pension trust or pension fund |
Company that meets the derivative benefits test |
Other tax exempt organization |
Company with an item of income that meets active trade or business test |
Publicly traded corporation |
Favorable discretionary determination by the U.S. competent authority received |
Subsidiary of a publicly traded corporation |
Other (specify Article and paragraph): |
c The beneficial owner is claiming treaty benefits for U.S. source 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).
15Special rates and conditions (if
The beneficial owner is claiming the provisions of Article and paragraph
of the treaty identified on line 14a above to claim a% rate of withholding on (specify type of income):
Explain the additional conditions in the Article the beneficial owner meets to be eligible for the rate of withholding:
Part IV |
Sponsored FFI |
16Name of sponsoring entity:
17Check whichever box applies.
I certify that the entity identified in Part I:
•Is an investment entity;
•Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
•Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
I certify that the entity identified in Part I:
•Is a controlled foreign corporation as defined in section 957(a);
•Is not a QI, WP, or WT;
•Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this entity; and
•Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or payees.
Form
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Page 3 |
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Part V |
Certified |
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I certify that the FFI identified in Part I: |
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•Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of incorporation or organization;
•Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to such bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater than 5% interest in such credit union or cooperative credit organization;
•Does not solicit account holders outside its country of organization;
•Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not advertised to the public and from which the FFI performs solely administrative support functions);
•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; and
•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 FFI identified in Part I and that meets the requirements set forth in this part.
Part VI |
Certified |
19 |
I certify that the FFI identified in Part I: |
•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;
•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); and
•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.
Part VII |
Certified |
20Name of sponsoring entity:
21 |
I certify that the entity identified in Part I: |
•Is an FFI solely because it is an investment entity described in Regulations section
•Is not a QI, WP, or WT;
•Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fulfilled by the sponsoring entity identified on line 20; and
•20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial institutions, participating FFIs, registered
Part VIII |
Certified |
22 |
I certify that the entity identified in Part I: |
•Was in existence as of January 17, 2013;
•Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar agreement; and
•Is certified
Part IX |
Certain Investment Entities that Do Not Maintain Financial Accounts |
23 |
I certify that the entity identified in Part I: |
•Is a financial institution solely because it is an investment entity described in Regulations section
•Does not maintain financial accounts.
Part X
Note: This status only applies if the U.S. financial institution, participating FFI, or reporting Model 1 FFI to which this form is given has agreed that it will treat the FFI as an
24a (All
•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 owned by or in an expanded affiliated group 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;
•Does not maintain a financial account for any nonparticipating FFI; and
•Does not have any specified U.S. persons that own an equity interest or debt interest (other than a debt interest that is not a financial account or that has a balance or value not exceeding $50,000) in the FFI other than those identified on the FFI owner reporting statement.
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Part X |
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Check box 24b or 24c, whichever applies. b
•Has provided, or will provide, an FFI owner reporting statement that contains:
(i)The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S. person that owns a direct or indirect equity interest in the
(ii)The name, address, TIN (if any), and chapter 4 status of every individual and specified U.S. person that owns a debt interest in the
(iii)Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.
•Has provided, or will provide, valid documentation meeting the requirements of Regulations section
c
Check box 24d if applicable (optional, see instructions).
d I certify that the entity identified on line 1 is a trust that does not have any contingent beneficiaries or designated classes with unidentified beneficiaries.
Part XI
25a
•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 customers unrelated to each other and less than half of its customers are related to each other;
•Is required to perform AML due diligence procedures under the
•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; and
•Does not distribute any debt or securities of the restricted fund to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.
Check box 25b or 25c, 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
Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and U.S. resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.
c
Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the procedures identified in Regulations section
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Part XII |
Nonreporting IGA FFI |
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26 |
I certify that the entity identified in Part I: |
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• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
. The applicable IGA is a
Model 1 IGA or a
Model 2 IGA; and
is treated as a |
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under the provisions of the applicable IGA or Treasury regulations |
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(if applicable, see instructions); |
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• If you are a trustee documented trust or a sponsored entity, provide the name of the trustee or sponsor |
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The trustee is:
U.S.
Foreign
Part XIII Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue
27
I certify that the entity identified in Part I is the beneficial owner of the payment, and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is submitted (except as permitted in Regulations section
Part XIV |
International Organization |
Check box 28a or 28b, whichever applies.
28a |
I certify that the entity identified in Part I is an international organization described in section 7701(a)(18). |
b |
I certify that the entity identified in Part I: |
•Is comprised primarily of foreign governments;
•Is recognized as an intergovernmental or supranational organization under a foreign law similar to the International Organizations Immunities Act or that has in effect a headquarters agreement with a foreign government;
•The benefit of the entity's income does not inure to any private person; and
•Is the beneficial owner of the payment and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is submitted (except as permitted in Regulations section
Part XV |
Exempt Retirement Plans |
Check box 29a, b, c, d, e, or f, whichever applies. 29a
•Is established in a country with which the United States has an income tax treaty in force (see Part III if claiming treaty benefits);
•Is operated principally to administer or provide pension or retirement benefits; and
•Is entitled to treaty benefits on income that the fund derives from U.S. sources (or would be entitled to benefits if it derived any such income) as a resident of the other country which satisfies any applicable limitation on benefits requirement.
b
•Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former employees of one or more employers in consideration for services rendered;
•No single beneficiary has a right to more than 5% of the FFI's assets;
•Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the country in which the fund is established or operated; and
(i)Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its status as a retirement or pension plan;
(ii)Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section
(iii)Either does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to retirement, disability, or death (except rollover distributions to accounts described in Regulations section
(iv)Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
c
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Part XV |
Exempt Retirement Plans (CONTINUED) |
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I certify that the entity identified in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other |
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than the requirement that the plan be funded by a trust created or organized in the United States. |
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e |
I certify that the entity identified in Part I is established exclusively to earn income for the benefit of one or more retirement funds |
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described in this part or in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section |
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retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 IGA. |
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f |
I certify that the entity identified in Part I: |
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•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
Part XVI |
Entity Wholly Owned by Exempt Beneficial Owners |
30 |
I certify that the entity identified in Part I: |
•Is an FFI solely because it is an investment entity;
•Each direct holder of an equity interest in the investment entity is an exempt beneficial owner described in Regulations section
•Each direct holder of a debt interest in the investment entity is either a depository institution (with respect to a loan made to such entity) or an exempt beneficial owner described in Regulations section
•Has provided an owner reporting statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the type of documentation provided to the withholding agent for every person that owns a debt interest constituting a financial account or direct equity interest in the entity; and
•Has provided documentation establishing that every owner of the entity is an entity described in Regulations section
(f)and/or (g) without regard to whether such owners are beneficial owners.
Part XVII |
Territory Financial Institution |
31
I certify that the entity identified in Part I is a financial institution (other than an investment entity) that is incorporated or organized under the laws of a possession of the United States.
Part XVIII |
Excepted Nonfinancial Group Entity |
32 |
I certify that the entity identified in Part I: |
•Is a holding company, treasury center, or captive finance company and substantially all of the entity's activities are functions described in Regulations section
•Is a member of a nonfinancial group described in Regulations section
•Is not a depository or custodial institution (other than for members of the entity's expanded affiliated group); 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 with an investment strategy to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes.
Part XIX |
Excepted Nonfinancial |
33 |
I certify that the entity identified in Part I: |
•Was formed on (or, in the case of a new line of business, the date of board resolution approving the new line of business) (date must be less than 24 months prior to date of payment);
•Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of business other than that of a financial institution or passive NFFE;
•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 XX |
Excepted Nonfinancial Entity in Liquidation or Bankruptcy |
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34 |
I certify that the entity identified in Part I: |
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• Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on |
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•During the past 5 years has not been engaged in business as a financial institution or acted as a passive NFFE;
•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 3 years.
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Part XXI |
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501(c) Organization |
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35 |
I certify that the entity identified in Part I is a 501(c) organization that: |
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• Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization that is |
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dated |
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; or |
•Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization (without regard to whether the payee is a foreign private foundation).
Part XXII |
Nonprofit Organization |
36 |
I certify that the entity identified in Part I is a nonprofit organization that meets the following requirements. |
•The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes;
•The entity is exempt from income tax in its country of residence;
•The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
•Neither the applicable laws of the entity's country of residence nor the entity's formation documents permit any income or assets of the entity to be distributed to, or applied for the benefit of, a private person or noncharitable entity other than pursuant to the conduct of the entity's charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property which the entity has purchased; and
•The applicable laws of the entity's country of residence or the entity's formation documents require that, upon the entity'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 or escheats to the government of the entity's country of residence or any political subdivision thereof.
Part XXIII Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation
Check box 37a or 37b, whichever applies.
37a |
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).
b 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 a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is |
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; and |
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• The name of the securities market on which the stock is regularly traded is |
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Part XXIV |
Excepted Territory NFFE |
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38 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:
(i)Does not accept deposits in the ordinary course of a banking or similar business;
(ii)Does not hold, as a substantial portion of its business, financial assets for the account of others; or
(iii)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 is organized or incorporated.
Part XXV Active NFFE
39 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 are assets that produce or are held for the production of passive income (calculated as a weighted average of the percentage of passive assets measured quarterly) (see instructions for the definition of passive income).
Part XXVI Passive NFFE
40a
I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a possession of the United States) and is not certifying its status as a publicly traded NFFE (or affiliate), excepted territory NFFE, active NFFE, direct reporting NFFE, or sponsored direct reporting NFFE.
Check box 40b or 40c, whichever applies. b
c
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Part XXVII |
Excepted |
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41 |
I certify that the entity identified in Part I: |
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•Is a member of an expanded affiliated group;
•Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group);
•Does not make withholdable payments to any person other than to members of its expanded affiliated group;
•Does not hold an account (other than depository accounts in the country in which the entity is operating to pay for expenses) with or receive payments from any withholding agent other than a member of its expanded affiliated group; and
•Has not agreed to report under Regulations section
Part XXVIII Sponsored Direct Reporting NFFE (see instructions for when this is permitted)
42Name of sponsoring entity:
43
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 42.
Part XXIX Substantial U.S. Owners of Passive NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see the instructions for a definition of substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or reporting Model 2 FFI, an NFFE may also use this part for reporting its controlling U.S. persons under an applicable IGA.
Name
Address
TIN
Part XXX 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:
•The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4 purposes, or is a merchant submitting this form for purposes of section 6050W;
•The entity identified on line 1 of this form is not a U.S. person;
•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
•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 the entity on line 1 is the beneficial owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
Sign Here
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Signature of individual authorized to sign for beneficial owner |
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Date |
I certify that I have the capacity to sign for the entity identified on line 1 of this form.
Form
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Form
(Rev. July 2017)
Department of the Treasury Internal Revenue Service
Certificate of Foreign Government or Other Foreign
Organization for United States Tax
Withholding and Reporting
(For use by foreign governments, international organizations, foreign central banks of issue, foreign
Go to WWW.IRS.GOV/FORMW8EXP for instructions and the latest information.
Section references are to the Internal Revenue Code.
Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No.
Do not use this form for: |
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Instead, use Form: |
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• |
A foreign government or other foreign organization that is not claiming the applicability of section(s) 115(2), 501(c), 892, 895, |
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or 1443(b) |
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• |
A beneficial owner solely claiming foreign status or treaty benefits |
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A foreign partnership or a foreign trust |
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A person claiming that income is effectively connected with the conduct of a trade or business in the United States . . |
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. . . |
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A person acting as an intermediary |
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. . . |
Part I Identification of Beneficial Owner
1Name of organization
2Country of incorporation or organization
3Type of entity
Foreign government International organization
Foreign central bank of issue (not wholly owned by the foreign sovereign)
Foreign
4Chapter 4 Status (FATCA status):
Participating FFI. Reporting Model 1 FFI. Reporting Model 2 FFI.
Registered
Nonreporting IGA FFI. Complete Part III. Territory financial institution. Complete Part III. International organization.
Foreign government (including a political subdivision), government of a U.S. possession, or foreign central bank of issue. Complete Part III.
Exempt retirement plan of foreign government. Complete Part III. 501(c) organization. Complete Part III.
Passive NFFE. Complete Part III. Direct reporting NFFE.
Sponsored direct reporting NFFE. Complete Part III.
5 Permanent address (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate. |
Country |
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6Mailing address (if different from above).
City or town, state or province. Include postal or ZIP code where appropriate. |
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7 U.S. TIN, if required (see instructions) |
8a GIIN |
b Foreign TIN (see instructions) |
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9Reference number(s) (see instructions)
Part II Qualification Statement for Chapter 3 Status
10 For a foreign government:
a I certify that the entity identified in Part I is a foreign government within the meaning of section 892 and the payments are within the scope of the exemption granted by section 892.
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Check box 10b or box 10c, whichever applies. |
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b |
The entity identified in Part I is an integral part of the government of |
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c |
The entity identified in Part I is a controlled entity of the government of |
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11For an international organization:
I certify that:
•The entity identified in Part I is an international organization within the meaning of section 7701(a)(18), and
•The payments are within the scope of the exemption granted by section 892.
12For a foreign central bank of issue (not wholly owned by the foreign sovereign):
I certify that:
•The entity identified in Part I is a foreign central bank of issue,
•The entity identified in Part I does not hold obligations or bank deposits to which this form relates for use in connection with the conduct of a commercial banking function or other commercial activity, and
•The payments are within the scope of the exemption granted by section 895.
For Paperwork Reduction Act Notice, see separate instructions. |
Cat. No. 25401F |
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Part II Qualification Statement for Chapter 3 Status (CONTINUED)
13 For a foreign
If any of the income to which this certification relates constitutes income includible under section 512 in computing the entity’s unrelated business taxable income, attach a statement identifying the amounts.
Check either box 13a or box 13b.
a I certify that the entity identified in Part I has been issued a determination letter by the IRS dated
that is currently in effect and that concludes that it is an exempt organization described in section 501(c).
b I have attached to this form an opinion from U.S. counsel concluding that the entity identified in Part I is described in section 501(c).
For section 501(c)(3) organizations only, check either box 13c or box 13d.
c If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section 501(c)(3), I certify that the organization is not a private foundation described in section 509. I have attached an affidavit of the organization setting forth sufficient facts for the IRS to determine that the organization is not a private foundation because it meets one of the exceptions described in section 509(a)(1), (2), (3), or (4).
d If the determination letter or opinion of counsel concludes that the entity identified in Part I is described in section 501(c)(3), I certify that the organization is a private foundation described in section 509.
14For a government of a U.S. possession:
I certify that the entity identified in Part I is a government of a possession of the United States, or is a political subdivision thereof, and is claiming the exemption granted by section 115(2).
Part III Qualification Statement for Chapter 4 Status (if required)
15 For a nonreporting IGA FFI:
I certify that the entity identified in Part I:
• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States
and |
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; |
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• Is treated as a |
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under the provisions of the applicable IGA (see instructions); and |
•If you are an FFI treated as a registered
.
16For a territory financial institution:
I certify that the entity identified in Part I is a financial institution (other than an investment entity) that is incorporated or organized under the laws of a possession of the United States.
17For a foreign government (including a political subdivision), government of a U.S. possession, or foreign central bank of issue: I certify that the entity identified in Part I is the beneficial owner of the payment and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is submitted (except as permitted in Regulations section
18For an exempt retirement plan of a foreign government: I certify that the entity identified in Part I:
•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
19For a 501(c) organization:
I certify that the entity identified in Part I is an entity described in section 501(c) but is not an insurance company described in section 501(c)(15).
20For a passive NFFE:
a I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a possession of the United States).
Check box 20b or 20c, 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 a statement including the name, address, and TIN of each substantial U.S. owner of the NFFE (see instructions).
21Name of sponsoring entity:
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 21.
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Part IV |
Certification |
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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:
•The organization for which I am signing is the beneficial owner of the income and other payments to which this form relates,
•The beneficial owner is not a U.S. person,
•For a beneficial owner that is a controlled entity of a foreign sovereign (other than a central bank of issue wholly owned by a foreign sovereign), the beneficial owner is not engaged in commercial activities within or outside the United States, and
•For a beneficial owner that is a central bank of issue wholly owned by a foreign sovereign, the beneficial owner is not engaged in commercial activities within the United States.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the payments of which I am the beneficial owner or any withholding agent that can disburse or make payments of the amounts of which I am the beneficial owner.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.
Sign |
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Here |
Signature of authorized official |
Print name |
Date |
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I certify that I have the capacity to sign for the entity identified on line 1 of this form.
Form
Printed on recycled paper
Form |
Certificate of Foreign Intermediary, Foreign |
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U.S. Branches for United States Tax Withholding and Reporting |
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(Rev. June 2017) |
Section references are to the Internal Revenue Code. |
OMB No. |
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Department of the Treasury |
Go to www.irs.gov/FormW8IMY for instructions and the latest information. |
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Internal Revenue Service |
Give this form to the withholding agent or payer. Do not send to the IRS. |
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Do not use this form for: |
Instead, use Form: |
•A beneficial owner solely claiming foreign status or treaty benefits (other than a qualified intermediary (QI) acting as a qualified
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derivatives dealer (QDD)) |
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• |
A hybrid entity claiming treaty benefits on its own behalf (other than a QI acting as a QDD) |
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A foreign person claiming that income is effectively connected with the conduct of a trade or business in the United States |
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. . |
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•A disregarded entity with a single foreign owner that is the beneficial owner (other than a QI acting as a QDD) of the income to which this form
relates. Instead, the single foreign owner should use . . . . . . . . . . . . . . . . . . .
•A foreign government, international organization, foreign central bank of issue, foreign
government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) |
. . |
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• U.S. entity or U.S. citizen or resident |
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•A foreign person documenting itself for purposes of section 6050W . . . . . . . . . . . . . .
Part I Identification of Entity
1Name of organization that is acting as intermediary
2Country of incorporation or organization
3Name of disregarded entity (if applicable), see instructions
4Chapter 3 Status (entity type) (Must check one box only.):
QI (including a QDD). Complete Part III. Nonqualified intermediary. Complete Part IV. Territory financial institution. Complete Part V. U.S. branch. Complete Part VI.
Withholding foreign partnership. Complete Part VII.
Withholding foreign trust. Complete Part VII. Nonwithholding foreign partnership. Complete Part VIII. Nonwithholding foreign simple trust. Complete Part VIII. Nonwithholding foreign grantor trust. Complete Part VIII.
5Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity’s applicable status.)
(Must check one box only.): |
Certain investment entities that do not maintain financial |
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Nonparticipating foreign financial institution (FFI) (including an FFI |
accounts. Complete Part XVI. |
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related to a Reporting IGA FFI other than a |
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participating FFI, or exempt beneficial owner). Complete Part IX (if |
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applicable). |
Restricted distributor. Complete Part XVII. |
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Participating FFI. |
Foreign central bank of issue. Complete Part XVIII. |
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Reporting Model 1 FFI. |
Nonreporting IGA FFI. Complete Part XIX. |
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Reporting Model 2 FFI. |
Exempt retirement plans. Complete Part XX. |
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Registered |
Excepted nonfinancial group entity. Complete Part XXI. |
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sponsored FFI, or nonreporting IGA FFI covered in Part XIX). |
Excepted nonfinancial |
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Territory financial institution. Complete Part V. |
Excepted nonfinancial entity in liquidation or bankruptcy. |
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Sponsored FFI (other than a certified |
Complete Part XXIII. |
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closely held investment vehicle). Complete Part X. |
Publicly traded NFFE or NFFE affiliate of a publicly traded |
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Certified |
corporation. Complete Part XXIV. |
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Certified |
Excepted territory NFFE. Complete Part XXV. |
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Certified |
Active NFFE. Complete Part XXVI. |
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vehicle. Complete Part XIV. |
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Passive NFFE. Complete Part XXVII. |
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Certified |
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Direct reporting NFFE. |
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Complete Part XV. |
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Sponsored direct reporting NFFE. Complete Part XXVIII. |
6Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
7Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
8U.S. taxpayer identification number, if required
EIN |
9GIIN (if applicable)
10Reference number(s) (see instructions)
For Paperwork Reduction Act Notice, see separate instructions. |
Cat. No. 25402Q |
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Page 2 |
Part II Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a branch of an FFI in a country other than the FFI’s country of residence. Do not complete Part II for QDD branches. See instructions.)
11Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment.
Branch treated as nonparticipating FFI. |
Reporting Model 1 FFI. |
Participating FFI. |
Reporting Model 2 FFI. |
U.S. Branch.
12Address of branch (street, apt. or suite no., or rural route). Do not use a P.O. box or
City or town, state or province. Include postal code where appropriate.
Country
13GIIN (if any)
Chapter 3 Status Certifications
Part III Qualified Intermediary
All Qualified Intermediaries
14
I certify that the entity identified in Part I (or branch, if relevant):
•Is a QI with respect to the accounts identified on line 10 or in a withholding statement associated with this form (as required) that is one or more of the following:
(i)not acting for its own account;
(ii)a QDD receiving payments on underlying securities and/or potential section 871(m) transactions;
(iii)a QI assuming primary withholding responsibility for payments of substitute interest, as permitted by the QI Agreement.
•Has provided or will provide a withholding statement (as required) for purposes of chapters 3 and 4 that is subject to the certifications made on this form.
Qualified Intermediaries not Acting as Qualified Derivatives Dealers (check all that apply)
15a I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 for each account identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts).
b I certify that the entity identified in Part I of this form assumes primary Form 1099 reporting and backup withholding responsibility or reporting responsibility as a participating FFI or registered
c I certify that the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding responsibility.
d (Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding responsibility.) If the entity identified in Part I of this form has allocated or will allocate a portion of a payment to a chapter 4 withholding rate pool of U.S. payees on a withholding statement associated with this form, I certify that the entity meets the requirements of Regulations section
e (Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding responsibility.) If the entity identified in Part I of this form has allocated or will allocate a portion of a payment to a chapter 4 withholding rate pool of U.S. payees on a withholding statement associated with this form, to the extent the U.S. payees are account holders of an intermediary or
f I certify that the entity identified in Part I of this form is acting as a qualified securities lender with respect to payments associated with this form that are U.S. source substitute dividends received from the withholding agent.
g I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 and primary Form 1099 reporting and backup withholding responsibility for all payments of substitute interest associated with this form, as permitted by the QI Agreement.
Qualified Derivatives Dealers
16a I certify that each QDD identified in Part I of this form or on a withholding statement associated with this form meets the requirements to act as a QDD and assumes primary withholding and reporting responsibilities under chapters 3, 4, and 61 and section 3406 with respect to any payments it makes with respect to potential section 871(m) transactions.
bEntity classification of QDD:
Corporation |
Partnership |
Disregarded Entity |
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Part IV |
Nonqualified Intermediary |
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Check all that apply. |
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17a
b
c
d
(All nonqualified intermediaries and QIs that are not acting in their capacity as such check here.) I certify that the entity identified in Part I of this form is not acting as a qualified intermediary with respect to each account(s) for which this form is provided and is not acting for its own account.
I certify that the entity identified in Part I of this form is using this form to transmit withholding certificates and/or other documentation and has provided, or will provide, a withholding statement, as required.
I certify that the entity identified in Part I of this form meets the requirements of Regulations section
I certify that the entity identified in Part I of this form is acting as a qualified securities lender with respect to payments associated with this form that are U.S. source substitute dividends received from the withholding agent.
Part V Territory Financial Institution
18a
I certify that the entity identified in Part I is a financial institution (other than an investment entity that is not also a depository institution, custodial institution, or specified insurance company) that is incorporated or organized under the laws of a possession of the United States.
Check box 18b or 18c, whichever applies.
b
c
I further certify that the entity identified in Part I is using this form as evidence of its agreement with the withholding agent to be treated as a U.S. person for purposes of chapters 3 and 4 with respect to any payments associated with this withholding certificate.
I further certify that the entity identified in Part I:
•Is using this form to transmit withholding certificates and/or other documentation for the persons for whom it receives a payment; and
•Has provided or will provide a withholding statement, as required.
Part VI |
Certain U.S. Branches |
19a
I certify that the entity identified in Part I is receiving payments that are not effectively connected with the conduct of a trade or business in the United States.
Check box 19b or 19c, whichever applies.
b
c
I certify that the entity identified in Part I is a U.S. branch of a foreign bank or insurance company described in Regulations
section
I certify that the entity identified in Part I:
•Is using this form to transmit withholding certificates and/or other documentation for the persons for whom the branch receives a payment;
•Has provided or will provide a withholding statement, as required; and
•In the case of a withholdable payment, is applying the rules described in Regulations section
Part VII |
Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT) |
20
I certify that the entity identified in Part I is a withholding foreign partnership or a withholding foreign trust that is compliant with the terms of its WP or WT agreement.
Part VIII Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
Check all that apply.
21a
b
I certify that the entity identified in Part I:
•Is a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and is providing this form for payments that are not effectively connected, or are not treated as effectively connected, with the conduct of a trade or business in the United States; and
•Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding statement, as required for purposes of chapters 3 and 4, that is subject to the certifications made on this form.
I certify that the entity identified in Part I is a foreign partnership that is a partner in a
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Chapter 4 Status Certifications |
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Part IX |
Nonparticipating FFI with Exempt Beneficial Owners |
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22
I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding statement that indicates the portion of the payment allocated to one or more exempt beneficial owners.
Part X Sponsored FFI
23a |
Name of sponsoring entity: |
Check box 23b or 23c, whichever applies.
b
c
I certify that the entity identified in Part I:
•Is an investment entity;
•Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
•Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
I certify that the entity identified in Part I:
•Is a controlled foreign corporation as defined in section 957(a);
•Is not a QI, WP, or WT;
•Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this entity; and
•Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or payees.
Part XI
Note: This status only applies if the U.S. financial institution, participating FFI, reporting Model 1 FFI, or reporting Model 2 FFI to which this form is given has agreed that it will treat the FFI as an
24a
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 (other than an FFI that is also treated as an
•Does not maintain a financial account for any nonparticipating FFI.
Check box 24b or 24c, whichever applies.
b
c
I certify that the FFI identified in Part I:
•Has provided, or will provide, an FFI owner reporting statement (including any applicable owner documentation) that contains:
(i)The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S. person that owns a direct or indirect equity interest in the
(ii)The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S. person that owns a debt interest in the
(iii)Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.
I certify that the FFI identified in Part I:
•Has provided, or will provide, an auditor’s letter, signed no more than 4 years prior to 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 and debt holders identified in Regulations section
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Page 5 |
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Part XII |
Certified |
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25
I certify that the FFI identified in Part I:
•Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of incorporation or organization;
•Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to such bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater than 5% interest in such credit union or cooperative credit organization;
•Does not solicit account holders outside its country of organization;
•Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not advertised to the public and from which the FFI performs solely administrative support functions);
•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; and
•Does not have any member of its expanded affiliated group that is an FFI, other than an FFI that is incorporated or organized in the same country as the FFI identified in Part I and that meets the requirements set forth in this Part XII.
Part XIII Certified
26
I certify that the FFI identified in Part I:
•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;
•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); and
•Neither the FFI nor the FFI’s entire expanded affiliated group, if any, has more than $50 million in assets on its consolidated or combined balance sheet as of the end of its most recent accounting year.
Part XIV Certified
27a
b
Name of sponsoring entity:
I certify that the FFI identified in Part I:
•Is an FFI solely because it is an investment entity described in Regulations section
•Is not a QI, WP, or WT;
•Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fulfilled by the sponsoring entity identified on line 27a; and
•20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial institutions, participating FFIs, registered
Part XV Certified
28
I certify that the FFI identified in Part I:
•Was in existence as of January 17, 2013;
•Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar agreement; and
•Is certified
Part XVI Certain Investment Entities That Do Not Maintain Financial Accounts
29
I certify that the entity identified in Part I:
•Is a financial institution solely because it is an investment entity described in Regulations section
•Does not maintain financial accounts.
Part XVII Restricted Distributor
30a
(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 customers unrelated to each other and less than half of its customers are related to each other;
•Is required to perform AML due diligence procedures under the
•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; and
•Does not distribute any debt or securities of the restricted fund to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.
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Part XVII |
Restricted Distributor (CONTINUED) |
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Check box 30b or 30c, 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
Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and U.S. resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.
Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the procedures identified in Regulations section
Part XVIII Foreign Central Bank of Issue
31
I certify that the entity identified in Part I is treated as the beneficial owner of the payment solely for purposes of chapter 4 under Regulations section
Part XIX Nonreporting IGA FFI
32
I certify that the entity identified in Part I:
• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
. The
applicable IGA is a |
Model 1 IGA or a |
Model 2 IGA; and is treated as a |
under the provisions of the applicable IGA or Treasury regulations (if applicable, see instructions); and
•If you are a trustee documented trust or sponsored entity, provide the name of the trustee or sponsor
The trustee is: U.S.
Foreign
Part XX Exempt Retirement Plans
Check box 33a, b, c, d, e, or f, whichever applies.
33a
b
c
d
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;
•Is operated principally to administer or provide pension or retirement benefits; and
•Is entitled to treaty benefits on income that the fund derives from U.S. sources (or would be entitled to benefits if it derived any such income) as a resident of the other country which satisfies any applicable limitation on benefits requirement.
I certify that the entity identified in Part I:
•Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former employees of one or more employers in consideration for services rendered;
•No single beneficiary has a right to more than 5% of the FFI’s assets;
•Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the country in which the fund is established or operated; and
(i)Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its status as a retirement or pension plan;
(ii)Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section
(iii)Either does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to retirement, disability, or death (except rollover distributions to accounts described in Regulations section
(iv)Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
I certify that the entity identified in Part I:
•Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former employees of one or more employers in consideration for services rendered;
•Has fewer than 50 participants;
•Is sponsored by one or more employers, each of which is not an investment entity or passive NFFE;
•Employee and employer contributions to the fund (disregarding transfers of assets from other plans described in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section
•Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20% of the fund’s assets; and
•Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the country in which the fund is established or operates.
I certify that the entity identified in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other than the requirement that the plan be funded by a trust created or organized in the United States.
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Part XX |
Exempt Retirement Plans (CONTINUED) |
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e
I certify that the entity identified in Part I is established exclusively to earn income for the benefit of one or more retirement funds described in this part or in an applicable Model 1 or Model 2 IGA, accounts described in Regulations section
f
I certify that the entity identified in Part I:
•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
2 IGA to provide retirement, disability, or death benefits to beneficiaries or participants that are current or former employees of the sponsor (or persons designated by such employees); or
•Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section
Part XXI Excepted Nonfinancial Group Entity
34
I certify that the entity identified in Part I:
•Is a holding company, treasury center, or captive finance company and substantially all of the entity’s activities are functions described in Regulations section
•Is a member of a nonfinancial group described in Regulations section
•Is not a depository or custodial institution (other than for members of the entity’s expanded affiliated group); 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 with an investment strategy to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes.
Part XXII Excepted Nonfinancial
35
I certify that the entity identified in Part I:
•Was formed on (or in the case of a new line of business, the date of board resolution approving the new line of business) (date must be less than 24 months prior to date of payment);
•Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of business other than that of a financial institution or passive NFFE; 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 XXIII Excepted Nonfinancial Entity in Liquidation or Bankruptcy
36
I certify that the entity identified in Part I:
• Filed a plan of liquidation, filed a plan for reorganization, or filed for bankruptcy on the following date: |
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•Has not been engaged during the past 5 years in business as a financial institution or acted as a passive NFFE;
•Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a nonfinancial entity; and
•Has provided, 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 3 years.
Part XXIV Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation
Check box 37a or 37b, whichever applies.
37a
b
I certify that: |
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• The entity identified in Part I is a foreign corporation that is not a financial institution; and |
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• The stock of such corporation is regularly traded on one or more established securities markets, including |
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I certify that: |
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•The entity identified in Part I is a foreign corporation that is not a financial institution;
•The entity identified in Part I is a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is |
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• The name of the securities market on which the stock is regularly traded is |
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Part XXV |
Excepted Territory NFFE |
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38
I certify that:
•The entity identified in Part I is an entity that is organized in a possession of the United States;
•All of the owners of the entity identified in Part I are bona fide residents of the possession in which the NFFE is organized or incorporated; and
•The entity identified in Part I:
(i)Does not accept deposits in the ordinary course of a banking or similar business;
(ii)Does not hold, as a substantial portion of its business, financial assets for the account of others; and
(iii)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.
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Part XXVI |
Active NFFE |
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39
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 are assets that produce or are held for the production of passive income (calculated as a weighted average of the percentage of passive assets measured quarterly). See the instructions for the definition of passive income.
Part XXVII Passive NFFE
40
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 using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding statement, as required.
Part XXVIII Sponsored Direct Reporting NFFE
41Name of sponsoring entity:
42
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 41.
Part XXIX 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. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any withholding agent that can disburse or make payments of the amounts for which I am providing this form.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.
Sign Here
Signature of authorized official |
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