Form W-8BEN: Certificate of Foreign Status for Individuals

In Part I Identification of Beneficial Owner (see instructions), enter the Name of individual who is the beneficial owner on line 1 and the Country of citizenship on line 2.

On line 3, enter the Permanent residence address (street, apt. or suite no., or rural route), the City or town, state or province with the postal code where appropriate, and the Country. Do not use a P.O. box or in-care-of address.

On line 4, enter the Mailing address (if different from above): the City or town, state or province with the postal code where appropriate, and the Country.

On line 5, enter the U.S. taxpayer identification number (SSN or ITIN), if required (see instructions).

On line 6a, enter the Foreign tax identifying number (see instructions). On line 6b, check if FTIN not legally required.

On line 7, enter the Reference number(s) (see instructions). On line 8, enter the Date of birth (MM-DD-YYYY) (see instructions).

Part II Claim of Tax Treaty Benefits is for chapter 3 purposes only (see instructions).

On line 9, certify that the beneficial owner is a resident of the Country you enter within the meaning of the income tax treaty between the United States and that country. On line 10, for Special rates and conditions (if applicable, see instructions), enter the Article and paragraph of the treaty identified on line 9 above, the % rate of withholding and the type of income, and explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding.

Under penalties of perjury, you declare that you have examined the information on this form and to the best of your knowledge and belief it is true, correct, and complete. You further certify under penalties of perjury that you are the individual that is the beneficial owner (or are authorized to sign for the individual that is the beneficial owner) of all the income or proceeds to which this form relates or are using this form to document you for chapter 4 purposes, and that the person named on line 1 of this form is not a U.S. person.

You also certify that this form relates to: (a) income not effectively connected with the conduct of a trade or business in the United States; (b) income effectively connected with the conduct of a trade or business in the United States but is not subject to tax under an applicable income tax treaty; (c) the partner's share of a partnership's effectively connected taxable income; or (d) the partner's amount realized from the transfer of a partnership interest subject to withholding under section 1446(f).

For broker transactions or barter exchanges, you certify that the beneficial owner is an exempt foreign person as defined in the instructions.

You authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which you are the beneficial owner or any withholding agent that can disburse or make payments of the income of which you are the beneficial owner. You agree that you will submit a new form within 30 days if any certification made on this form becomes incorrect.

Sign on the line for the Signature of beneficial owner (or individual authorized to sign for beneficial owner), enter the Date (MM-DD-YYYY) and the Print name of signer.

By checking this box, you certify that you have the capacity to sign for the person identified on line 1 of this form.

Do NOT use this form if you are NOT an individual. Instead, use Form W-8BEN-E.

If you are a U.S. citizen or other U.S. person, including a resident alien individual, do NOT use this form. Instead, use Form W-9.

A beneficial owner claiming that income is effectively connected with the conduct of trade or business within the United States (other than personal services): do NOT use this form. Instead, use Form W-8ECI.

Where you are a beneficial owner who is receiving compensation for personal services performed in the United States, do NOT use this form. Instead, use Form 8233 or W-4.

When you are a person acting as an intermediary, do NOT use this form. Instead, use Form W-8IMY.