W-8BEN (Individuals)
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)

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Part I: Identification of Beneficial Owner
1. Name of the individual who is the beneficial owner

Your email address

2. Country of citizenship

3. Permanent residence street address


Permanent residence city / suburb / town

Permanent residence state / province

Permanent residence postcode

Permanent residence country

4. Is your postal address the same as your residential address? * 5. U.S. taxpayer identification number (SSN or ITIN), if required

6. Non U.S. tax identifying number

7. Reference number(s)

8. Date of birth

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Part II: Claim of Tax Treaty Benefits
9. I certify that the beneficial owner is a resident of:

within the meaning of the income tax treaty between the United States and that country.

10. Do any special rates or conditions apply?

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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 Question 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 Question 1 of this form is a resident of the treaty country listed on Question 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.

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