EFTA01357419.pdf

For, W-8BEN Certificate of Foreign Status of Beneficial Owner (Rev. Februay 2035) for United States Tax Withholding OMB No. 1545-1821 Depanment of the Treasury 110 Section references are to the Internal Revenue Code. P See separate instructions. Internal Revenue Service ► Give this form to the withholding agent or payer. Do not send to the IRS. Do not tea this form for Instead, use Form: • A U.S. citizen or other U.S. person, including a resident alien individual W-9 • A person claiming that income is effectively connected with the conduct of a trade or business in the United States W-8ECI • A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) W-8ECI or W-8MAY • A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892.895, or 1443(b) (see instructions) W-BECI or W-8EXP Note: These entities should use Form W-St3EN if they are claiming treaty benefits or am providing the form only to claim they are a foreign person exempt from backup withholding. • A person acting as an intermediary W-8IMY Note: Soo instructions for additional exceptions. Part I Identification of Beneficial Owner (See instructions.) 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 Type of beneficial owner: O Incfrodual O Corporation O Disregarded entity O Pannershp LI Simple trust O Grantor trust O Complex trust O Estate O Government O International organzaton O Central bank of esue O Tax-exempt organization O Private fourxlation 4 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. City or town. state or province. Include postal code where appropriate. Country (do not abbreviate) 5 Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country (do not abbreviate) 6 U.S. taxpayer identification number, if required (see instructions) 7 Foreign tax identifying number, if any (optionag O SSN or /TIN O EIN 8 Reference numbers) (see instructions) Part II Claim of Tax Treaty Benefits (if applicable) 9 I certify that (check all that apply): a O he bonefca! crane, is a residert ci vibe the messing cl the sametax Ireay between the United States and taut country. b O If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). c O The beneficial owner is not an individual, 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 (see instructions). d O The beneficial owner is not an individual, is claiming treaty benefits for 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). e O The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(bl, and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000. 10 Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article of the treaty identified on line 9a above to claim a % rate of withholding on (specify typo of income): Explain the reasons the beneficial owner meets the terms of the treaty article: Part III Notional Principal Contracts 11 O I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Certification Under penalise of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it ra trua correct, and complete. ; further certify under penartiee of perjury that 1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which the form relates, 2 Tho beneficial owner is not a U.S. person. 3 The 't ome to which this form relates Is (a) not °Poeta/ay connected with the conduct of a trade or business in the United Stales. (b) eflectively corw,ecled tut is not subject to tax under an income tax treaty, or (c) the partner's share of a partnershp's etfectrvely connected income, and 4 For broker transactions or barter exchanges, the barefoot owner • an exempt foreign patron as defined in the astholons. Furthermore, 1 authorize this form to be provided to any withholding agent that hes control, recent or custody of the rooms of vthich I am the teneficial owner or any withholding agent that can disburse or make payments of the income of which I am the benehoal owns'. Sign Here 0 ° Signature of beneficial owner (or individual authorized to sign for beneficed owner) For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 250472 Date (SAM-DO-YYYY) Capacity in which acting Form W-8BEN (Rev. 2-2006) Printed an RecycledPaw 0 CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0043970 CONFIDENTIAL SDNY_GM_00 190154 EFTA01357419