IRS Form W-8BEN-E "Certificate of Status of Beneficial Owner for United States Tax Withholding and Reporting (Entities)"

What Is IRS Form W-8BEN-E?

This is a tax form that was released by the Internal Revenue Service (IRS) - a subdivision of the U.S. Department of the Treasury on July 1, 2017. Check the official IRS-issued instructions before completing and submitting the form.

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  • A 8-page form available for download in PDF;
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Download IRS Form W-8BEN-E "Certificate of Status of Beneficial Owner for United States Tax Withholding and Reporting (Entities)"

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W-8BEN-E
Certificate of Status of Beneficial Owner for
Form
United States Tax Withholding and Reporting (Entities)
OMB No. 1545-1621
(Rev. July 2017)
For use by entities. Individuals must use Form W-8BEN.
Section references are to the Internal Revenue Code.
Department of the Treasury
Go to www.irs.gov/FormW8BENE for instructions and the latest information.
Internal Revenue Service
Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form for:
Instead use Form:
• U.S. entity or U.S. citizen or resident .
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. W-9
• A foreign individual
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. W-8BEN (Individual) or Form 8233
• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits) .
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. W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions)
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. W-8IMY
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or
government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) .
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W-8ECI or W-8EXP
• Any person acting as an intermediary (including a qualified intermediary acting as a qualified derivatives dealer) .
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. W-8IMY
Part I
Identification of Beneficial Owner
1
Name of organization that is the beneficial owner
2 Country of incorporation or organization
3
Name 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
Government
Simple trust
Grantor trust
Complex trust
Estate
Central Bank of Issue
Tax-exempt organization
Private foundation
International organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
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.)
Nonparticipating FFI (including an FFI related to a Reporting IGA
Nonreporting IGA FFI. Complete Part XII.
FFI other than a deemed-compliant FFI, participating FFI, or
Foreign government, government of a U.S. possession, or foreign
exempt beneficial owner).
central bank of issue. Complete Part XIII.
Participating FFI.
International organization. Complete Part XIV.
Reporting Model 1 FFI.
Exempt retirement plans. Complete Part XV.
Reporting Model 2 FFI.
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
Registered deemed-compliant FFI (other than a reporting Model 1
Territory financial institution. Complete Part XVII.
FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII).
Excepted nonfinancial group entity. Complete Part XVIII.
See instructions.
Excepted nonfinancial start-up company. Complete Part XIX.
Sponsored FFI. Complete Part IV.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XX.
Certified deemed-compliant nonregistering local bank. Complete
Part V.
501(c) organization. Complete Part XXI.
Certified deemed-compliant FFI with only low-value accounts.
Nonprofit organization. Complete Part XXII.
Complete Part VI.
Publicly traded NFFE or NFFE affiliate of a publicly traded
corporation. Complete Part XXIII.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Excepted territory NFFE. Complete Part XXIV.
Active NFFE. Complete Part XXV.
Certified deemed-compliant limited life debt investment entity.
Complete Part VIII.
Passive NFFE. Complete Part XXVI.
Certain investment entities that do not maintain financial accounts.
Excepted inter-affiliate FFI. Complete Part XXVII.
Complete Part IX.
Direct reporting NFFE.
Owner-documented FFI. Complete Part X.
Sponsored direct reporting NFFE. Complete Part XXVIII.
Restricted distributor. Complete Part XI.
Account that is not a financial account.
6
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
City or town, state or province. Include postal code where appropriate.
Country
7
Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
9a GIIN
b Foreign TIN
8
U.S. taxpayer identification number (TIN), if required
10
Reference number(s) (see instructions)
Note: Please complete remainder of the form including signing the form in Part XXX.
W-8BEN-E
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 59689N
Form
(Rev. 7-2017)
W-8BEN-E
Certificate of Status of Beneficial Owner for
Form
United States Tax Withholding and Reporting (Entities)
OMB No. 1545-1621
(Rev. July 2017)
For use by entities. Individuals must use Form W-8BEN.
Section references are to the Internal Revenue Code.
Department of the Treasury
Go to www.irs.gov/FormW8BENE for instructions and the latest information.
Internal Revenue Service
Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form for:
Instead use Form:
• U.S. entity or U.S. citizen or resident .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. W-9
• A foreign individual
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. W-8BEN (Individual) or Form 8233
• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits) .
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.
.
.
. W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions)
.
. W-8IMY
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or
government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming the applicability of section(s) 115(2),
501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions for other exceptions) .
.
.
.
.
.
.
.
.
W-8ECI or W-8EXP
• Any person acting as an intermediary (including a qualified intermediary acting as a qualified derivatives dealer) .
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.
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. W-8IMY
Part I
Identification of Beneficial Owner
1
Name of organization that is the beneficial owner
2 Country of incorporation or organization
3
Name 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
Government
Simple trust
Grantor trust
Complex trust
Estate
Central Bank of Issue
Tax-exempt organization
Private foundation
International organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
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.)
Nonparticipating FFI (including an FFI related to a Reporting IGA
Nonreporting IGA FFI. Complete Part XII.
FFI other than a deemed-compliant FFI, participating FFI, or
Foreign government, government of a U.S. possession, or foreign
exempt beneficial owner).
central bank of issue. Complete Part XIII.
Participating FFI.
International organization. Complete Part XIV.
Reporting Model 1 FFI.
Exempt retirement plans. Complete Part XV.
Reporting Model 2 FFI.
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
Registered deemed-compliant FFI (other than a reporting Model 1
Territory financial institution. Complete Part XVII.
FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII).
Excepted nonfinancial group entity. Complete Part XVIII.
See instructions.
Excepted nonfinancial start-up company. Complete Part XIX.
Sponsored FFI. Complete Part IV.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XX.
Certified deemed-compliant nonregistering local bank. Complete
Part V.
501(c) organization. Complete Part XXI.
Certified deemed-compliant FFI with only low-value accounts.
Nonprofit organization. Complete Part XXII.
Complete Part VI.
Publicly traded NFFE or NFFE affiliate of a publicly traded
corporation. Complete Part XXIII.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Excepted territory NFFE. Complete Part XXIV.
Active NFFE. Complete Part XXV.
Certified deemed-compliant limited life debt investment entity.
Complete Part VIII.
Passive NFFE. Complete Part XXVI.
Certain investment entities that do not maintain financial accounts.
Excepted inter-affiliate FFI. Complete Part XXVII.
Complete Part IX.
Direct reporting NFFE.
Owner-documented FFI. Complete Part X.
Sponsored direct reporting NFFE. Complete Part XXVIII.
Restricted distributor. Complete Part XI.
Account that is not a financial account.
6
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
City or town, state or province. Include postal code where appropriate.
Country
7
Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
9a GIIN
b Foreign TIN
8
U.S. taxpayer identification number (TIN), if required
10
Reference number(s) (see instructions)
Note: Please complete remainder of the form including signing the form in Part XXX.
W-8BEN-E
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 59689N
Form
(Rev. 7-2017)
2
Form W-8BEN-E (Rev. 7-2017)
Page
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.)
11
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment
Branch treated as nonparticipating FFI.
Reporting Model 1 FFI.
U.S. Branch.
Participating FFI.
Reporting Model 2 FFI.
12
Address of disregarded entity or branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a
registered address).
City or town, state or province. Include postal code where appropriate.
Country
13
GIIN (if any)
Part III
Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only.)
14
I certify that (check all that apply):
The beneficial owner is a resident of
a
within the meaning of the income tax
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).
15
Special rates and conditions (if applicable—see instructions):
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
16
Name of sponsoring entity:
17
Check 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.
W-8BEN-E
Form
(Rev. 7-2017)
3
Form W-8BEN-E (Rev. 7-2017)
Page
Part V
Certified Deemed-Compliant Nonregistering Local Bank
18
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 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 Deemed-Compliant FFI with Only Low-Value Accounts
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 Deemed-Compliant Sponsored, Closely Held Investment Vehicle
20
Name 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 1.1471-5(e)(4);
• 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 deemed-compliant FFIs, and certified deemed-compliant FFIs and equity interests owned by an entity if that
entity owns 100% of the equity interests in the FFI and is itself a sponsored FFI).
Part VIII
Certified Deemed-Compliant Limited Life Debt Investment Entity
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 deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the
restrictions with respect to its assets and other requirements under Regulations section 1.1471-5(f)(2)(iv)).
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 1.1471-5(e)(4)(i)(A), and
• Does not maintain financial accounts.
Part X
Owner-Documented FFI
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 owner-documented FFI (see instructions for eligibility requirements). In addition, the FFI must make the certifications below.
24a
(All owner-documented FFIs check here) 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 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.
W-8BEN-E
Form
(Rev. 7-2017)
4
Form W-8BEN-E (Rev. 7-2017)
Page
Part X
Owner-Documented FFI (continued)
Check box 24b or 24c, whichever applies.
b
I certify that the FFI identified in Part I:
• 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 owner-documented FFI (looking through all entities other than specified
U.S. persons);
(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
owner-documented FFI (including any indirect debt interest, which includes debt interests in any entity that directly or indirectly owns
the payee or any direct or indirect equity interest in a debt holder of the payee) that constitutes a financial account in excess of
$50,000 (disregarding all such debt interests owned by participating FFIs, registered deemed-compliant FFIs, certified deemed-
compliant FFIs, excepted NFFEs, exempt beneficial owners, or U.S. persons other than specified U.S. persons); and
(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 1.1471-3(d)(6)(iii) for each person
identified in the FFI owner reporting statement.
c
I certify that the FFI identified in Part I has provided, or will provide, an auditor's letter, signed within 4 years of 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 1.1471-3(d)(6)(iv)(A)(2),
and that the FFI meets all the requirements to be an owner-documented FFI. The FFI identified in Part I has also provided, or will provide,
an FFI owner reporting statement of its owners that are specified U.S. persons and Form(s) W-9, with applicable waivers.
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
Restricted Distributor
25a
(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 anti-money laundering laws of its country of organization (which is an FATF-
compliant jurisdiction);
• 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 1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any, or caused the restricted
fund to transfer the securities to a distributor that is a participating FFI or reporting Model 1 FFI securities which were sold to specified U.S.
persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.
W-8BEN-E
Form
(Rev. 7-2017)
5
Form W-8BEN-E (Rev. 7-2017)
Page
Part XII
Nonreporting IGA FFI
26
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);
.
• If you are a trustee documented trust or a sponsored entity, provide the name of the trustee or sponsor
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 1.1471-6(h)(2)).
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 1.1471-6(h)(2)).
Part XV
Exempt Retirement Plans
Check box 29a, b, c, d, e, or f, whichever applies.
29 a
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 (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
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 1.1471-5(b)(2)(i)(A));
(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 1.1471-5(b)(2)(i)(A) (referring to retirement
and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, or to other retirement
funds described in this part or in an applicable Model 1 or Model 2 IGA); or
(iv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
c
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 1.1471-5(b)(2)(i)(A)) are
limited by reference to earned income and compensation of the employee, respectively;
• 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.
W-8BEN-E
Form
(Rev. 7-2017)