Countries and Languages
| Countries | Languages |
|---|---|
| USA | English |
| French | |
| German | |
| German (New Spelling) |
Part I — Identification of Entity
Basic Information
| Field | Description |
|---|---|
| Form | The fixed W-8IMY string, if applicable. |
| Box 1 - Name of Organization | The name of the organization. |
| Box 2 - Country of Incorporation or Organization | The country under the laws of which the foreign government or other foreign organization was created, incorporated, organized, or governed. |
| Box 3 - Name of Disregarded Entity | The name of the disregarded entity. |
Box 4 - Chapter 3 Status Entity Type
| Field | Description |
|---|---|
| QI | The status of the entity. |
| Nonqualified Intermediary | The status of the entity. |
| Territory Financial Institution | The status of the entity. |
| US Branch | The status of the entity. |
| Withholding Foreign Partnership | The status of the entity. |
| Withholding Foreign Trust | The status of the entity. |
| Nonwithholding Foreign Partnership | The status of the entity. |
| Nonwithholding Foreign Simple Trust | The status of the entity. |
| Nonwithholding Foreign Grantor Trust | The status of the entity. |
Box 5 - Chapter 4 Status FATCA Status
| Field | Description |
|---|---|
| Nonparticipating FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Participating FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Reporting Model 1 FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Reporting Model 2 FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Registered Deemed-Compliant FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Territory Financial Institution | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Sponsored FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Certified Deemed-Compliant Nonregistering Local Bank | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Certified Deemed-Compliant FFI with Only Low-Value Accounts | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Certified Deemed-Compliant Sponsored Closely Held Investment Vehicle | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Certified Deemed-Compliant Limited Life Debt Investment Entity | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Certain Investment Entities That Do Not Maintain Financial Accounts | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Owner-Documented FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Restricted Distributor | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Foreign Central Bank of Issue | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Nonreporting IGA FFI | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Exempt Retirement Plans | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Excepted Nonfinancial Group Entity | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Excepted Nonfinancial Start-Up Company | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Excepted Nonfinancial Entity In Liquidation or Bankruptcy | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Publicly Traded NFFE or NFFE Affiliate of Publicly Traded Corporation | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Excepted Territory NFFE | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Active NFFE | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Passive NFFE | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Direct Reporting NFFE | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
| Sponsored Direct Reporting NFFE | The Foreign Account Tax Compliance Act (FATCA) status of the entity. |
Address Information
Box 6 - Permanent Residence Address
| Field | Description |
|---|---|
| Address | The permanent residence address of the organization. |
| City and State or Province | The permanent residence address of the organization. |
| Country | The permanent residence address of the organization. |
Box 7 - Mailing Address
| Field | Description |
|---|---|
| Address | The address to which correspondence should be sent. |
| City and State or Province | The address to which correspondence should be sent. |
| Country | The address to which correspondence should be sent. |
Identification Numbers
Box 8 - US Taxpayer Identification Number
| Field | Description |
|---|---|
| US Taxpayer Identification Number | The U.S. Taxpayer Identification Number. |
| QI-EIN | The QI Employer Identification Number. |
| WP-EIN | The WP Employer Identification Number. |
| WT-EIN | The WT Employer Identification Number. |
| EIN | The Employer Identification Number. |
| Field | Description |
|---|---|
| Box 9a - GIIN | The Global Intermediary Identification Number (GIIN) of the entity. |
| Box 9b - Foreign Taxpayer Identification Number | The Foreign Taxpayer Identification Number (Foreign TIN) of the entity. |
| Box 10 - Reference Number | Any useful referencing information. |
Part II — Disregarded Entity or Branch Receiving Payment
Box 11 - Chapter 4 Status FATCA Status of Disregarded Entity or Branch
| Field | Description |
|---|---|
| Branch Treated As Nonparticipating FFI | The Foreign Account Tax Compliance Act (FATCA) status of the disregarded entity or branch. |
| Participating FFI | The Foreign Account Tax Compliance Act (FATCA) status of the disregarded entity or branch. |
| Reporting Model 1 FFI | The Foreign Account Tax Compliance Act (FATCA) status of the disregarded entity or branch. |
| Reporting Model 2 FFI | The Foreign Account Tax Compliance Act (FATCA) status of the disregarded entity or branch. |
| US Branch | The Foreign Account Tax Compliance Act (FATCA) status of the disregarded entity or branch. |
Box 12 - Address of Disregarded Entity or Branch
| Field | Description |
|---|---|
| Address | The address of the disregarded entity or branch. |
| City and State or Province | The address of the disregarded entity or branch. |
| Country | The address of the disregarded entity or branch. |
| Field | Description |
|---|---|
| Box 13 - GIIN of Disregarded Entity | The Global Intermediary Identification Number (GIIN) of the disregarded entity. |
Part III — Qualified Intermediary
| Field | Description |
|---|---|
| Box 14 | Indicates that the entity is a QI for the payments for which the form is provided. |
| Box 15a | Indicates that the entity assumes primary withholding responsibility for purposes of chapters 3 and 4 for each account identified on a withholding statement attached to the form (or, if no withholding statement is attached to this form, for all accounts). |
| Box 15b | Indicates that the entity assumes primary withholding and reporting responsibilities under section 1446(f) for each payment of an amount realized on a sale of a PTP interest associated with each account identified on a withholding statement attached to this form for receiving such amounts (or, if no withholding statement is attached to this form, for all accounts). |
| Box 15c | Indicates that the entity assumes primary withholding responsibility as a nominee for each distribution by a PTP that is associated with each account identified on a withholding statement attached to this form for receiving such distributions (or, if no withholding statement is attached to this form, for all accounts). |
| Box 15d | Indicates that the entity is a QI that is acting as a qualified security lender assuming primary withholding and reporting responsibilities with respect to payments that are U.S. source substitute dividends received from the withholding agent associated with each account identified on a withholding statement attached to the form (or, if no withholding statement is attached to this form, for all accounts). |
| Box 15e | Indicates that the entity is a QI that is assuming primary withholding responsibility under chapter 3 and chapter 4 and primary Form 1099 reporting and backup withholding responsibility with respect to all payments associated with this form that are U.S. source interest and substitute interest payments, as permitted by (and described in) the QI agreement. |
| Box 15f | Indicates that the entity assumes primary Form 1099 reporting and backup withholding responsibility with respect to the accounts identified in a withholding statement associated with this form or if the entity is a participating FFI or registered deemed-compliant FFI that meets the requirements to report only under Regulations sections 1.6049-4(c)(4)(i) and (c)(4)(ii). |
| Box 15g | Indicates that the entity doesn’t assume primary Form 1099 reporting and backup withholding responsibility with respect to the account(s) identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts). |
| Box 15h | Indicates that the entity meets the requirements of Regulation section, if the entity 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 to this form. |
| Box 15i | Indicates that the entity has obtained, or will obtain, documentation sufficient to establish each such intermediary or flow-through entity status as a participating FFI, registered deemed-compliant FFI, or FFI that is a QI. |
| Box 16a | Indicates that each QDD identified on the form or on the QDD withholding statement that is acting as a QDD meets the requirements to act as a QDD in Regulations section 1.1441-1(e)(6) and assumes primary withholding and reporting responsibilities under chapters 3, 4, and 61, and section 3406 with respect to potential section 871(m) transactions and has been approved by the IRS to act as a QDD. |
Box 16b - Entity Classification of QDD
| Field | Description |
|---|---|
| Corporation | The entity classification of QDD. |
| Partnership | The entity classification of QDD. |
| Disregarded Entity | The entity classification of QDD. |
Part IV — Nonqualified Intermediary
| Field | Description |
|---|---|
| Box 17a | Indicates that the entity is not acting as a QI with respect to each account(s) for which the form is provided and is not acting for its own account. |
| Box 17b | Indicates that the entity uses form to transmit withholding certificates or other documentation along with a withholding statement that satisfies the requirements of chapters 3 and 4 (including for purposes of section 1446(a) and including if the entity is providing pooled information for purposes of chapter 61 under the alternative procedure for U.S. non-exempt recipients, or chapter 4 withholding rate pools (as applicable) for a withholdable payment). |
| Box 17c | Indicates that the entity is permitted under Regulations section 1.6049-4(c)(4) to provide a chapter 4 withholding rate pool of U.S. payees to which a payment is allocated on a withholding statement associated with the Form W-8IMY. |
| Box 17d | Indicates that the entity is acting as a QSL with respect to the accounts identified on this line or in a withholding statement associated with this form with respect to a payment that is a U.S. source substitute dividend. |
| Box 17e | Indicates that the entity is providing an alternative withholding statement. |
Part V — Territory Financial Institution
| Field | Description |
|---|---|
| Box 18a | Indicates that the entity is a financial institution (other than an investment entity that is not also a depository institution, custodial institution, or specified insurance company) incorporated or organized under the laws of a territory of the United States. |
| Box 18b | Indicates that the entity has agreed to be treated as a U.S. person for purposes of both chapter 3 and chapter 4 with respect to payments of reportable amounts and withholdable payments associated with this Form W-8IMY. |
| Box 18c | Indicates that the entity is a territory financial institution that has not agreed to be treated as a U.S. person for reportable amounts and withholdable payments associated with this form. |
| Box 18d | Indicates that the entity has agreed to be treated as a U.S. person under Regulations section 1.1446(f)-4(a)(2)(i)(B) with respect to an amount realized from a sale of a PTP interest. |
| Box 18e | Indicates that the entity has agreed to be treated as a U.S. person (as described in Regulations section 1.1441-1(b)(2)(iv)) and as a nominee under Regulations section 1.1446-4(b)(3) with respect to distributions made by PTPs. |
| Box 18f | Indicates that the entity receives PTP distributions for which the entity doesn’t act as a nominee under Regulations section 1.1446-4(b)(3). |
Part VI — Certain U.S. Branches
| Field | Description |
|---|---|
| Box 19a | Indicates that the entity is a U.S. branch receiving payments of income that are reportable amounts or withholdable payments not effectively connected with the conduct of a trade or business in the United States, payments of PTP distributions, or payments of amounts realized. |
| Box 19b | Indicates that the entity is a U.S. branch of a foreign bank or insurance company described in this certification that has agreed with the withholding agent to be treated as a U.S. person under Regulations section 1.1441-1(b)(2)(iv) with respect to such payments associated with this Form W-8IMY. |
| Box 19c | Indicates that the entity is a U.S. branch that does not have an agreement with the withholding agent to be treated as a U.S. person under Regulations section 1.1441-1(b)(2)(iv). |
| Box 19d | Indicates that the entity is a U.S. branch described in Regulations section 1.1446(f)-4(a)(2)(i)(B) that is acting as a U.S. person with respect to an amount realized from the sale of a PTP interest. |
| Box 19e | Indicates that the entity is a U.S. branch described in Regulations section 1.1441-1(b)(2)(iv) that is acting as a nominee with respect to distributions by PTPs under Regulations section 1.1446-4(b)(3). |
| Box 19f | Indicates that the entity is a U.S. branch receiving PTP distributions associated with the form and are not acting as a nominee for the distributions under Regulations section 1.1446-4(b)(3) |
Part VII — Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT)
| Field | Description |
|---|---|
| Box 20 | Indicates that the entity is a WP or a WT and you are receiving the payment on behalf of your partners, beneficiaries, or owners. |
Part VIII — Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
| Field | Description |
|---|---|
| Box 21a | Indicates that the entity a foreign partnership or a foreign simple or grantor trust that is not a WP or WT, 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. |
| Box 21b | Indicates that the entity is a foreign partnership or foreign grantor trust providing this form for purposes of section 1446(a). |
| Box 21c | Indicates that the entity is a foreign partnership that is a transferor of an interest in a partnership receiving an amount realized from the transfer. |
| Box 21d | Indicates that the entity is providing a withholding statement for a modified amount realized on the transfer. |
| Box 21e | Indicates that the entity is a foreign grantor trust providing the form on behalf of each grantor or owner of the trust under Regulations section 1.1446(f)-1(c)(2) (vii) that is transmitting withholding certificates and providing a withholding statement to allocate an amount realized to each grantor or other owner in the trust for purposes of section 1446(f). |
| Box 21f | Indicates that the entity represents that the information on all the withholding certificates associated with the withholding statement may be relied on based on the standard of knowledge under section 1441 or section 1471 applicable to the entity. |
Part IX — Nonparticipating FFI With Exempt Beneficial Owners
| Field | Description |
|---|---|
| Box 22 | Indicates that the entity is transmitting withholding certificates or other documentation for exempt beneficial owners for chapter 4 purposes on whose behalf you are receiving a payment that is a withholdable payment. |
Part X — Sponsored FFI
| Field | Description |
|---|---|
| Box 23a - Name of Sponsoring Entity | The name of the sponsoring entity that has agreed to fulfill the chapter 4 due diligence, reporting, and withholding obligations on the entity’s behalf. |
| Box 23b | Indicates that the entity is either an investment entity or controlled foreign corporation (within the meaning of section 957(a)) and satisfies the other relevant requirements for this classification. |
| Box 23c | Indicates that the entity is either an investment entity or controlled foreign corporation (within the meaning of section 957(a)) and satisfies the other relevant requirements for this classification. |
Part XI — Owner-Documented FFI
| Field | Description |
|---|---|
| Box 24a | Indicates that the entity satisfies the requirements for owner-documented FFI status and is providing this form to a U.S. financial institution, a participating FFI, or a reporting Model 1 FFI that has agreed to act as a designated withholding agent with respect to the entity. |
| Box 24b | Indicates that the entity has provided or will provide the documentation set forth in the certifications, including the owner reporting statement. |
| Box 24c | Indicates that the entity has provided or will provide an auditor’s letter that satisfies the requirements. |
Part XII — Certified Deemed-Compliant Nonregistering Local Bank
| Field | Description |
|---|---|
| Box 25 | Indicates that the entity satisfies all of the requirements for certified deemed-compliant nonregistering local bank status. |
Part XIII — Certified Deemed-Compliant FFI with Only Low-Value Accounts
| Field | Description |
|---|---|
| Box 26 | Indicates that the entity satisfies all of the requirements for certified deemed-compliant FFI with only low-value account status. |
Part XIV — Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
| Field | Description |
|---|---|
| Box 27a - Name of Sponsoring Entity | The name of the sponsoring entity that has agreed to fulfill your chapter 4 due diligence, reporting, and withholding obligations on the entity behalf. |
| Box 27b | Indicates that the entity satisfies the requirements for certified deemed-compliant classification as a sponsored closely held investment vehicle. |
Part XV — Certified Deemed-Compliant Limited Life Debt Investment Entity
| Field | Description |
|---|---|
| Box 28 | Indicates that the entity satisfies the requirements for certified deemed-compliant limited life debt investment entity status. |
Part XVI — Certain Investment Entities that Do Not Maintain Financial Accounts
| Field | Description |
|---|---|
| Box 29 | Indicates that the entity meets all of the requirements for certified deemed-compliant status as an investment entity that doesn’t maintain financial accounts. |
Part XVII — Restricted Distributor
| Field | Description |
|---|---|
| Box 30a | Indicates that the entity satisfies the requirements of restricted distributor status. |
| Box 30b | Indicates that the entity’s distribution agreement meets the requirements of this classification. |
| Box 30c | Indicates that the entity’s distribution agreement meets the requirements of this classification. |
Part XVIII — Foreign Central Bank of Issue
| Field | Description |
|---|---|
| Box 31 | Indicates that the entity is a foreign central bank of issue acting as an intermediary and is an entity defined in Regulations section 1.1471-6 that is treated as the beneficial owner of the payment for chapter 4 purposes (applying the rule in Regulations section 1.1471-6(d)(4)). |
Part XIX — Nonreporting IGA FFI
| Field | Description |
|---|---|
| Box 32 | Indicates that the entity is treated as a nonreporting IGA FFI. |
| Box 32 - Meets the Requirements | The name of the jurisdiction that has the applicable IGA in effect with the United States. |
| Box 32 - Is Treated As | The withholding agent with the specific category of entity described in Annex II of the IGA applicable to the entity status. |
| Box 32 - Name of Trustee or Sponsor | The name of the trustee or sponsor. |
Box 32 - IGA Model
| Field | Description |
|---|---|
| Model 1 IGA | The category of entity described in Annex II of the IGA applicable to the entity status. |
| Model 2 IGA | The category of entity described in Annex II of the IGA applicable to the entity status. |
Box 32 - US or Foreign Trustee
| Field | Description |
|---|---|
| US Trustee | The status of the foreign trustee. |
| Foreign Trustee | The status of the foreign trustee. |
Part XX — Exempt Retirement Plans
| Field | Description |
|---|---|
| Box 33a | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
| Box 33b | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
| Box 33c | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
| Box 33d | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
| Box 33e | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
| Box 33f | Indicates that the entity satisfies the requirements of exempt retirement plan status. |
Part XXI — Excepted Nonfinancial Group Entity
| Field | Description |
|---|---|
| Box 34 | Indicates that the entity satisfies the requirements of excepted nonfinancial group entity status. |
Part XXII — Excepted Nonfinancial Start-Up Company
| Field | Description |
|---|---|
| Box 35 | Indicates that the entity satisfies the requirements of excepted nonfinancial start-up company status. |
| Box 35 - Date | The date the entity was formed or your board passed a resolution (or equivalent measure) approving a new line of business (which cannot be that of a financial institution or passive NFFE). |
Part XXIII — Excepted Nonfinancial Entity in Liquidation or Bankruptcy
| Field | Description |
|---|---|
| Box 36 | Indicates that the entity satisfies the requirements of excepted nonfinancial entity in liquidation or bankruptcy status. |
| Box 36 - Date | The date that the entity filed a plan of liquidation, plan of reorganization, or bankruptcy petition. |
Part XXIV — Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation
| Field | Description |
|---|---|
| Box 37a | Indicates that the entity is not a financial institution. |
| Box 37a - Securities Exchange | The name of a securities exchange on which your stock is publicly traded. |
| Box 37b | Indicates that the entity is an NFFE affiliate of a publicly traded corporation. |
| Box 37b - Name of Entity | The name of the publicly traded entity. |
| Box 37b - Name of Securities Market | The name of the securities market on which the stock of the publicly traded entity is traded. |
Part XXV — Excepted Territory NFFE
| Field | Description |
|---|---|
| Box 38 | Indicates that the entity satisfies the requirements for excepted territory NFFE status. |
Part XXVI — Active NFFE
| Field | Description |
|---|---|
| Box 39 | Indicates that the entity satisfies the requirements of active NFFE status. |
Part XXVII — Passive NFFE
| Field | Description |
|---|---|
| Box 40 | Indicates that the entity is not a financial institution (other than an investment entity organized in a possession of the United States). |
Part XXVIII— Sponsored Direct Reporting NFFE
| Field | Description |
|---|---|
| Box 41 - Name of Sponsoring Entity | The name of the sponsoring entity. |
| Box 42 | Indicates that the entity is not a financial institution and that the entity satisfies all relevant requirements for this classification. |
Signature Information
| Field | Description |
|---|---|
| Print Name | The printed name of the authorized official. |
| Date | The date of signing. |
Key Fields
- Box 1 - Name of Organization
- Date