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

For use by entities only. Individuals must use Form W-8BEN. Do not send this form to the IRS – provide it to the withholding agent or payer.

Local contact email (internal use only):

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Part I – Identification of Beneficial Owner

3. Entity classification (Chapter 3 status – select one)

5. Chapter 4 status (FATCA – select the closest description)

6. Permanent residence address (no P.O. box / c/o)

7. Mailing address (if different)

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Part III – Claim of Tax Treaty Benefits (summary, if applicable)

If the entity is claiming benefits under an income tax treaty with the United States, complete this section. If not applicable, you may leave it blank.

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Part XXX – Certification

By signing, the authorised individual certifies under penalties of perjury that the information on this form is true, correct and complete and that the entity meets the requirements in the certification section of Form W-8BEN-E.

Declarations acknowledged:

The entity identified on line 1 is the beneficial owner of the income/proceeds or is using this form to certify its status for chapter 4 / sections 6050W or 6050Y. The entity identified on line 1 is not a U.S. person. This form relates only to income that qualifies for non-U.S. status as described in the IRS Form W-8BEN-E instructions. For broker transactions / barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. I agree to submit a new Form W-8BEN-E within 30 days if any certification becomes incorrect. I certify that I have the capacity to sign for the entity identified on line 1 of this form.