Label & Mint
For use by individuals only. Entities must use Form W-8BEN-E. Do not send this form to the IRS – provide it to the withholding agent or payer.
Contact email (local requirement – not part of IRS form):
Email address for correspondence
1. Name of individual who is the beneficial owner
2. Country of citizenship
Street address (including apt/suite or rural route)
City or town
State / province (if applicable)
Postal code
Country
Street / mailing address
State / province
5. U.S. taxpayer identification number (SSN or ITIN), if required
6a. Foreign tax identifying number (FTIN)
6b. FTIN not legally required?
Check if FTIN not legally required
7. Reference number(s) (e.g. account number with withholding agent)
8. Date of birth (MM-DD-YYYY)
If you are claiming treaty benefits, complete this section. If not, you may skip to Part III.
9. I certify that the beneficial owner is a resident of (treaty country)
Article
Paragraph
Rate of withholding (%)
Type of income to which this rate applies
Explanation – additional conditions in the treaty Article/paragraph that are met
By signing, you certify under penalties of perjury that the statements on Form W-8BEN are true, correct and complete and that you meet the requirements listed in the certification section of the IRS form.
Signature of beneficial owner (or individual authorised to sign for beneficial owner)
Date (MM-DD-YYYY)
Print name of signer
Capacity in which acting (if not the individual identified on line 1)
