Free Form W-8IMY (Rev. February 2006) - Federal

Form

W-8IMY

(Rev. February 2006)

Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding
Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS.

OMB No. 1545-1621

Department of the Treasury Internal Revenue Service

Do not use this form for:
A beneficial owner solely claiming foreign status or treaty benefits A hybrid entity claiming treaty benefits on its own behalf A person claiming that income is effectively connected with the conduct of a trade or business in the United States A disregarded entity. Instead, the single foreign owner should use 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 the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)

Instead, use Form: W-8BEN W-8BEN W-8ECI W-8BEN or W-8ECI W-8EXP

Part I
1 3

Identification of Entity
2 Country of incorporation or organization

Name of individual or organization that is acting as intermediary Type of entity--check the appropriate box: Qualified intermediary. Complete Part II. Nonqualified intermediary. Complete Part III. U.S. branch. Complete Part IV. Withholding foreign partnership. Complete Part V.

Withholding foreign trust. Complete Part V. Nonwithholding foreign partnership. Complete Part VI. Nonwithholding foreign simple trust. Complete Part VI. Nonwithholding foreign grantor trust. Complete Part VI.

4

Permanent residence address (street, apt. or suite no., or rural route). Do not use P.O. box.

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) SSN or ITIN EIN QI-EIN

7

Foreign tax identifying number, if any (optional)

8

Reference number(s) (see instructions)

Part II
9a

Qualified Intermediary (All qualified intermediaries check here) I certify that the entity identified in Part I: Is a qualified intermediary and is not acting for its own account with respect to the account(s) identified on line 8 or in a withholding statement associated with this form and Has provided or will provide a withholding statement, as required.

b

(If applicable) I certify that the entity identified in Part I has assumed primary withholding responsibility under Chapter 3 of the Code with respect to the account(s) identified on this line 9b or in a withholding statement associated with this form

c

(If applicable) I certify that the entity identified in Part I has assumed primary Form 1099 reporting and backup withholding responsibility as authorized in its withholding agreement with the IRS with respect to the account(s) identified on this line 9c or in a withholding statement associated with this form Nonqualified Intermediary (All nonqualified intermediaries check here) I certify that the entity identified in Part I is not a qualified intermediary and is not acting for its own account. (If applicable) I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentary evidence and has provided or will provide a withholding statement, as required.
Cat. No. 25402Q Form W-8IMY (Rev. 2-2006)

Part III
10a

b

For Paperwork Reduction Act Notice, see separate instructions.

Page 2 Part IV Certain United States Branches Note: You may use this Part if the entity identified in Part I is a U.S. branch of a foreign bank or insurance company and is subject to certain regulatory requirements (see instructions). I certify that the entity identified in Part I is a U.S. branch and that the payments are not effectively 11 connected with the conduct of a trade or business in the United States. Check box 12 or box 13, whichever applies: 12 I certify that the entity identified in Part I is using this form as evidence of its agreement with the withholding agent to be treated as a U.S. person with respect to any payments associated with this certificate. I certify that the entity identified in Part I: 13 Is using this form to transmit withholding certificates or other documentary evidence for the persons for whom the branch receives a payment and Has provided or will provide a withholding statement, as required. Form W-8IMY (Rev. 2-2006)

Part V
14

Withholding Foreign Partnership or Withholding Foreign Trust I certify that the entity identified in Part I: Is a withholding foreign partnership or a withhholding foreign trust and Has provided or will provide a withholding statement, as required.

Part VI
15

Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust
I certify that the entity identified in Part I: Is a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and that the payments to which this certificate relates are not effectively connected, or are not treated as effectively connected, with the conduct of a trade or business in the United States and Is using this form to transmit withholding certificates and/or other documentary evidence and has provided or will provide a withholding statement, as required.

Part VII Certification
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any withholding agent that can disburse or make payments of the income for which I am providing this form.

Sign Here

Signature of authorized official

Date (MM-DD-YYYY) Form W-8IMY (Rev. 2-2006)