Free Form W-8BEN (Rev. February 2006) - Texas

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Date: January 19, 2007
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State: Texas
Category: Court Forms - Local
Author: SE:W:CAR:MP
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Page Size: 612 x 792.008 pts (letter)

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(Rev. February 2006) Department of the Treasury Internal Revenue Service

Certificate of Foreign Status of Beneficial Owner 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

Do not use this form for: A U.S. citizen or other U.S. person, including a resident alien individual A person claiming that income is effectively connected with the conduct of a trade or business in the United States A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions) Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A person acting as an intermediary Note: See instructions for additional exceptions.

Instead, use Form: W-9 W-8ECI W-8ECI or W-8IMY W-8ECI or W-8EXP


Part I
1 3

Identification of Beneficial Owner (See instructions.)
Disregarded entity Government

Name of individual or organization that is the beneficial owner Type of beneficial owner:
Grantor trust Central bank of issue Individual Complex trust Tax-exempt organization Corporation Estate Private foundation

Country of incorporation or organization
Partnership Simple trust

International organization


Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. City or town, state or province. Include postal code where appropriate. Country (do not abbreviate)


Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country (do not abbreviate) 7 EIN Foreign tax identifying number, if any (optional)

6 8

U.S. taxpayer identification number, if required (see instructions) SSN or ITIN Reference number(s) (see instructions)

Part II
9 a b c d e 10

Claim of Tax Treaty Benefits (if applicable)
The beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country.

I certify that (check all that apply): If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). The beneficial owner is not an individual, 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 (see instructions). The beneficial owner is not an individual, is claiming treaty benefits for 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). The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000. Special rates and conditions (if applicable--see instructions): The beneficial owner is claiming the provisions of Article treaty identified on line 9a above to claim a % rate of withholding on (specify type of income): Explain the reasons the beneficial owner meets the terms of the treaty article: of the .

Part III

Notional Principal Contracts
I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required.

Part IV


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. I further certify under penalties of perjury that: 1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, 2 The beneficial owner is not a U.S. person, 3 The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner's share of a partnership's effectively connected income, and 4 For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.

Sign Here

Signature of beneficial owner (or individual authorized to sign for beneficial owner)

Date (MM-DD-YYYY) Form

Capacity in which acting

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 25047Z
Printed on Recycled Paper


(Rev. 2-2006)