Form W-8IMY Certificate of Foreign Intermediary, Foreign Flow-Throug

Version A, Cycle 10

Form

W-8IMY

(Rev. October 2021)

Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain
U.S. Branches for United States Tax Withholding and Reporting

Department of the Treasury
Internal Revenue Service

▶ Section

references are to the Internal Revenue Code.
to www.irs.gov/FormW8IMY for instructions and the latest information.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.

OMB No. 1545-1621

▶ Go

Do not use this form for:
Instead, use Form:
• A beneficial owner solely claiming foreign status or treaty benefits (other than a qualified intermediary (QI) acting as a qualified
derivatives dealer (QDD))
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN or W-8BEN-E
• A hybrid entity claiming treaty benefits on its own behalf (other than a QI acting as a QDD) . . . . . . . . . . . . . . W-8BEN-E
• A foreign person claiming that income is effectively connected with the conduct of a trade or business in the United States
. . . . . W-8ECI
• A disregarded entity with a single foreign owner that is the beneficial owner (other than a QI acting as a QDD) of the income to which this form

relates. Instead, the single foreign owner should use

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. W-8BEN, W-8ECI, or W-8BEN-E

• 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)
. . . . . . . . . . .
. . . . . . . . . . .

• U.S. entity or U.S. citizen or resident . . . . . . . . . .
• A foreign person documenting itself for purposes of section 6050W .

Part I

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. . . . . . . W-8EXP
. . . . . . . . W-9
W-8BEN, W-8BEN-E, or W-8ECI

Identification of Entity

1

Name of organization that is acting as intermediary

2

3

Name of disregarded entity (if applicable), see instructions

4 Chapter 3 Status (entity type) (Must check one box only.):
QI (including a QDD). Complete Part III.
Nonqualified intermediary. Complete Part IV.

Country of incorporation or organization

Withholding foreign trust. Complete Part VII.
Nonwithholding foreign partnership. Complete Part VIII.

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021
Territory financial institution. Complete Part V.
U.S. branch. Complete Part VI.
Withholding foreign partnership. Complete Part VII.

Nonwithholding foreign simple trust. Complete Part VIII.
Nonwithholding foreign grantor trust. Complete Part VIII.

5 Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity’s applicable status.)
(Must check one box only.):
Nonparticipating foreign financial institution (FFI) (including an FFI related
Owner-documented FFI. Complete Part XI.
to a Reporting IGA FFI other than a deemed-compliant FFI, participating
Restricted distributor. Complete Part XVII.
FFI, or exempt beneficial owner). Complete Part IX (if applicable).
Participating FFI.
Foreign central bank of issue. Complete Part XVIII.
Reporting Model 1 FFI.
Reporting Model 2 FFI.

Registered deemed-compliant FFI (other than a reporting Model 1 FFI,
sponsored FFI, or nonreporting IGA FFI covered in Part XIX).
Territory financial institution. Complete Part V.
Sponsored FFI (other than a certified deemed-compliant sponsored,
closely held investment vehicle). Complete Part X.

Nonreporting IGA FFI. Complete Part XIX.
Exempt retirement plans. Complete Part XX.
Excepted nonfinancial group entity. Complete Part XXI.

Excepted nonfinancial start-up company. Complete Part XXII.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XXIII.

Certified deemed-compliant nonregistering local bank. Complete Part XII.

Publicly traded NFFE or NFFE affiliate of a publicly traded
corporation. Complete Part XXIV.

Certified deemed-compliant FFI with only low-value accounts. Complete Part XIII.

Excepted territory NFFE. Complete Part XXV.

Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part XIV.
Certified deemed-compliant limited life debt investment entity. Complete Part XV.

Active NFFE. Complete Part XXVI.
Passive NFFE. Complete Part XXVII.
Direct reporting NFFE.

Certain investment entities that do not maintain financial accounts. Complete Part XVI.

Sponsored direct reporting NFFE. Complete Part XXVIII.

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

Country

7 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
8 U.S. taxpayer identification number, if required

Country

▶

QI-EIN
WP-EIN
9a GIIN (if applicable) ▶
b Foreign taxpayer identification number, if required
10 Reference number(s) (see instructions)

WT-EIN

EIN

▶

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 25402Q

Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Part II

11

Page

2

Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or
a branch of an FFI in a country other than the FFI’s country of residence. Do not complete Part II for QDD
branches. See instructions.)

Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment.
Branch treated as nonparticipating FFI.
Reporting Model 1 FFI.
U.S. Branch.
Participating FFI.
Reporting Model 2 FFI.
Address of branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).

12

City or town, state or province. Include postal code where appropriate.
13

GIIN (if any)

Country

▶

Chapter 3 Status Certifications
Part III

Qualified Intermediary

All Qualified Intermediaries
14

I certify that the entity identified in Part I (or branch, if relevant):
• Is a QI with respect to the accounts identified on line 10 or in a withholding statement associated with this form (as required) that is one
or more of the following:
(i) not acting for its own account;
(ii) a QDD receiving payments on underlying securities and/or potential section 871(m) transactions;
(iii) a QI assuming primary withholding responsibility for payments of substitute interest, as permitted by the QI Agreement.
• Has provided or will provide a withholding statement (as required) for purposes of chapters 3 and 4, and section 1446(a), or section
1446(f), subject to the certifications made on this form.

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

• To the extent it acts as a disclosing QI for purposes of section 1446(a) or (f) for payments associated with this form, the QI is to provide
the required payee documentation to associate with an amount realized or an amount subject to withholding on a PTP distribution.

Qualified Intermediaries When Not Acting As Qualified Derivatives Dealers (check all that apply)
15a
b

c

d

I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 for each
account identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts).
I certify that the entity identified in Part I of this form assumes primary withholding and reporting responsibility for each payment of an amount
realized from the sale of an interest in a publicly traded partnership under section 1446(f) 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).
I certify that the entity identified in Part I of this form assumes primary withholding as a nominee under Regulations section 1.1446-4(b)(3)
for each distribution by a publicly traded partnership 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).
I certify that the entity identified in Part I of this form is a QI acting as a qualified securities 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 this form (or, if no withholding statement is attached to this
form, for all accounts).

e

I certify that the entity identified in Part I of this form assumes primary withholding responsibility for purposes of chapters 3 and 4 and
primary Form 1099 reporting and backup withholding responsibility for all payments of U.S. source interest and substitute interest
associated with this form, as permitted by the QI Agreement.

f

I certify that the entity identified in Part I of this form assumes primary Form 1099 reporting and backup withholding responsibility or
reporting responsibility as a participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains that are held by
specified U.S. persons as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting for each account
identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts).

g

I certify that the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding responsibility for each
account identified on a withholding statement attached to this form (or, if no withholding statement is attached to this form, for all accounts).

h

(Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding
responsibility.) If the entity identified in Part I of this form 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 with this form, I certify that the entity meets the requirements of Regulations section
1.6049-4(c)(4)(iii) with respect to any account holder of an account it maintains that is included in such a withholding rate pool.

i

(Complete only to the extent the entity identified in Part I of this form does not assume primary Form 1099 reporting and backup withholding
responsibility.) If the entity identified in Part I of this form 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 with this form, to the extent the U.S. payees are account holders of an intermediary or
flow-through entity receiving a payment from the entity, I certify 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.
Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Page

3

Qualified Derivatives Dealers
16a

I certify that each QDD identified in Part I of this form or on a withholding statement associated with this form meets the requirements to
act as a QDD (including approval by the IRS to so act) and assumes primary withholding and reporting responsibilities under chapters 3, 4,
and 61 and section 3406 with respect to any payments it makes with respect to potential section 871(m) transactions.

b

Entity classification of QDD:

Part IV

Corporation

Partnership

Disregarded Entity

Nonqualified Intermediary

Check all that apply.
17a

(All nonqualified intermediaries and QIs that are not acting in their capacity as such check here.) I certify that the entity identified in Part I of this
form is not acting as a QI with respect to each account(s) for which this form is provided and is not acting for its own account.

b

I certify that the entity identified in Part I of this form is using this form to transmit withholding certificates and/or other documentation and
has provided, or will provide, a withholding statement, as required. Note: If this form is provided for purposes of the entity's interest in a
publicly traded partnership, see the instructions for Part IV before checking this box.

c

I certify that the entity identified in Part I of this form meets the requirements of Regulations section 1.6049-4(c)(4)(iii) with respect to any
account holder of an account it maintains that is included in a withholding rate pool of U.S. payees provided on a withholding statement
associated with this form (excluding a distribution from a publicly traded partnership).

d

I certify that the entity identified in Part I of this form is acting as a qualified securities lender (other than a QI) assuming primary withholding and reporting
responsibilities with respect to payments associated with this form that are U.S. source substitute dividends received from the withholding agent.

e

To the extent that the entity identified in Part I of this form is providing an alternative withholding statement described in Regulations
section 1.1441-1(e)(3)(iv)(C)(3) for any payments associated with the form, the entity represents that the information on all of the
withholding statements associated with this withholding certificate have been (or will be) verified for inconsistency with any other account
information the entity has for the beneficial owners for determining the rate of withholding with respect to each payee (applying the
standards of knowledge under section 1441 or section 1471, as applicable).

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

Part V
18a

Territory Financial Institution

I certify that the entity identified in Part I is a financial institution (other than an investment entity that is not also a depository institution,
custodial institution, or specified insurance company) that is incorporated or organized under the laws of a territory of the United States.

Check the box on line 18b or 18c, whichever applies.
b
c

I further 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
for purposes of chapters 3 and 4 with respect to any reportable amounts and withholdable payments associated with this withholding certificate.

I further certify that the entity identified in Part I:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom it receives a payment of a
reportable amount or a withholdable payment; and
• Has provided or will provide a withholding statement, as required.

Check the boxes on lines 18d, and 18e or 18f, as applicable.
d

I certify that the entity identified in Part I agrees to be treated as a U.S. person under Regulations section 1.1446(f)-4(a)(2)(i)(B) with respect
to amounts realized on sales of interests in publicly traded partnerships.

e

I certify that the entity identified in Part I agrees to be treated as a U.S. person (as described in Regulations section 1.1441-1(b)(2)(iv)(A))
and as a nominee under Regulations section 1.1446-4(b)(3) with respect to distributions by publicly traded partnerships, or

f

Is not acting as a nominee for distributions from publicly traded partnerships and is providing withholding statements for the distributions.
Note: If this form is provided for an amount realized, see the instructions for Part V before providing a withholding statement for an amount
realized when the entity does not check the box on line 18d.

Part VI
19a

Certain U.S. Branches
I certify that the entity identified in Part I is a U.S. branch receiving reportable amounts or withholdable payments that are not income
effectively connected with the conduct of a trade or business in the United States, distributions from publicly traded partnerships, or
amounts realized on sales of interests in publicly traded partnerships.

Check the box on line 19b or 19c, whichever applies.
b

I certify that the entity identified in Part I is a U.S. branch of a foreign bank or insurance company described in Regulations section
1.1441-1(b)(2) (iv)(A) that 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 reportable amounts or withholdable payments associated with this withholding certificate.

c

I certify that the entity identified in Part I:
• Is using this form to transmit withholding certificates and/or other documentation for the persons for whom the branch receives a payment of a reportable amount;
• Has provided or will provide a withholding statement, as required; and
• In the case of a withholdable payment, is applying the rules described in Regulations section 1.1471-4(d)(2)(iii)(C).

Check the boxes on lines 19d, and 19e or 19f, as applicable.
d
e
f

I certify that the entity identified in Part I is a U.S. branch (as described in Regulations section 1.1446(f)-4(a)(2)(i)(B)) that is acting as a U.S.
person with respect to amounts realized on the sales of interests in publicly traded partnerships,
I certify that the entity identified in Part I is a U.S. branch (as described in Regulations section 1.1441-1(b)(2)(iv)(A)) that is treated as a
U.S. person and as a nominee with respect to distributions by publicly traded partnerships under Regulations section 1.1446-4(b)(3), or
Is not acting as a nominee for distributions from publicly traded partnerships and is providing withholding statements for the distributions.
Note: If this form is provided for an amount realized, see the instructions for Part VI before providing a withholding statement for an amount
realized when the U.S. branch does not check the box on line 19d.
Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Part VII

Page

4

Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT)
I certify that the entity identified in Part I is a withholding foreign partnership or a withholding foreign trust that is compliant with the terms
of its WP or WT agreement.

20

Part VIII

Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust

Check all that apply.
21a

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 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; and
• Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding
statement, as required for purposes of chapters 3 and 4, that is subject to the certifications made on this form.

b

I certify that the entity identified in Part I is a foreign partnership or foreign grantor trust that is a partner in a lower-tier partnership and is
providing this Form W-8IMY for purposes of section 1446(a).

c

I certify that the entity identified in Part I is a foreign partnership receiving an amount realized on the transfer of an interest in a partnership
for purposes of section 1446(f).

d

I certify that the entity identified in Part I is a foreign partnership providing a withholding statement for a modified amount realized from the
transfer (check, when applicable, only if box 21c is checked).

e

I certify that the entity identified in Part I is a foreign grantor trust providing the form on behalf of each grantor or other 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
the amount realized to each grantor or other owner.

f

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

To the extent the entity identified in Part I of this form is providing an alternative withholding statement described in Regulations section
1.1441-1(e)(3)(iv)(C)(3) for any payments associated with the form, the entity represents that the information on all of the withholding
certificates associated with the withholding statement may be relied on based on the standards of knowledge under section 1441 or
section 1471 applicable to the entity.

Chapter 4 Status Certifications

Part IX
22

Part X
23a

Nonparticipating FFI with Exempt Beneficial Owners

I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentation and has provided
or will provide a withholding statement that indicates the portion of the payment allocated to one or more exempt beneficial owners.

Sponsored FFI

Name of sponsoring entity:

▶

Check the box on line 23b or 23c, whichever applies.
b

c

Part XI

I certify that the entity identified in Part I:
• Is an investment entity;
• Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
• Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.

I certify that the entity identified in Part I:
• Is a controlled foreign corporation as defined in section 957(a);
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
entity; and
• Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all
account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not limited
to, customer identification information, customer documentation, account balance, and all payments made to account holders or payees.

Owner-Documented FFI

Note: This status only applies if the U.S. financial institution, participating FFI, reporting Model 1 FFI, or reporting Model 2 FFI to which this form is
given has agreed that it will treat the FFI as an owner-documented FFI. The owner-documented FFI must make the certifications below.
24a

I certify that the FFI identified in Part I:
• Does not act as an intermediary;
• Does not accept deposits in the ordinary course of a banking or similar business;
• Does not hold, as a substantial portion of its business, financial assets for the account of others;
• Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a financial account;
• Is not affiliated with an entity (other than an FFI that is also treated as an owner-documented FFI) that accepts deposits in the ordinary
course of a banking or similar business, holds, as a substantial portion of its business, financial assets for the account of others, or is an
insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with respect to a
financial account; and
• Does not maintain a financial account for any nonparticipating FFI.
Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Part XI

Page

5

Owner-Documented FFI (continued)

Check the box on line 24b or 24c, whichever applies.
I certify that the FFI identified in Part I:

b

• Has provided, or will provide, an FFI owner reporting statement (including any applicable owner documentation) that contains:
(i) The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified
U.S. person that owns a direct or indirect equity interest in the owner-documented FFI (looking through all entities other than
specified U.S. persons);
(ii) The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified
U.S. person that owns a debt interest in the owner-documented FFI (including any indirect debt interest, which includes debt interests
in any entity that directly or indirectly owns the payee or any direct or indirect equity interest in a debt holder of the payee) that
constitutes a financial account in excess of $50,000 (disregarding all such debt interests owned by participating FFIs, registered
deemed-compliant FFIs, certified deemed-compliant FFIs, excepted NFFEs, exempt beneficial owners, or U.S. persons other than
specified U.S. persons); and
(iii) Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.
c

I certify that the FFI identified in Part I:
• Has provided, or will provide, an auditor’s letter, signed no more than 4 years prior to the date of payment, from an independent
accounting firm or legal representative with a location in the United States stating that the firm or representative has reviewed the FFI’s
documentation with respect to all of its owners and debt holders identified in Regulations section 1.1471-3(d)(6)(iv)(A)(2) and that the FFI
meets all the requirements to be an owner-documented FFI. The FFI identified in Part I has also provided, or will provide, an FFI owner
reporting statement and Form W-9, with applicable waivers, as described in Regulations section 1.1471-3(d)(6)(iv).

Part XII
25

Certified Deemed-Compliant Nonregistering Local Bank
I certify that the FFI identified in Part I:
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country
of incorporation or organization;

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to
such bank and, with respect to a credit union or similar cooperative credit organization, members, provided that no member has a greater
than 5% interest in such credit union or cooperative credit organization;
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no
more than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is an FFI, other than an FFI that is incorporated or organized in the same
country as the FFI identified in Part I and that meets the requirements set forth in this Part XII.

Part XIII
26

Certified Deemed-Compliant FFI With Only Low-Value Accounts

I certify that the FFI identified in Part I:

• Is not engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional
principal contracts, insurance or annuity contracts, or any interest (including a futures or forward contract or option) in such security,
partnership interest, commodity, notional principal contract, insurance contract, or annuity contract;
• No financial account maintained by the FFI or any member of its expanded affiliated group, if any, has a balance or value in excess of
$50,000 (as determined after applying applicable account aggregation rules); and
• Neither the FFI nor the FFI’s entire expanded affiliated group, if any, has more than $50 million in assets on its consolidated or combined
balance sheet as of the end of its most recent accounting year.

Part XIV
27 a
b

Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle
Name of sponsoring entity:

▶

I certify that the FFI identified in Part I:
• Is an FFI solely because it is an investment entity described in Regulations section 1.1471-5(e)(4);
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities (determined as if the FFI were a participating FFI) fulfilled by
the sponsoring entity identified on line 27a; and
• 20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial
institutions, participating FFIs, registered deemed-compliant FFIs, and certified deemed-compliant FFIs and equity interests owned by an
entity that owns 100% of the equity interests in the FFI identified in Part I and is itself a sponsored FFI).

Part XV
28

Certified Deemed-Compliant Limited Life Debt Investment Entity
I certify that the FFI identified in Part I:
• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar
agreement; and
• Is certified deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the
restrictions with respect to its assets and other requirements under Regulations section 1.1471-5(f)(2)(iv)).
Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Part XVI

Page

6

Certain Investment Entities That Do Not Maintain Financial Accounts
I certify that the entity identified in Part I:
• Is a financial institution solely because it is an investment entity described in Regulations section 1.1471-5(e)(4)(i)(A); and
• Does not maintain financial accounts.

29

Part XVII

Restricted Distributor
(All restricted distributors check here.) I certify that the entity identified in Part I:

30a

• Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished;
• Provides investment services to at least 30 customers unrelated to each other and less than half of its customers are related to each
other;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is a
FATF-compliant jurisdiction);
• Operates solely in its country of incorporation or organization, has no fixed place of business outside of that country, and has the same
country of incorporation or organization as all members of its affiliated group, if any;
• Does not solicit customers outside its country of incorporation or organization;
• Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement
for the most recent accounting year;
• Is not a member of an expanded affiliated group that has more than $500 million in total assets under management or more than $20
million in gross revenue for its most recent accounting year on a combined or consolidated income statement; and
• Does not distribute any debt or securities of the restricted fund to specified U.S. persons, passive NFFEs with one or more substantial
U.S. owners, or nonparticipating FFIs.

Check the box on line 30b or 30c, whichever applies.

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

I further certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made
after December 31, 2011, the entity identified in Part I:
b

c

Part XVIII

Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities and U.S.
resident individuals and is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any
specified U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI.
Is currently bound by a distribution agreement that contains a prohibition on the sale of debt or securities to any specified U.S. person,
passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a
restriction was included in its distribution agreement, has reviewed all accounts related to such sales in accordance with the procedures
identified in Regulations section 1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any securities which were sold
to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs, or will transfer the securities
to a distributor that is a participating FFI, reporting Model 1 FFI, or reporting Model 2 FFI.

Foreign Central Bank of Issue

I certify that the entity identified in Part I is treated as the beneficial owner of the payment solely for purposes of chapter 4 under
Regulations section 1.1471-6(d)(4).

31

Part XIX

Nonreporting IGA FFI

I certify that the entity identified in Part I:
• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
. The

32

applicable IGA is a

Model 1 IGA or a

Model 2 IGA; and is treated as a

under the provisions of the applicable IGA or Treasury regulations (if applicable, see instructions); and
• If you are a trustee documented trust or sponsored entity, provide the name of the trustee or sponsor
The trustee is:
U.S.

Part XX

Foreign

Exempt Retirement Plans

Check the box on line 33a, b, c, d, e, or f, whichever applies.
33a

I certify that the entity identified in Part I:
• Is established in a country with which the United States has an income tax treaty in force;
• Is operated principally to administer or provide pension or retirement benefits; and
• Is entitled to treaty benefits on income that the fund derives from U.S. sources (or would be entitled to benefits if it derived any such
income) as a resident of the other country which satisfies any applicable limitation on benefits requirement.

b

I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former
employees of one or more employers in consideration for services rendered;
• No single beneficiary has a right to more than 5% of the FFI’s assets;
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the
country in which the fund is established or operated; and

Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Form W-8IMY (Rev. 10-2021)

Part XX

Page

7

Exempt Retirement Plans (continued)
(i) Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its
status as a retirement or pension plan;
(ii) Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans
described in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds
described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section 1.1471-5(b)(2)(i)(A));
(iii) Either does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to
retirement, disability, or death (except rollover distributions to accounts described in Regulations section 1.1471-5(b)(2)(i)(A)
(referring to retirement and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2
IGA, or to other retirement funds described in this part or in an applicable Model 1 or Model 2 IGA); or
(iv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former
employees of one or more employers in consideration for services rendered;

c

• Has fewer than 50 participants;
• Is sponsored by one or more employers, each of which is not an investment entity or passive NFFE;
• Employee and employer contributions to the fund (disregarding transfers of assets from other plans described in this part, retirement and
pension accounts described in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section 1.1471-5(b)(2)(i)(A)) are
limited by reference to earned income and compensation of the employee, respectively;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20% of the fund’s assets; and
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the
country in which the fund is established or operates.

d
e

f

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021

I certify that the entity identified in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other
than the requirement that the plan be funded by a trust created or organized in the United States.
I certify that the entity identified in Part I is established exclusively to earn income for the benefit of one or more retirement funds described
in this part or in an applicable Model 1 or Model 2 IGA, accounts described in Regulations section 1.1471-5(b)(2)(i)(A) (referring to
retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 IGA.
I certify that the entity identified in Part I:

• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S.
possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described in an applicable Model 1 or Model
2 IGA to provide retirement, disability, or death benefits to beneficiaries or participants that are current or former employees of the sponsor
(or persons designated by such employees); or
• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S.
possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described in an applicable Model 1 or Model
2 IGA to provide retirement, disability, or death benefits to beneficiaries or participants that are not current or former employees of such
sponsor, but are in consideration of personal services performed for the sponsor.

Part XXI
34

Excepted Nonfinancial Group Entity

I certify that the entity identified in Part I:
• Is a holding company, treasury center, or captive finance company and substantially all of the entity’s activities are functions described in
Regulations section 1.1471-5(e)(5)(i)(C) through (E);

• Is a member of a nonfinancial group described in Regulations section 1.1471-5(e)(5)(i)(B);
• Is not a depository or custodial institution (other than for members of the entity’s expanded affiliated group); and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or
any investment vehicle with an investment strategy to acquire or fund companies and then hold interests in those companies as capital
assets for investment purposes.

Part XXII
35

Excepted Nonfinancial Start-Up Company
I certify that the entity identified in Part I:
• Was formed on (or in the case of a new line of business, the date of board resolution approving the new line of business)
(date must be less than 24 months prior to date of payment);
• Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of
business other than that of a financial institution or passive NFFE; and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or
any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for
investment purposes.

Part XXIII
36

Excepted Nonfinancial Entity in Liquidation or Bankruptcy
I certify that the entity identified in Part I:
• Filed a plan of liquidation, filed a plan for reorganization, or filed for bankruptcy on the following date:

;

• Has not been engaged during the past 5 years in business as a financial institution or acted as a passive NFFE;
• Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a
nonfinancial entity; and
• Has provided, or will provide, documentary evidence such as a bankruptcy filing or other public documentation that supports its claim if
it remains in bankruptcy or liquidation for more than 3 years.
Form

W-8IMY

(Rev. 10-2021)

Version A, Cycle 10
Page 8

Form W-8IMY (Rev. 10-2021)

Part XXIV

Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation

Check the box on line 37a or 37b, whichever applies.
37a

I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution; and
• The stock of such corporation is regularly traded on one or more established securities markets, including

b

.

I certify that:
• The entity identified in Part I is a foreign corporation that is not a financial institution;
• The entity identified in Part I is a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an
established securities market;
• The name of the entity, the stock of which is regularly traded on an established securities market, is
• The name of the securities market on which the stock is regularly traded is ▶

Excepted Territory NFFE

Part XXV
38

I certify that:
• The entity identified in Part I is an entity that is organized in a possession of the United States;
• All of the owners of the entity identified in Part I are bona fide residents of the possession in which the NFFE is organized or incorporated;
and
• The entity identified in Part I:
(i) Does not accept deposits in the ordinary course of a banking or similar business;
(ii) Does not hold, as a substantial portion of its business, financial assets for the account of others; and
(iii) Is not an insurance company (or the holding company of an insurance company) that issues or is obligated to make payments with
respect to a financial account.

Part XXVI
39

; and
.

Active NFFE

INTERNAL USE ONLY
DRAFT AS OF
September 20, 2021
I certify that:
• The entity identified in Part I is a foreign entity that is not a financial institution;
• Less than 50% of such entity’s gross income for the preceding calendar year is passive income; and

• Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income (calculated as a
weighted average of the percentage of passive assets measured quarterly). See the instructions for the definition of passive income.

Part XXVII Passive NFFE
40

I certify that the entity identified in Part I:

• Is a foreign entity that is not a financial institution (this category includes an entity organized in a possession of the United States that
engages (or holds itself out as being engaged) primarily in the business of investing, reinvesting, or trading in securities, partnership
interests, commodities, notional principal contracts, insurance or annuity contracts, or any interest in such security, partnership interest,
commodity, notional principal contract, insurance contract, or annuity contract); and
• Is using this form to transmit withholding certificates and/or other documentation and has provided or will provide a withholding
statement, as required.

Part XXVIII Sponsored Direct Reporting NFFE
41
42

Name of sponsoring entity: ▶
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 41.

Part XXIX 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 or proceeds for
which I am providing this form or any withholding agent that can disburse or make payments of the amounts for which I am providing this form.
I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.

▲

Sign Here

Signature of authorized official

Date (MM-DD-YYYY)

Print Name
Form

W-8IMY

(Rev. 10-2021)