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https://www.track1099.com/blaze/enter/d3ede1f2-1c50-4dc8-b380-44ff4391d2db
Submission: On January 13 via manual from CA — Scanned from CA
Submission: On January 13 via manual from CA — Scanned from CA
Form analysis 2 forms found in the DOM
<form id="form" autocomplete="off">
<h3><b>Part I</b> Identification of Beneficial Owner</h3>
<div class="row">
<div class="col-sm-7">
<div class="tiny-label-two-digit" data-label="1">
<div data-fields="name">
<div class="form-group field-name">
<label class="control-label" for="c3_name"><span class="label-inner">Name of organization that is the beneficial owner</span></label>
<div data-editor=""><input id="c3_name" class="form-control" name="name" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-5" data-fields="citizenship_country">
<div class="form-group field-citizenship_country">
<label class="control-label" for="c3_citizenship_country"><span class="label-inner"><b>2</b> Country of incorporation or organization</span></label>
<div data-editor=""><select id="c3_citizenship_country" class="form-control" name="citizenship_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="3">
<div data-fields="disregarded_entity">
<div class="form-group field-disregarded_entity">
<label class="control-label" for="c3_disregarded_entity"><span class="label-inner">Name of disregarded entity receiving the payment (if applicable, see instructions)</span></label>
<div data-editor=""><input id="c3_disregarded_entity" class="form-control" name="disregarded_entity" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-two-digit" data-label="4">
<div data-fields="chapter_3_entity_type">
<div class="form-group field-chapter_3_entity_type">
<label class="control-label" for="c3_chapter_3_entity_type"><span class="label-inner">Chapter 3 Status (entity type)</span></label>
<div data-editor=""><select id="c3_chapter_3_entity_type" class="form-control" name="chapter_3_entity_type">
<option value="">Choose...</option>
<option value="1">1 - Corporation</option>
<option value="2">2 - Disregarded entity</option>
<option value="3">3 - Partnership</option>
<option value="4">4 - Simple trust</option>
<option value="5">5 - Grantor trust</option>
<option value="6">6 - Complex trust</option>
<option value="7">7 - Estate</option>
<option value="8">8 - Government</option>
<option value="9">9 - Central Bank of Issue</option>
<option value="10">10 - Tax-exempt organization</option>
<option value="11">11 - Private foundation</option>
<option value="12">12 - International organization</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="making_treaty_claim">
<div class="checkbox solo">
<label for="c3_making_treaty_claim"><span data-editor=""><input id="c3_making_treaty_claim" name="making_treaty_claim" type="checkbox"></span> If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the
entity a hybrid making a treaty claim? If 'Yes' complete Part III.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="5">
<div data-fields="chapter_4_fatca_status">
<div class="form-group field-chapter_4_fatca_status">
<label class="control-label" for="c3_chapter_4_fatca_status"><span class="label-inner">Chapter 4 Status (FATCA status)</span></label>
<div data-editor=""><select id="c3_chapter_4_fatca_status" class="form-control" name="chapter_4_fatca_status">
<option value="">Choose...</option>
<option value="1">1 - Nonparticipating FFI (including a limited FFI or an FFI related to a Reporting IGA FFI other than a deemed-compliant FFI, participating FFI, or exempt beneficial owner).</option>
<option value="2">2 - Participating FFI.</option>
<option value="3">3 - Reporting Model 1 FFI.</option>
<option value="4">4 - Reporting Model 2 FFI.</option>
<option value="5">5 - Registered deemed-compliant FFI (other than a reporting Model 1 FFI, sponsored FFI, or nonreporting IGA FFI covered in Part XII). See instructions.</option>
<option value="6">6 - Sponsored FFI that has not obtained a GIIN. Complete Part IV.</option>
<option value="7">7 - Certified deemed-compliant nonregistering local bank. Complete Part V.</option>
<option value="8">8 - Certified deemed-compliant FFI with only low-value accounts. Complete Part VI.</option>
<option value="9">9 - Certified deemed-compliant sponsored, closely held investment vehicle. Complete Part VII.</option>
<option value="10">10 - Certified deemed-compliant limited life debt investment entity. Complete Part VIII.</option>
<option value="11">11 - Certain investment entities that do not maintain financial accounts. Complete Part IX.</option>
<option value="12">12 - Owner-documented FFI. Complete Part X.</option>
<option value="13">13 - Restricted distributor. Complete Part XI.</option>
<option value="14">14 - Nonreporting IGA FFI. Complete Part XII.</option>
<option value="15">15 - Foreign government, government of a U.S. possession, or foreign central bank of issue. Complete Part XIII.</option>
<option value="16">16 - International organization. Complete Part XIV.</option>
<option value="17">17 - Exempt retirement plans. Complete Part XV.</option>
<option value="18">18 - Entity wholly owned by exempt beneficial owners. Complete Part XVI.</option>
<option value="19">19 - Territory financial institution. Complete Part XVII.</option>
<option value="20">20 - Nonfinancial group entity. Complete Part XVIII.</option>
<option value="21">21 - Excepted nonfinancial start-up company. Complete Part XIX.</option>
<option value="22">22 - Excepted nonfinancial entity in liquidation or bankruptcy. Complete Part XX.</option>
<option value="23">23 - 501(c) organization. Complete Part XXI.</option>
<option value="24">24 - Nonprofit organization. Complete Part XXII.</option>
<option value="25">25 - Publicly traded NFFE or NFFE affiliate of a publicly traded corporation. Complete Part XXIII.</option>
<option value="26">26 - Excepted territory NFFE. Complete Part XXIV.</option>
<option value="27">27 - Active NFFE. Complete Part XXV.</option>
<option value="28">28 - Passive NFFE. Complete Part XXVI.</option>
<option value="29">29 - Excepted inter-affiliate FFI. Complete Part XXVII.</option>
<option value="30">30 - Direct reporting NFFE.</option>
<option value="31">31 - Sponsored direct reporting NFFE. Complete Part XXVIII.</option>
<option value="32">32 - Account that is not a financial account.</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="6">Permanent residence address </div>
</div>
</div>
<div class="residence-address subsection">
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="residence_address">
<div class="form-group field-residence_address">
<label class="control-label" for="c3_residence_address"><span class="label-inner">Street Address</span></label>
<div data-editor=""><input id="c3_residence_address" class="form-control" name="residence_address" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block">Do not use a P.O. box or in-care-of address</p>
</div>
</div>
</div>
</div>
<div class="col-sm-4" data-fields="residence_country">
<div class="form-group field-residence_country">
<label class="control-label" for="c3_residence_country"><span class="label-inner">Country</span></label>
<div data-editor=""><select id="c3_residence_country" class="form-control" name="residence_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row address-fields">
<div class="col-sm-5 city-col">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="residence_city">
<div class="form-group field-residence_city">
<label class="control-label" for="c3_residence_city"><span class="label-inner">City</span></label>
<div data-editor=""><input id="c3_residence_city" class="form-control" name="residence_city" maxlength="40" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4 state-col" data-fields="residence_state">
<div class="form-group field-residence_state">
<label class="control-label" for="c3_residence_state"><span class="label-inner">State or Province</span></label>
<div data-editor=""><select id="c3_residence_state" class="form-control" name="residence_state" disabled=""></select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="col-sm-3 zip-col" data-fields="residence_postal_code">
<div class="form-group field-residence_postal_code">
<label class="control-label" for="c3_residence_postal_code"><span class="label-inner">Postal Code</span></label>
<div data-editor=""><input id="c3_residence_postal_code" class="form-control" name="residence_postal_code" maxlength="10" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="mailing-address">
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="7">Mailing address </div>
</div>
</div>
<div class="subsection">
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="residence_is_mailing">
<div class="checkbox solo">
<label for="c3_residence_is_mailing"><span data-editor=""><input id="c3_residence_is_mailing" name="residence_is_mailing" type="checkbox"></span> <b>Check if mailing address is the same as residence</b></label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="mailing_address">
<div class="form-group field-mailing_address">
<label class="control-label" for="c3_mailing_address"><span class="label-inner">Street Address</span></label>
<div data-editor=""><input id="c3_mailing_address" class="form-control" name="mailing_address" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4" data-fields="mailing_country">
<div class="form-group field-mailing_country">
<label class="control-label" for="c3_mailing_country"><span class="label-inner">Country</span></label>
<div data-editor=""><select id="c3_mailing_country" class="form-control" name="mailing_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row address-fields">
<div class="col-sm-5 city-col">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="mailing_city">
<div class="form-group field-mailing_city">
<label class="control-label" for="c3_mailing_city"><span class="label-inner">City</span></label>
<div data-editor=""><input id="c3_mailing_city" class="form-control" name="mailing_city" maxlength="40" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4 state-col" data-fields="mailing_state">
<div class="form-group field-mailing_state">
<label class="control-label" for="c3_mailing_state"><span class="label-inner">State or Province</span></label>
<div data-editor=""><select id="c3_mailing_state" class="form-control" name="mailing_state" disabled=""></select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="col-sm-3 zip-col" data-fields="mailing_postal_code">
<div class="form-group field-mailing_postal_code">
<label class="control-label" for="c3_mailing_postal_code"><span class="label-inner">Postal Code</span></label>
<div data-editor=""><input id="c3_mailing_postal_code" class="form-control" name="mailing_postal_code" maxlength="10" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="subsection">
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-two-digit" data-label="8">
<div data-fields="tin">
<div class="form-group field-tin">
<label class="control-label" for="c3_tin"><span class="label-inner">U.S. taxpayer identification number (TIN), if required</span></label>
<div data-editor=""><input id="c3_tin" class="form-control" name="tin" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="tiny-label-two-digit" data-label="9a">
<div data-fields="giin">
<div class="form-group field-giin">
<label class="control-label" for="c3_giin"><span class="label-inner">GIIN</span></label>
<div data-editor=""><input id="c3_giin" class="form-control" name="giin" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-6" data-fields="foreign_tin">
<div class="form-group field-foreign_tin">
<label class="control-label" for="c3_foreign_tin"><span class="label-inner"><b>9b</b> Foreign TIN </span></label>
<div data-editor=""><input id="c3_foreign_tin" class="form-control" name="foreign_tin" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="tiny-label-two-digit" data-label="10">
<div data-fields="reference_number">
<div class="form-group field-reference_number">
<label class="control-label" for="c3_reference_number"><span class="label-inner">Reference number(s) </span></label>
<div data-editor=""><input id="c3_reference_number" class="form-control" name="reference_number" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-6" data-fields="email">
<div class="form-group field-email">
<label class="control-label" for="c3_email"><span class="label-inner">Email</span></label>
<div data-editor=""><input id="c3_email" class="form-control" name="email" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part II</b> 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. See instructions.)</h3>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="11">
<div data-fields="disregarded_entity_chapter_4_fatca_status">
<div class="form-group field-disregarded_entity_chapter_4_fatca_status">
<label class="control-label" for="c3_disregarded_entity_chapter_4_fatca_status"><span class="label-inner">Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment</span></label>
<div data-editor=""><select id="c3_disregarded_entity_chapter_4_fatca_status" class="form-control" name="disregarded_entity_chapter_4_fatca_status">
<option value="">Choose...</option>
<option value="1">1 - Branch treated as nonparticipating FFI.</option>
<option value="2">2 - U.S. Branch</option>
<option value="3">3 - Participating FFI.</option>
<option value="4">4 - Reporting Model 1 FFI.</option>
<option value="5">5 - Reporting Model 2 FFI.</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="disregarded-address">
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="12">Disregarded entity address </div>
</div>
</div>
<div class="subsection">
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="disregarded_address">
<div class="form-group field-disregarded_address">
<label class="control-label" for="c3_disregarded_address"><span class="label-inner">Street Address</span></label>
<div data-editor=""><input id="c3_disregarded_address" class="form-control" name="disregarded_address" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4">
<div data-fields="disregarded_country">
<div class="form-group field-disregarded_country">
<label class="control-label" for="c3_disregarded_country"><span class="label-inner">Country</span></label>
<div data-editor=""><select id="c3_disregarded_country" class="form-control" name="disregarded_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="row address-fields">
<div class="col-sm-5 city-col">
<div class="tiny-label-two-digit" data-label="">
<div data-fields="disregarded_city">
<div class="form-group field-disregarded_city">
<label class="control-label" for="c3_disregarded_city"><span class="label-inner">City</span></label>
<div data-editor=""><input id="c3_disregarded_city" class="form-control" name="disregarded_city" maxlength="40" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4 state-col" data-fields="disregarded_state">
<div class="form-group field-disregarded_state">
<label class="control-label" for="c3_disregarded_state"><span class="label-inner">State or Province</span></label>
<div data-editor=""><select id="c3_disregarded_state" class="form-control" name="disregarded_state" disabled=""></select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="col-sm-3 zip-col" data-fields="disregarded_postal_code">
<div class="form-group field-disregarded_postal_code">
<label class="control-label" for="c3_disregarded_postal_code"><span class="label-inner">Postal Code</span></label>
<div data-editor=""><input id="c3_disregarded_postal_code" class="form-control" name="disregarded_postal_code" maxlength="10" type="text" disabled=""></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="tiny-label-two-digit" data-label="13">
<div data-fields="disregarded_entity_giin">
<div class="form-group field-disregarded_entity_giin">
<label class="control-label" for="c3_disregarded_entity_giin"><span class="label-inner">GIIN (if any)</span></label>
<div data-editor=""><input id="c3_disregarded_entity_giin" class="form-control" name="disregarded_entity_giin" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<h3><b>Part III</b> Claim of Tax Treaty Benefits (if applicable). (For chapter 3 purposes only.)</h3>
<div class="tiny-label-three-digit leave-one-char" data-label="14">I certify that (check all that apply):</div>
<div class="subsection">
<div class="row">
<div class="col-sm-8">
<div class="tiny-label-three-digit" data-label="a">
<div data-fields="certify_box_14a">
<div class="checkbox solo">
<label for="c3_certify_box_14a"><span data-editor=""><input id="c3_certify_box_14a" name="certify_box_14a" type="checkbox"></span> The beneficial owner is a resident of <span class="fill-in-blank">x</span>within the meaning of the
income tax treaty between the United States and that country.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="col-sm-4" data-fields="treaty_country">
<div class="form-group field-treaty_country">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<select id="c3_treaty_country" class="form-control" name="treaty_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select>
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_14b">
<div class="checkbox solo">
<label for="c3_certify_box_14b"><span data-editor=""><input id="c3_certify_box_14b" name="certify_box_14b" type="checkbox"></span> The beneficial owner 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. The following are types of limitation on benefits provisions that may be included in an applicable tax treaty</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-three-digit">
<div data-fields="benefit_limitation">
<div class="form-group field-benefit_limitation">
<div data-editor=""><select id="c3_benefit_limitation" class="form-control" name="benefit_limitation">
<option value="">Choose...</option>
<option value="1">1 - Government</option>
<option value="2">2 - Tax exempt pension trust or pension fund</option>
<option value="3">3 - Other tax exempt organization</option>
<option value="4">4 - Publicly traded corporation</option>
<option value="5">5 - Subsidiary of a publicly traded corporation</option>
<option value="6">6 - Company that meets the ownership and base erosion test</option>
<option value="7">7 - Company that meets the derivative benefits test</option>
<option value="8">8 - Company with an item of income that meets active trade or business test</option>
<option value="9">9 - Favorable discretionary determination by the U.S. competent authority received</option>
<option value="10">10 - Other</option>
</select></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-three-digit" data-label="c">
<div data-fields="certify_box_14c">
<div class="checkbox solo">
<label for="c3_certify_box_14c"><span data-editor=""><input id="c3_certify_box_14c" name="certify_box_14c" type="checkbox"></span> The beneficial owner is claiming treaty benefits for U.S. source 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).</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="tiny-label-three-digit leave-one-char" data-label="15">
<div class="row">
<div class="col-sm-9"> Special rates and conditions (if applicable): The beneficial owner is claiming the provisions of Article and paragraph<span class="fill-in-blank">x</span> of the treaty identified on line 14a above to claim a<span
class="fill-in-blank">y</span>% rate of withholding on (specify type of income): <span class="fill-in-blank">z</span>
</div>
<div class="col-sm-3" data-fields="treaty_article,withholding_rate">
<div class="form-group field-treaty_article">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<input id="c3_treaty_article" class="form-control" name="treaty_article" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
<div class="form-group field-withholding_rate">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">y</span></div>
<input id="c3_withholding_rate" class="form-control" name="withholding_rate" maxlength="5" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div data-fields="income_type">
<div class="form-group field-income_type">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">z</span></div>
<input id="c3_income_type" class="form-control" name="income_type" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div data-fields="treaty_reasons">
<div class="form-group field-treaty_reasons">
<label class="control-label" for="c3_treaty_reasons"><span class="label-inner">Explain the additional conditions in the Article the beneficial owner meets to be eligible for the rate of withholding:</span></label>
<div data-editor=""><input id="c3_treaty_reasons" class="form-control" name="treaty_reasons" maxlength="180" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part IV</b> Sponsored FFI</h3>
<div class="row">
<div class="col-sm-12">
<div class="tiny-label-two-digit" data-label="16">
<div data-fields="part_4_sponsoring_entity">
<div class="form-group field-part_4_sponsoring_entity">
<label class="control-label" for="c3_part_4_sponsoring_entity"><span class="label-inner">Name of sponsoring entity:</span></label>
<div data-editor=""><input id="c3_part_4_sponsoring_entity" class="form-control" name="part_4_sponsoring_entity" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
<div class="tiny-label-two-digit" data-label="17">
<b>Check whichever box applies</b>
<div class="subsection">
<div data-fields="certify_box_17_1">
<div class="checkbox solo">
<label for="c3_certify_box_17_1"><span data-editor=""><input id="c3_certify_box_17_1" name="certify_box_17_1" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is an investment entity;</li>
<li> Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; <b>and</b></li>
<li>Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity. </li>
</ul>
<div data-fields="certify_box_17_2">
<div class="checkbox solo">
<label for="c3_certify_box_17_2"><span data-editor=""><input id="c3_certify_box_17_2" name="certify_box_17_2" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li> Is a controlled foreign corporation as defined in section 957(a);</li>
<li> Is not a QI, WP, or WT;</li>
<li> 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; <b>and</b></li>
<li>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. </li>
</ul>
</div>
</div>
<h3><b>Part V</b> Certified Deemed-Compliant Nonregistering Local Bank</h3>
<div class="tiny-label-two-digit" data-label="18">
<div data-fields="certify_box_18">
<div class="checkbox solo">
<label for="c3_certify_box_18"><span data-editor=""><input id="c3_certify_box_18" name="certify_box_18" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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;</li>
<li>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 five percent interest in such credit union or cooperative credit organization;</li>
<li>Does not solicit account holders outside its country of organization;</li>
<li>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);
</li>
<li>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; <b>and</b></li>
<li>Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution 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 V. </li>
</ul>
</div>
<h3><b>Part VI</b> Certified Deemed-Compliant FFI with Only Low-Value Accounts </h3>
<div class="tiny-label-two-digit" data-label="19">
<div data-fields="certify_box_19">
<div class="checkbox solo">
<label for="c3_certify_box_19"><span data-editor=""><input id="c3_certify_box_19" name="certify_box_19" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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;</li>
<li>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); <b>and</b></li>
<li>Neither the FFI nor the entire expanded affiliated group, if any, of the FFI, have more than $50 million in assets on its consolidated or combined balance sheet as of the end of its most recent accounting year. </li>
</ul>
</div>
<h3><b>Part VII</b> Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle</h3>
<div class="tiny-label-two-digit" data-label="20">
<div data-fields="part_7_sponsoring_entity">
<div class="form-group field-part_7_sponsoring_entity">
<label class="control-label" for="c3_part_7_sponsoring_entity"><span class="label-inner">Name of sponsoring entity:</span></label>
<div data-editor=""><input id="c3_part_7_sponsoring_entity" class="form-control" name="part_7_sponsoring_entity" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-two-digit" data-label="21">
<div data-fields="certify_box_21">
<div class="checkbox solo">
<label for="c3_certify_box_21"><span data-editor=""><input id="c3_certify_box_21" name="certify_box_21" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is an FFI solely because it is an investment entity described in §1.1471-5(e)(4);</li>
<li>Is not a QI, WP, or WT;</li>
<li>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 20; <b>and</b></li>
<li>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 if that entity owns 100 percent of the equity interests in the FFI and is itself a sponsored FFI). </li>
</ul>
</div>
<h3><b>Part VIII</b> Certified Deemed-Compliant Limited Life Debt Investment Entity </h3>
<div class="tiny-label-two-digit" data-label="22">
<div data-fields="certify_box_22">
<div class="checkbox solo">
<label for="c3_certify_box_22"><span data-editor=""><input id="c3_certify_box_22" name="certify_box_22" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Was in existence as of January 17, 2013;</li>
<li>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; <b>and</b></li>
<li>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 § 1.1471-5(f)(2)(iv)). </li>
</ul>
</div>
<h3><b>Part IX</b> Certain Investment Entities that Do Not Maintain Financial Accounts </h3>
<div class="tiny-label-two-digit" data-label="23">
<div data-fields="certify_box_23">
<div class="checkbox solo">
<label for="c3_certify_box_23"><span data-editor=""><input id="c3_certify_box_23" name="certify_box_23" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is a financial institution solely because it is an investment entity described in §1.1471-5(e)(4)(i)(A); <b>and</b></li>
<li>Does not maintain financial accounts. </li>
</ul>
</div>
<h3><b>Part X</b> Owner-Documented FFI </h3>
<p>
<strong>Note.</strong> This status only applies if the U.S. financial institution, participating FFI, or reporting Model 1 FFI to which this form is given has agreed that it will treat the FFI as an owner-documented FFI (see instructions for
eligibility requirements). In addition, the FFI must make the certifications below.
</p>
<div class="tiny-label-three-digit" data-label="24a">
<div data-fields="certify_box_24a">
<div class="checkbox solo">
<label for="c3_certify_box_24a"><span data-editor=""><input id="c3_certify_box_24a" name="certify_box_24a" type="checkbox"></span> (All owner-documented FFIs check here) I certify that the FFI identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Does not act as an intermediary;</li>
<li>Does not accept deposits in the ordinary course of a banking or similar business;</li>
<li>Does not hold, as a substantial portion of its business, financial assets for the account of others;</li>
<li>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;</li>
<li>Is not owned by or in an expanded affiliated group with an entity 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;</li>
<li>Does not maintain a financial account for any nonparticipating FFI; <b>and</b></li>
<li>Does not have any specified U.S. persons that own an equity interest or debt interest (other than a debt interest that is not a financial account or that has a balance or value not exceeding $50,000) in the FFI other than those identified
on the FFI owner reporting statement. </li>
</ul>
</div>
<p><b>Check box 24b or 24c, whichever applies.</b></p>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_24b">
<div class="checkbox solo">
<label for="c3_certify_box_24b"><span data-editor=""><input id="c3_certify_box_24b" name="certify_box_24b" type="checkbox"></span> I certify that the FFI identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li> Has provided, or will provide, an FFI owner reporting statement that contains: <ul class="for-certify">
<li>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);</li>
<li>The name, address, TIN (if any), and chapter 4 status 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); <b>and</b></li>
<li>Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity. </li>
</ul>
</li>
<li>Has provided, or will provide, valid documentation meeting the requirements of §1.1471-3(d)(6)(iii) for each person identified in the FFI owner reporting statement. </li>
</ul>
</div>
<div class="tiny-label-three-digit" data-label="c">
<div data-fields="certify_box_24c">
<div class="checkbox solo">
<label for="c3_certify_box_24c"><span data-editor=""><input id="c3_certify_box_24c" name="certify_box_24c" type="checkbox"></span> I certify that the FFI identified in Part I has provided, or will provide, an auditor's letter, signed within
four years of 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 §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
of its owners that are specified U.S. persons and Form(s) W-9, with applicable waivers.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<p><b>Check box 24d if applicable</b> (optional, see instructions)</p>
<div class="tiny-label-three-digit" data-label="d">
<div data-fields="certify_box_24d">
<div class="checkbox solo">
<label for="c3_certify_box_24d"><span data-editor=""><input id="c3_certify_box_24d" name="certify_box_24d" type="checkbox"></span> I certify that the entity identified on line 1 is a trust that does not have any contingent beneficiaries or
designated classes with unidentified beneficiaries.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XI</b> Restricted Distributor</h3>
<div class="tiny-label-three-digit" data-label="25a">
<div data-fields="certify_box_25a">
<div class="checkbox solo">
<label for="c3_certify_box_25a"><span data-editor=""><input id="c3_certify_box_25a" name="certify_box_25a" type="checkbox"></span> (All restricted distributors check here) I certify that the FFI identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to which this form is furnished;</li>
<li>Provides investment services to at least 30 customers unrelated to each other and less than half of its customers are related to each other;</li>
<li>Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is an FATF compliant jurisdiction);</li>
<li>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;</li>
<li>Does not solicit customers outside its country of incorporation or organization;</li>
<li>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;</li>
<li>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;
<b>and</b></li>
<li>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. </li>
</ul>
</div>
<p>
<b>Check box 25b or 25c, whichever applies.</b><br> 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:
</p>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_25b">
<div class="checkbox solo">
<label for="c3_certify_box_25b"><span data-editor=""><input id="c3_certify_box_25b" name="certify_box_25b" type="checkbox"></span> 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.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="c">
<div data-fields="certify_box_25c">
<div class="checkbox solo">
<label for="c3_certify_box_25c"><span data-editor=""><input id="c3_certify_box_25c" name="certify_box_25c" type="checkbox"></span> 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 §1.1471-4(c) applicable to preexisting accounts and has redeemed or retired any, or caused the restricted fund to transfer the securities to a distributor that
is a participating FFI or reporting Model 1 FFI securities which were sold to specified U.S. persons, passive NFFEs with one or more substantial U.S. owners, or nonparticipating FFIs.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XII</b> Nonreporting IGA FFI</h3>
<div class="tiny-label-two-digit" data-label="26">
<div class="row">
<div class="col-sm-8">
<div data-fields="certify_box_26">
<div class="checkbox solo">
<label for="c3_certify_box_26"><span data-editor=""><input id="c3_certify_box_26" name="certify_box_26" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify"> Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and <span class="fill-in-blank">a</span>The applicable IGA is a <span
class="fill-in-blank">b</span> and is treated as a <span class="fill-in-blank">c</span> under the provisions of the applicable IGA or Treaty regulations (if applicable, see instructions); <li> If you are a trustee documented trust or a
sponsored entity, provide the name of the trustee or sponsor <span class="fill-in-blank">d</span> The trustee is <span class="fill-in-blank">e</span>
</li>
</ul>
</div>
<div class="col-sm-3" data-fields="part_12_iga_country,part_12_iga_type,part_12_fatca_status_under_iga_annex_ii">
<div class="form-group field-part_12_iga_country">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">a</span></div>
<select id="c3_part_12_iga_country" class="form-control" name="part_12_iga_country">
<option value="">Choose...</option>
<option value="US">US - United States</option>
<option value="AF">AF - Afghanistan</option>
<option value="AX">AX - Akrotiri</option>
<option value="AL">AL - Albania</option>
<option value="AG">AG - Algeria</option>
<option value="AQ">AQ - American Samoa</option>
<option value="AN">AN - Andorra</option>
<option value="AO">AO - Angola</option>
<option value="AV">AV - Anguilla</option>
<option value="AY">AY - Antarctica</option>
<option value="AC">AC - Antigua and Barbuda</option>
<option value="AR">AR - Argentina</option>
<option value="AM">AM - Armenia</option>
<option value="AA">AA - Aruba</option>
<option value="AT">AT - Ashmore and Cartier Islands</option>
<option value="AS">AS - Australia</option>
<option value="AU">AU - Austria</option>
<option value="AJ">AJ - Azerbaijan</option>
<option value="BF">BF - Bahamas</option>
<option value="BA">BA - Bahrain</option>
<option value="FQ">FQ - Baker Island</option>
<option value="BG">BG - Bangladesh</option>
<option value="BB">BB - Barbados</option>
<option value="BO">BO - Belarus</option>
<option value="BE">BE - Belgium</option>
<option value="BH">BH - Belize</option>
<option value="BN">BN - Benin</option>
<option value="BD">BD - Bermuda</option>
<option value="BT">BT - Bhutan</option>
<option value="BL">BL - Bolivia</option>
<option value="BK">BK - Bosnia-Herzegovina</option>
<option value="BC">BC - Botswana</option>
<option value="BV">BV - Bouvet Island</option>
<option value="BR">BR - Brazil</option>
<option value="IO">IO - British Indian Ocean Territory</option>
<option value="VI">VI - British Virgin Islands</option>
<option value="BX">BX - Brunei</option>
<option value="BU">BU - Bulgaria</option>
<option value="UV">UV - Burkina Faso</option>
<option value="BM">BM - Burma</option>
<option value="BY">BY - Burundi</option>
<option value="CB">CB - Cambodia</option>
<option value="CM">CM - Cameroon</option>
<option value="CA">CA - Canada</option>
<option value="CV">CV - Cape Verde</option>
<option value="CJ">CJ - Cayman Islands</option>
<option value="CT">CT - Central African Republic</option>
<option value="CD">CD - Chad</option>
<option value="CI">CI - Chile</option>
<option value="CH">CH - China</option>
<option value="KT">KT - Christmas Island</option>
<option value="IP">IP - Clipperton Island</option>
<option value="CK">CK - Cocos (Keeling) Islands</option>
<option value="CO">CO - Colombia</option>
<option value="CN">CN - Comoros</option>
<option value="CF">CF - Congo (Brazzaville)</option>
<option value="CG">CG - Congo (Kinshasa)</option>
<option value="CW">CW - Cook Islands</option>
<option value="CR">CR - Coral Sea Islands</option>
<option value="CS">CS - Costa Rica</option>
<option value="IV">IV - Cote DIvoire (Ivory Coast)</option>
<option value="HR">HR - Croatia</option>
<option value="CU">CU - Cuba</option>
<option value="UC">UC - Curacao</option>
<option value="CY">CY - Cyprus</option>
<option value="EZ">EZ - Czech Republic</option>
<option value="DA">DA - Denmark</option>
<option value="DX">DX - Dhekelia</option>
<option value="DJ">DJ - Djibouti</option>
<option value="DO">DO - Dominica</option>
<option value="DR">DR - Dominican Republic</option>
<option value="TT">TT - East Timor</option>
<option value="EC">EC - Ecuador</option>
<option value="EG">EG - Egypt</option>
<option value="ES">ES - El Salvador</option>
<option value="EK">EK - Equatorial Guinea</option>
<option value="ER">ER - Eritrea</option>
<option value="EN">EN - Estonia</option>
<option value="ET">ET - Ethiopia</option>
<option value="FK">FK - Falkland Islands (Islas Malvinas)</option>
<option value="FO">FO - Faroe Islands</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="FJ">FJ - Fiji</option>
<option value="FI">FI - Finland</option>
<option value="FR">FR - France</option>
<option value="FP">FP - French Polynesia</option>
<option value="FS">FS - French Southern and Antarctic Lands</option>
<option value="GB">GB - Gabon</option>
<option value="GA">GA - The Gambia</option>
<option value="GG">GG - Georgia</option>
<option value="GM">GM - Germany</option>
<option value="GH">GH - Ghana</option>
<option value="GI">GI - Gibraltar</option>
<option value="GR">GR - Greece</option>
<option value="GL">GL - Greenland</option>
<option value="GJ">GJ - Grenada</option>
<option value="GQ">GQ - Guam</option>
<option value="GT">GT - Guatemala</option>
<option value="GK">GK - Guernsey</option>
<option value="GV">GV - Guinea</option>
<option value="PU">PU - Guinea-Bissau</option>
<option value="GY">GY - Guyana</option>
<option value="HA">HA - Haiti</option>
<option value="HM">HM - Heard Island and McDonald Islands</option>
<option value="VT">VT - Holy See</option>
<option value="HO">HO - Honduras</option>
<option value="HK">HK - Hong Kong</option>
<option value="HQ">HQ - Howland Island</option>
<option value="HU">HU - Hungary</option>
<option value="IC">IC - Iceland</option>
<option value="IN">IN - India</option>
<option value="ID">ID - Indonesia</option>
<option value="IR">IR - Iran</option>
<option value="IZ">IZ - Iraq</option>
<option value="EI">EI - Ireland</option>
<option value="IS">IS - Israel</option>
<option value="IT">IT - Italy</option>
<option value="JM">JM - Jamaica</option>
<option value="JN">JN - Jan Mayen</option>
<option value="JA">JA - Japan</option>
<option value="DQ">DQ - Jarvis Island</option>
<option value="JE">JE - Jersey</option>
<option value="JQ">JQ - Johnston Atoll</option>
<option value="JO">JO - Jordan</option>
<option value="KZ">KZ - Kazakhstan</option>
<option value="KE">KE - Kenya</option>
<option value="KQ">KQ - Kingman Reef</option>
<option value="KR">KR - Kiribati</option>
<option value="KN">KN - Korea, Democratic Peoples Republic of (North)</option>
<option value="KS">KS - Korea, Republic of (South)</option>
<option value="KV">KV - Kosovo</option>
<option value="KU">KU - Kuwait</option>
<option value="KG">KG - Kyrgyzstan</option>
<option value="LA">LA - Laos</option>
<option value="LG">LG - Latvia</option>
<option value="LE">LE - Lebanon</option>
<option value="LT">LT - Lesotho</option>
<option value="LI">LI - Liberia</option>
<option value="LY">LY - Libya</option>
<option value="LS">LS - Liechtenstein</option>
<option value="LH">LH - Lithuania</option>
<option value="LU">LU - Luxembourg</option>
<option value="MC">MC - Macau</option>
<option value="MK">MK - Macedonia</option>
<option value="MA">MA - Madagascar</option>
<option value="MI">MI - Malawi</option>
<option value="MY">MY - Malaysia</option>
<option value="MV">MV - Maldives</option>
<option value="ML">ML - Mali</option>
<option value="MT">MT - Malta</option>
<option value="IM">IM - Man, Isle of</option>
<option value="RM">RM - Marshall Islands</option>
<option value="MR">MR - Mauritania</option>
<option value="MP">MP - Mauritius</option>
<option value="MX">MX - Mexico</option>
<option value="MQ">MQ - Midway Islands</option>
<option value="MD">MD - Moldova</option>
<option value="MN">MN - Monaco</option>
<option value="MG">MG - Mongolia</option>
<option value="MJ">MJ - Montenegro</option>
<option value="MH">MH - Montserrat</option>
<option value="MO">MO - Morocco</option>
<option value="MZ">MZ - Mozambique</option>
<option value="WA">WA - Namibia</option>
<option value="NR">NR - Nauru</option>
<option value="BQ">BQ - Navassa Island</option>
<option value="NP">NP - Nepal</option>
<option value="NL">NL - Netherlands</option>
<option value="NC">NC - New Caledonia</option>
<option value="NZ">NZ - New Zealand</option>
<option value="NU">NU - Nicaragua</option>
<option value="NG">NG - Niger</option>
<option value="NI">NI - Nigeria</option>
<option value="NE">NE - Niue</option>
<option value="NF">NF - Norfolk Island</option>
<option value="CQ">CQ - Northern Mariana Islands</option>
<option value="NO">NO - Norway</option>
<option value="MU">MU - Oman</option>
<option value="PK">PK - Pakistan</option>
<option value="PS">PS - Palau</option>
<option value="LQ">LQ - Palmyra Atoll</option>
<option value="PM">PM - Panama</option>
<option value="PP">PP - Papua-New Guinea</option>
<option value="PF">PF - Paracel Islands</option>
<option value="PA">PA - Paraguay</option>
<option value="PE">PE - Peru</option>
<option value="RP">RP - Philippines</option>
<option value="PC">PC - Pitcairn Islands</option>
<option value="PL">PL - Poland</option>
<option value="PO">PO - Portugal</option>
<option value="RQ">RQ - Puerto Rico</option>
<option value="QA">QA - Qatar</option>
<option value="RO">RO - Romania</option>
<option value="RS">RS - Russia</option>
<option value="RW">RW - Rwanda</option>
<option value="TB">TB - Saint Barthelemy</option>
<option value="RN">RN - Saint Martin</option>
<option value="WS">WS - Samoa</option>
<option value="SM">SM - San Marino</option>
<option value="TP">TP - Sao Tome and Principe</option>
<option value="SA">SA - Saudi Arabia</option>
<option value="SG">SG - Senegal</option>
<option value="RI">RI - Serbia</option>
<option value="SE">SE - Seychelles</option>
<option value="SL">SL - Sierra Leone</option>
<option value="SN">SN - Singapore</option>
<option value="NN">NN - Sint Maarten</option>
<option value="LO">LO - Slovakia</option>
<option value="SI">SI - Slovenia</option>
<option value="BP">BP - Solomon Islands</option>
<option value="SO">SO - Somalia</option>
<option value="SF">SF - South Africa</option>
<option value="SX">SX - South Georgia and the South Sandwich Islands</option>
<option value="SP">SP - Spain</option>
<option value="PG">PG - Spratly Islands</option>
<option value="CE">CE - Sri Lanka</option>
<option value="SH">SH - St. Helena</option>
<option value="SC">SC - St. Kitts and Nevis</option>
<option value="ST">ST - St. Lucia Island</option>
<option value="SB">SB - St. Pierre and Miquelon</option>
<option value="VC">VC - St. Vincent and the Grenadines</option>
<option value="SU">SU - Sudan</option>
<option value="NS">NS - Suriname</option>
<option value="SV">SV - Svalbard</option>
<option value="WZ">WZ - Swaziland</option>
<option value="SW">SW - Sweden</option>
<option value="SZ">SZ - Switzerland</option>
<option value="SY">SY - Syria</option>
<option value="TW">TW - Taiwan</option>
<option value="TI">TI - Tajikistan</option>
<option value="TZ">TZ - Tanzania</option>
<option value="TH">TH - Thailand</option>
<option value="TO">TO - Togo</option>
<option value="TL">TL - Tokelau</option>
<option value="TN">TN - Tonga</option>
<option value="TD">TD - Trinidad and Tobago</option>
<option value="TS">TS - Tunisia</option>
<option value="TU">TU - Turkey</option>
<option value="TX">TX - Turkmenistan</option>
<option value="TK">TK - Turks and Caicos Islands</option>
<option value="TV">TV - Tuvalu</option>
<option value="UG">UG - Uganda</option>
<option value="UP">UP - Ukraine</option>
<option value="AE">AE - United Arab Emirates</option>
<option value="UK">UK - United Kingdom</option>
<option value="UY">UY - Uruguay</option>
<option value="UZ">UZ - Uzbekistan</option>
<option value="NH">NH - Vanuatu</option>
<option value="VE">VE - Venezuela</option>
<option value="VM">VM - Vietnam</option>
<option value="VQ">VQ - Virgin Islands</option>
<option value="WQ">WQ - Wake Island</option>
<option value="WF">WF - Wallis and Futuna</option>
<option value="WI">WI - Western Sahara</option>
<option value="YM">YM - Yemen (Aden)</option>
<option value="ZA">ZA - Zambia</option>
<option value="ZI">ZI - Zimbabwe</option>
</select>
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
<div class="form-group field-part_12_iga_type">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">b</span></div>
<select id="c3_part_12_iga_type" class="form-control" name="part_12_iga_type">
<option value="">Choose...</option>
<option value="1">1 - Model 1 IGA</option>
<option value="2">2 - Model 2 IGA</option>
</select>
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
<div class="form-group field-part_12_fatca_status_under_iga_annex_ii">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">c</span></div>
<input id="c3_part_12_fatca_status_under_iga_annex_ii" class="form-control" name="part_12_fatca_status_under_iga_annex_ii" maxlength="50" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12" data-fields="part_12_trustee_name,part_12_trustee_is_foreign">
<div class="form-group field-part_12_trustee_name">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">d</span></div>
<input id="c3_part_12_trustee_name" class="form-control" name="part_12_trustee_name" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
<div class="form-group field-part_12_trustee_is_foreign">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">e</span></div>
<select id="c3_part_12_trustee_is_foreign" class="form-control" name="part_12_trustee_is_foreign">
<option value="">The trustee is...</option>
<option value="f">f - U.S.</option>
<option value="t">t - Foreign</option>
</select>
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part XIII</b> Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue</h3>
<div class="tiny-label-two-digit" data-label="27">
<div data-fields="certify_box_27">
<div class="checkbox solo">
<label for="c3_certify_box_27"><span data-editor=""><input id="c3_certify_box_27" name="certify_box_27" type="checkbox"></span> I certify that the entity identified in Part I is the beneficial owner of the payment and is not engaged in
commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is submitted (except as permitted in
§1.1471-6(h)(2)).</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XIV</b> International Organization</h3>
<p><b>Check box 28a or 28b, whichever applies.</b></p>
<div class="tiny-label-three-digit" data-label="28a">
<div data-fields="certify_box_28a">
<div class="checkbox solo">
<label for="c3_certify_box_28a"><span data-editor=""><input id="c3_certify_box_28a" name="certify_box_28a" type="checkbox"></span> I certify that the entity identified in Part I is an international organization described in section
7701(a)(18).</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_28b">
<div class="checkbox solo">
<label for="c3_certify_box_28b"><span data-editor=""><input id="c3_certify_box_28b" name="certify_box_28b" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is comprised primarily of foreign governments;</li>
<li>Is recognized as an intergovernmental or supranational organization under a foreign law similar to the International Organizations Immunities Act or that has in effect a headquarters agreement with a foreign government;</li>
<li>The benefit of the entity's income does not inure to any private person; <strong>and</strong></li>
<li>Is the beneficial owner of the payment and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or
obligations for which this form is submitted (except as permitted in Regulations §1.1471-6(h)(2)). </li>
</ul>
</div>
<h3><b>Part XV</b> Exempt Retirement Plans</h3>
<p><b>Check box 29a, b, c, d, e, or f, whichever applies.</b></p>
<div class="tiny-label-three-digit" data-label="29a">
<div data-fields="certify_box_29a">
<div class="checkbox solo">
<label for="c3_certify_box_29a"><span data-editor=""><input id="c3_certify_box_29a" name="certify_box_29a" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is established in a country with which the United States has an income tax treaty in force (see Part III if claiming treaty benefits); </li>
<li>Is operated principally to administer or provide pension or retirement benefits; <b>and</b> </li>
<li>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. </li>
</ul>
</div>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_29b">
<div class="checkbox solo">
<label for="c3_certify_box_29b"><span data-editor=""><input id="c3_certify_box_29b" name="certify_box_29b" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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;</li>
<li>No single beneficiary has a right to more than 5% of the FFI's assets;</li>
<li>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; <b>and</b>
<ul>
<li>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;</li>
<li>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 §1.1471-5(b)(2)(i)(A)); </li>
<li>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 §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);
<b>or</b></li>
<li>Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually. </li>
</ul>
</li>
</ul>
</div>
<div class="tiny-label-three-digit" data-label="c">
<div data-fields="certify_box_29c">
<div class="checkbox solo">
<label for="c3_certify_box_29c"><span data-editor=""><input id="c3_certify_box_29c" name="certify_box_29c" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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;</li>
<li>Has fewer than 50 participants;</li>
<li>Is sponsored by one or more employers each of which is not an investment entity or passive NFFE;</li>
<li>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
§1.1471-5(b)(2)(i)(A)) are limited by reference to earned income and compensation of the employee, respectively;</li>
<li>Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20 percent of the fund's assets; <b>and</b></li>
<li>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. </li>
</ul>
</div>
<div class="tiny-label-three-digit" data-label="d">
<div data-fields="certify_box_29d">
<div class="checkbox solo">
<label for="c3_certify_box_29d"><span data-editor=""><input id="c3_certify_box_29d" name="certify_box_29d" type="checkbox"></span> 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. </label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="e">
<div data-fields="certify_box_29e">
<div class="checkbox solo">
<label for="c3_certify_box_29e"><span data-editor=""><input id="c3_certify_box_29e" name="certify_box_29e" type="checkbox"></span> 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, or 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.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="f">
<div data-fields="certify_box_29f">
<div class="checkbox solo">
<label for="c3_certify_box_29f"><span data-editor=""><input id="c3_certify_box_29f" name="certify_box_29f" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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 §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); <b>or</b></li>
<li>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 §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. </li>
</ul>
</div>
<h3><b>Part XVI</b> Entity Wholly Owned by Exempt Beneficial Owners</h3>
<div class="tiny-label-two-digit" data-label="30">
<div data-fields="certify_box_30">
<div class="checkbox solo">
<label for="c3_certify_box_30"><span data-editor=""><input id="c3_certify_box_30" name="certify_box_30" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is an FFI solely because it is an investment entity;</li>
<li>Each direct holder of an equity interest in the investment entity is an exempt beneficial owner described in Regulations section §1.1471-6 or in an applicable Model 1 or Model 2 IGA;</li>
<li>Each direct holder of a debt interest in the investment entity is either a depository institution (with respect to a loan made to such entity) or an exempt beneficial owner described in Regulations section §1.1471-6 or an applicable Model
1 or Model 2 IGA.</li>
<li>Has provided an owner reporting statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the type of documentation provided to the withholding agent for every person that owns a debt interest
constituting a financial account or direct equity interest in the entity; <b>and</b></li>
<li>Has provided documentation establishing that every owner of the entity is an entity described in §1.1471-6(b), (c), (d), (e), (f) and/or (g) without regard to whether such owners are beneficial owners. </li>
</ul>
</div>
<h3><b>Part XVII</b> Territory Financial Institution</h3>
<div class="tiny-label-two-digit" data-label="31">
<div data-fields="certify_box_31">
<div class="checkbox solo">
<label for="c3_certify_box_31"><span data-editor=""><input id="c3_certify_box_31" name="certify_box_31" type="checkbox"></span> I certify that the entity identified in Part I is a financial institution (other than an investment entity) that
is incorporated or organized under the laws of a possession of the United States. </label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XVIII</b> Excepted Nonfinancial Group Entity</h3>
<div class="tiny-label-two-digit" data-label="32">
<div data-fields="certify_box_32">
<div class="checkbox solo">
<label for="c3_certify_box_32"><span data-editor=""><input id="c3_certify_box_32" name="certify_box_32" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>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);</li>
<li>Is a member of a nonfinancial group described in Regulations section §1.1471-5(e)(5)(i)(B);</li>
<li>Is not a depository or custodial institution (other than for members of the entity's expanded affiliated group); <b>and</b></li>
<li>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. </li>
</ul>
</div>
<h3><b>Part XIX</b> Excepted Nonfinancial Start-Up Company</h3>
<div class="tiny-label-two-digit" data-label="33">
<div data-fields="certify_box_33">
<div class="checkbox solo">
<label for="c3_certify_box_33"><span data-editor=""><input id="c3_certify_box_33" name="certify_box_33" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-9">
<ul class="for-certify">
<li>Was formed on (or, in the case of a new line of business, the date of board resolution approving the new line of business)<span class="fill-in-blank">x</span>(date must be less than 24 months prior to date of payment); </li>
<li>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;</li>
<li>Is investing capital into assets with the intent to operate a business other than that of a financial institution; <b>and</b></li>
<li>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. </li>
</ul>
</div>
<div class="col-sm-3" data-fields="part_19_formation_or_resolution_date">
<div class="form-group field-part_19_formation_or_resolution_date">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<input id="c3_part_19_formation_or_resolution_date" class="form-control" name="part_19_formation_or_resolution_date" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part XX</b> Excepted Nonfinancial Entity in Liquidation or Bankruptcy</h3>
<div class="tiny-label-two-digit" data-label="34">
<div data-fields="certify_box_34">
<div class="checkbox solo">
<label for="c3_certify_box_34"><span data-editor=""><input id="c3_certify_box_34" name="certify_box_34" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-9">
<ul class="for-certify">
<li>Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on <span class="fill-in-blank">x</span>; </li>
<li>During the past 5 years has not been engaged in business as a financial institution or acted as a passive NFFE;</li>
<li>Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a nonfinancial entity; <b>and</b></li>
<li>Has, 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 three years. </li>
</ul>
</div>
<div class="col-sm-3" data-fields="part_20_filing_date">
<div class="form-group field-part_20_filing_date">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<input id="c3_part_20_filing_date" class="form-control" name="part_20_filing_date" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part XXI</b> 501(c) Organization</h3>
<div class="tiny-label-two-digit" data-label="35">
<div data-fields="certify_box_35">
<div class="checkbox solo">
<label for="c3_certify_box_35"><span data-editor=""><input id="c3_certify_box_35" name="certify_box_35" type="checkbox"></span> I certify that the entity identified in Part I is a 501(c) organization that:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-9">
<ul class="for-certify">
<li> Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization that is dated<span class="fill-in-blank">x</span>; <b>or</b>
<lihas provided="" a="" copy="" of="" an="" opinion="" from="" u.s.="" counsel="" certifying="" that="" the="" payee="" is="" section="" 501(c)="" organization="" (without="" regard="" to="" whether="" foreign="" private=""
foundation).="">
</lihas>
</li>
</ul>
</div>
<div class="col-sm-3" data-fields="part_21_determination_date">
<div class="form-group field-part_21_determination_date">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<input id="c3_part_21_determination_date" class="form-control" name="part_21_determination_date" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part XXII</b> Non-Profit Organization</h3>
<div class="tiny-label-two-digit" data-label="36">
<div data-fields="certify_box_36">
<div class="checkbox solo">
<label for="c3_certify_box_36"><span data-editor=""><input id="c3_certify_box_36" name="certify_box_36" type="checkbox"></span> I certify that the entity identified in Part I is a non-profit organization that meets the following
requirements:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes;</li>
<li>The entity is exempt from income tax in its country of residence;</li>
<li>The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets;</li>
<li>Neither the applicable laws of the entity's country of residence nor the entity's formation documents permit any income or assets of the entity to be distributed to, or applied for the benefit of, a private person or non-charitable entity
other than pursuant to the conduct of the entity's charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property which the entity has purchased; <b>and</b>
</li>
<li>The applicable laws of the entity's country of residence or the entity's formation documents require that, upon the entity's liquidation or dissolution, all of its assets be distributed to an entity that is a foreign government, an
integral part of a foreign government, a controlled entity of a foreign government, or another organization that is described in this part or escheats to the government of the entity's country of residence or any political subdivision
thereof. </li>
</ul>
</div>
<h3><b>Part XXIII</b> Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation</h3>
<p><b>Check box 37a or 37b, whichever applies.</b></p>
<div class="tiny-label-three-digit" data-label="37a">
<div data-fields="certify_box_37a">
<div class="checkbox solo">
<label for="c3_certify_box_37a"><span data-editor=""><input id="c3_certify_box_37a" name="certify_box_37a" type="checkbox"></span> I certify that:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-9">
<ul class="for-certify">
<li>The entity identified in Part I is a foreign corporation that is not a financial institution; <b>and</b></li>
<li>The stock of such corporation is regularly traded on one or more established securities markets, including <span class="fill-in-blank">x</span> (name one securities exchange upon which the stock is regularly traded). </li>
</ul>
</div>
<div class="col-sm-3" data-fields="box_37a_exchange">
<div class="form-group field-box_37a_exchange">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">x</span></div>
<input id="c3_box_37a_exchange" class="form-control" name="box_37a_exchange" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_37b">
<div class="checkbox solo">
<label for="c3_certify_box_37b"><span data-editor=""><input id="c3_certify_box_37b" name="certify_box_37b" type="checkbox"></span> I certify that:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-9">
<ul class="for-certify">
<li>The entity identified in Part I is a foreign corporation that is not a financial institution;</li>
<li>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;</li>
<li>The name of the entity, the stock of which is regularly traded on an established securities market, is <span class="fill-in-blank">y</span><b>and</b>; </li>
<li>The name of the securities market on which the stock is regularly traded is <span class="fill-in-blank">z</span>. </li>
</ul>
</div>
<div class="col-sm-3" data-fields="box_37b_entity,box_37b_exchange">
<div class="form-group field-box_37b_entity">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">y</span></div>
<input id="c3_box_37b_entity" class="form-control" name="box_37b_entity" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
<div class="form-group field-box_37b_exchange">
<div class="input-group" data-editor="">
<div class="input-group-prepend"><span class="input-group-text">z</span></div>
<input id="c3_box_37b_exchange" class="form-control" name="box_37b_exchange" maxlength="40" type="text">
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
<h3><b>Part XXIV</b> Excepted Territory NFFE</h3>
<div class="tiny-label-two-digit" data-label="38">
<div data-fields="certify_box_38">
<div class="checkbox solo">
<label for="c3_certify_box_38"><span data-editor=""><input id="c3_certify_box_38" name="certify_box_38" type="checkbox"></span> I certify that:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>The entity identified in Part I is an entity that is organized in a possession of the United States;</li>
<li>The entity identified in Part I: <ul>
<li>Does not accept deposits in the ordinary course of a banking or similar business,</li>
<li>Does not hold, as a substantial portion of its business, financial assets for the account of others; <strong>or</strong> </li>
<li>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; <b>and</b>
</li>
</ul>
</li>
<li>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. </li>
</ul>
</div>
<h3><b>Part XXV</b> Active NFFE</h3>
<div class="tiny-label-two-digit" data-label="39">
<div data-fields="certify_box_39">
<div class="checkbox solo">
<label for="c3_certify_box_39"><span data-editor=""><input id="c3_certify_box_39" name="certify_box_39" type="checkbox"></span> I certify that:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>The entity identified in Part I is a foreign entity that is not a financial institution;</li>
<li>Less than 50% of such entity's gross income for the preceding calendar year is passive income; <b>and</b></li>
<li>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 instructions for the
definition of passive income). </li>
</ul>
</div>
<h3><b>Part XXVI</b> Passive NFFE</h3>
<div class="tiny-label-three-digit" data-label="40a">
<div data-fields="certify_box_40a">
<div class="checkbox solo">
<label for="c3_certify_box_40a"><span data-editor=""><input id="c3_certify_box_40a" name="certify_box_40a" type="checkbox"></span> I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other
than an investment entity organized in a possession of the United States) and is not certifying its status as a publicly traded NFFE (or affiliate), excepted territory NFFE, active NFFE, direct reporting NFFE, or sponsored direct
reporting NFFE.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<p><b>Check box 40b or 40c, whichever applies.</b></p>
<div class="tiny-label-three-digit" data-label="b">
<div data-fields="certify_box_40b">
<div class="checkbox solo">
<label for="c3_certify_box_40b"><span data-editor=""><input id="c3_certify_box_40b" name="certify_box_40b" type="checkbox"></span> I further certify that the entity identified in Part I has no substantial U.S. owners (or, if applicable, no
controlling U.S. persons), <strong>or</strong></label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<div class="tiny-label-three-digit" data-label="c">
<div data-fields="certify_box_40c">
<div class="checkbox solo">
<label for="c3_certify_box_40c"><span data-editor=""><input id="c3_certify_box_40c" name="certify_box_40c" type="checkbox"></span> I further certify that the entity identified in Part I has provided the name, address, and TIN of each
substantial U.S. owner of the NFFE in Part XXIX.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XXVII</b> Excepted Inter-Affiliate FFI</h3>
<div class="tiny-label-three-digit" data-label="41">
<div data-fields="certify_box_41">
<div class="checkbox solo">
<label for="c3_certify_box_41"><span data-editor=""><input id="c3_certify_box_41" name="certify_box_41" type="checkbox"></span> I certify that the entity identified in Part I:</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<ul class="for-certify">
<li>Is a member of an expanded affiliated group;</li>
<li>Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group);</li>
<li>Does not make withholdable payments to any person other than to members of its expanded affiliated group;</li>
<li>Does not hold an account (other than a depository account in the country in which the entity is operating to pay for expenses) with or receive payments from any withholding agent other than a member of its expanded affiliated group;
<b>and</b></li>
<li>Has not agreed to report under Regulations section §1.1471-4(d)(2)(ii)(C) or otherwise act as an agent for chapter 4 purposes on behalf of any financial institution, including a member of its expanded affiliated group.</li>
</ul>
</div>
<h3><b>Part XXVIII</b> Sponsored Direct Reporting NFFE</h3>
<div class="tiny-label-two-digit" data-label="42">
<div data-fields="part_28_sponsoring_entity">
<div class="form-group field-part_28_sponsoring_entity">
<label class="control-label" for="c3_part_28_sponsoring_entity"><span class="label-inner">Name of sponsoring entity:</span></label>
<div data-editor=""><input id="c3_part_28_sponsoring_entity" class="form-control" name="part_28_sponsoring_entity" maxlength="40" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div data-fields="certify_box_43">
<div class="checkbox solo">
<label for="c3_certify_box_43"><span data-editor=""><input id="c3_certify_box_43" name="certify_box_43" type="checkbox"></span> I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity
identified in line 42.</label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
<h3><b>Part XXIX</b> Substantial U.S. Owners of Passive NFFE</h3>
<p>As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for definition of substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or
reporting Model 2 FFI, an NFFE may also use this Part for reporting its controlling U.S. persons under an applicable IGA.</p>
<div data-fields="substantial_us_owners_attributes" class="substantial-us-owners">
<div id="c3_substantial_us_owners_attributes" class="subform-list" name="substantial_us_owners_attributes">
<div class="substantial-owners-list outer-subform-list-container">
<div class="subform-list-container">
</div>
<div class="subform-add-container"><button type="button" class="subform-add btn btn-success"><i class="glyphicon glyphicon-add"></i> Add another substantial US owner</button></div>
</div>
</div>
</div>
<h3><b>Part XXX</b> Certification</h3>
<ul>
<li>
<p>The income to which this form relates is: </p>
<ol style="list-style-type:lower-alpha">
<li>
<p>not effectively connected with the conduct of a trade or business in the United States,</p>
</li>
<li>
<p>effectively connected but is not subject to tax under an income tax treaty, or</p>
</li>
<li>
<p>the partner's share of a partnership's effectively connected income; <b>and</b></p>
</li>
</ol>
</li>
<li>
<p>For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.</p>
<p>Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which the entity on line 1 is the beneficial owner or any withholding agent that can disburse or make
payments of the income of which the entity on line 1 is the beneficial owner.</p>
<p><b>I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.</b></p>
</li>
</ul>
<div class="row">
<div class="col-sm-10 offset-sm-1 col-xs-12">
<div data-fields="signature">
<div class="form-group field-signature">
<label class="control-label" for="c3_signature"><span class="label-inner">Signature of individual authorized to sign for beneficial owner</span></label>
<div data-editor="">
<div id="c3_signature" class="form-control signature-wrapper" name="signature">
<div class="signature-widget">
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1em !important; margin-bottom:1em !important;"></div><canvas
class="jSignature" width="708" style="margin: 0px; padding: 0px; border: none; height: 177px; width: 100%; touch-action: none; background-color: rgb(255, 255, 255);" height="177"></canvas>
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1.5em !important; margin-bottom:1.5em !important; position: relative;"></div>
</div><button class="clear-signature btn btn-sm btn-warning" type="button">Clear</button>
</div>
</div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="row">
<div class="col-sm-5" data-fields="signer_name">
<div class="form-group field-signer_name">
<label class="control-label" for="c3_signer_name"><span class="label-inner">Print Name</span></label>
<div data-editor=""><input id="c3_signer_name" class="form-control" name="signer_name" type="text"></div>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
<div class="col-sm-7" data-fields="certify_part_29_signature">
<div class="checkbox solo">
<label for="c3_certify_part_29_signature"><span data-editor=""><input id="c3_certify_part_29_signature" name="certify_part_29_signature" type="checkbox"></span>
<b>I certify that I have the capacity to sign for the entity identified on line 1 of this form.</b></label>
<p class="help-block" data-error=""></p>
<p class="help-block"></p>
</div>
</div>
</div>
</div>
</div>
</div>
</form><form id="search-help-form">
<div id="target"></div>
<i id="help-searching" class="icon-spinner icon-spin"></i>
<div id="powered-by">
<img src="/images/search-by-algolia-light-background.svg" alt="Algolia">
</div>
</form>Text Content
ALIGNMENT DEBT HOLDINGS 1, LLC
ONLINE
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1. 1 Please complete your W-8BEN-E for Alignment Debt Holdings 1, LLC
2. 2 We will send your W-8BEN-E to Alignment Debt Holdings 1, LLC and download
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more information.
4. 4 Scroll down for detailed W-8BEN-E instructions.
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IRS FORM W-8BEN-E
PART I IDENTIFICATION OF BENEFICIAL OWNER
Name of organization that is the beneficial owner
2 Country of incorporation or organization
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
Name of disregarded entity receiving the payment (if applicable, see
instructions)
Chapter 3 Status (entity type)
Choose...1 - Corporation2 - Disregarded entity3 - Partnership4 - Simple trust5 -
Grantor trust6 - Complex trust7 - Estate8 - Government9 - Central Bank of
Issue10 - Tax-exempt organization11 - Private foundation12 - International
organization
If you entered disregarded entity, partnership, simple trust, or grantor trust
above, is the entity a hybrid making a treaty claim? If 'Yes' complete Part III.
Chapter 4 Status (FATCA status)
Choose...1 - Nonparticipating FFI (including a limited FFI or an FFI related to
a Reporting IGA FFI other than a deemed-compliant FFI, participating FFI, or
exempt beneficial owner).2 - Participating FFI.3 - Reporting Model 1 FFI.4 -
Reporting Model 2 FFI.5 - Registered deemed-compliant FFI (other than a
reporting Model 1 FFI, sponsored FFI, or nonreporting IGA FFI covered in Part
XII). See instructions.6 - Sponsored FFI that has not obtained a GIIN. Complete
Part IV.7 - Certified deemed-compliant nonregistering local bank. Complete Part
V.8 - Certified deemed-compliant FFI with only low-value accounts. Complete Part
VI.9 - Certified deemed-compliant sponsored, closely held investment vehicle.
Complete Part VII.10 - Certified deemed-compliant limited life debt investment
entity. Complete Part VIII.11 - Certain investment entities that do not maintain
financial accounts. Complete Part IX.12 - Owner-documented FFI. Complete Part
X.13 - Restricted distributor. Complete Part XI.14 - Nonreporting IGA FFI.
Complete Part XII.15 - Foreign government, government of a U.S. possession, or
foreign central bank of issue. Complete Part XIII.16 - International
organization. Complete Part XIV.17 - Exempt retirement plans. Complete Part
XV.18 - Entity wholly owned by exempt beneficial owners. Complete Part XVI.19 -
Territory financial institution. Complete Part XVII.20 - Nonfinancial group
entity. Complete Part XVIII.21 - Excepted nonfinancial start-up company.
Complete Part XIX.22 - Excepted nonfinancial entity in liquidation or
bankruptcy. Complete Part XX.23 - 501(c) organization. Complete Part XXI.24 -
Nonprofit organization. Complete Part XXII.25 - Publicly traded NFFE or NFFE
affiliate of a publicly traded corporation. Complete Part XXIII.26 - Excepted
territory NFFE. Complete Part XXIV.27 - Active NFFE. Complete Part XXV.28 -
Passive NFFE. Complete Part XXVI.29 - Excepted inter-affiliate FFI. Complete
Part XXVII.30 - Direct reporting NFFE.31 - Sponsored direct reporting NFFE.
Complete Part XXVIII.32 - Account that is not a financial account.
Permanent residence address
Street Address
Do not use a P.O. box or in-care-of address
Country
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
City
State or Province
Postal Code
Mailing address
Check if mailing address is the same as residence
Street Address
Country
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
City
State or Province
Postal Code
U.S. taxpayer identification number (TIN), if required
GIIN
9b Foreign TIN
Reference number(s)
Email
PART II 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. SEE INSTRUCTIONS.)
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving
payment
Choose...1 - Branch treated as nonparticipating FFI.2 - U.S. Branch3 -
Participating FFI.4 - Reporting Model 1 FFI.5 - Reporting Model 2 FFI.
Disregarded entity address
Street Address
Country
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
City
State or Province
Postal Code
GIIN (if any)
PART III CLAIM OF TAX TREATY BENEFITS (IF APPLICABLE). (FOR CHAPTER 3 PURPOSES
ONLY.)
I certify that (check all that apply):
The beneficial owner is a resident of xwithin the meaning of the income tax
treaty between the United States and that country.
x
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
The beneficial owner 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. The following are types of
limitation on benefits provisions that may be included in an applicable tax
treaty
Choose...1 - Government2 - Tax exempt pension trust or pension fund3 - Other tax
exempt organization4 - Publicly traded corporation5 - Subsidiary of a publicly
traded corporation6 - Company that meets the ownership and base erosion test7 -
Company that meets the derivative benefits test8 - Company with an item of
income that meets active trade or business test9 - Favorable discretionary
determination by the U.S. competent authority received10 - Other
The beneficial owner is claiming treaty benefits for U.S. source 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).
Special rates and conditions (if applicable): The beneficial owner is claiming
the provisions of Article and paragraphx of the treaty identified on line 14a
above to claim ay% rate of withholding on (specify type of income): z
x
y
z
Explain the additional conditions in the Article the beneficial owner meets to
be eligible for the rate of withholding:
PART IV SPONSORED FFI
Name of sponsoring entity:
Check whichever box applies
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.
PART V CERTIFIED DEEMED-COMPLIANT NONREGISTERING LOCAL BANK
I certify that the entity 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;
* 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 five percent 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 a foreign
financial institution, other than a foreign financial institution 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 V.
PART VI CERTIFIED DEEMED-COMPLIANT FFI WITH ONLY LOW-VALUE ACCOUNTS
I certify that the entity 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 entire expanded affiliated group, if any, of the FFI,
have more than $50 million in assets on its consolidated or combined balance
sheet as of the end of its most recent accounting year.
PART VII CERTIFIED DEEMED-COMPLIANT SPONSORED, CLOSELY HELD INVESTMENT VEHICLE
Name of sponsoring entity:
I certify that the entity identified in Part I:
* Is an FFI solely because it is an investment entity described in
§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 20; 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 if that entity
owns 100 percent of the equity interests in the FFI and is itself a sponsored
FFI).
PART VIII CERTIFIED DEEMED-COMPLIANT LIMITED LIFE DEBT INVESTMENT ENTITY
I certify that the entity 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 §
1.1471-5(f)(2)(iv)).
PART IX 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 §1.1471-5(e)(4)(i)(A); and
* Does not maintain financial accounts.
PART X OWNER-DOCUMENTED FFI
Note. This status only applies if the U.S. financial institution, participating
FFI, or reporting Model 1 FFI to which this form is given has agreed that it
will treat the FFI as an owner-documented FFI (see instructions for eligibility
requirements). In addition, the FFI must make the certifications below.
(All owner-documented FFIs check here) 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 owned by or in an expanded affiliated group with an entity 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;
* Does not maintain a financial account for any nonparticipating FFI; and
* Does not have any specified U.S. persons that own an equity interest or debt
interest (other than a debt interest that is not a financial account or that
has a balance or value not exceeding $50,000) in the FFI other than those
identified on the FFI owner reporting statement.
Check box 24b or 24c, whichever applies.
I certify that the FFI identified in Part I:
* Has provided, or will provide, an FFI owner reporting statement that
contains:
* 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);
* The name, address, TIN (if any), and chapter 4 status 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
* Any additional information the withholding agent requests in order to
fulfill its obligations with respect to the entity.
* Has provided, or will provide, valid documentation meeting the requirements
of §1.1471-3(d)(6)(iii) for each person identified in the FFI owner reporting
statement.
I certify that the FFI identified in Part I has provided, or will provide, an
auditor's letter, signed within four years of 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
§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 of its owners that are specified U.S.
persons and Form(s) W-9, with applicable waivers.
Check box 24d if applicable (optional, see instructions)
I certify that the entity identified on line 1 is a trust that does not have any
contingent beneficiaries or designated classes with unidentified beneficiaries.
PART XI RESTRICTED DISTRIBUTOR
(All restricted distributors check here) I certify that the FFI identified in
Part I:
* 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 an 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 box 25b or 25c, whichever applies.
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:
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 §1.1471-4(c) applicable to preexisting accounts and
has redeemed or retired any, or caused the restricted fund to transfer the
securities to a distributor that is a participating FFI or reporting Model 1 FFI
securities which were sold to specified U.S. persons, passive NFFEs with one or
more substantial U.S. owners, or nonparticipating FFIs.
PART XII 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
a
The applicable IGA is a
b
and is treated as a
c
under the provisions of the applicable IGA or Treaty regulations (if
applicable, see instructions);
* If you are a trustee documented trust or a sponsored entity, provide the name
of the trustee or sponsor d The trustee is e
a
Choose...US - United StatesAF - AfghanistanAX - AkrotiriAL - AlbaniaAG -
AlgeriaAQ - American SamoaAN - AndorraAO - AngolaAV - AnguillaAY - AntarcticaAC
- Antigua and BarbudaAR - ArgentinaAM - ArmeniaAA - ArubaAT - Ashmore and
Cartier IslandsAS - AustraliaAU - AustriaAJ - AzerbaijanBF - BahamasBA -
BahrainFQ - Baker IslandBG - BangladeshBB - BarbadosBO - BelarusBE - BelgiumBH -
BelizeBN - BeninBD - BermudaBT - BhutanBL - BoliviaBK - Bosnia-HerzegovinaBC -
BotswanaBV - Bouvet IslandBR - BrazilIO - British Indian Ocean TerritoryVI -
British Virgin IslandsBX - BruneiBU - BulgariaUV - Burkina FasoBM - BurmaBY -
BurundiCB - CambodiaCM - CameroonCA - CanadaCV - Cape VerdeCJ - Cayman IslandsCT
- Central African RepublicCD - ChadCI - ChileCH - ChinaKT - Christmas IslandIP -
Clipperton IslandCK - Cocos (Keeling) IslandsCO - ColombiaCN - ComorosCF - Congo
(Brazzaville)CG - Congo (Kinshasa)CW - Cook IslandsCR - Coral Sea IslandsCS -
Costa RicaIV - Cote DIvoire (Ivory Coast)HR - CroatiaCU - CubaUC - CuracaoCY -
CyprusEZ - Czech RepublicDA - DenmarkDX - DhekeliaDJ - DjiboutiDO - DominicaDR -
Dominican RepublicTT - East TimorEC - EcuadorEG - EgyptES - El SalvadorEK -
Equatorial GuineaER - EritreaEN - EstoniaET - EthiopiaFK - Falkland Islands
(Islas Malvinas)FO - Faroe IslandsFM - Federated States of MicronesiaFJ - FijiFI
- FinlandFR - FranceFP - French PolynesiaFS - French Southern and Antarctic
LandsGB - GabonGA - The GambiaGG - GeorgiaGM - GermanyGH - GhanaGI - GibraltarGR
- GreeceGL - GreenlandGJ - GrenadaGQ - GuamGT - GuatemalaGK - GuernseyGV -
GuineaPU - Guinea-BissauGY - GuyanaHA - HaitiHM - Heard Island and McDonald
IslandsVT - Holy SeeHO - HondurasHK - Hong KongHQ - Howland IslandHU - HungaryIC
- IcelandIN - IndiaID - IndonesiaIR - IranIZ - IraqEI - IrelandIS - IsraelIT -
ItalyJM - JamaicaJN - Jan MayenJA - JapanDQ - Jarvis IslandJE - JerseyJQ -
Johnston AtollJO - JordanKZ - KazakhstanKE - KenyaKQ - Kingman ReefKR -
KiribatiKN - Korea, Democratic Peoples Republic of (North)KS - Korea, Republic
of (South)KV - KosovoKU - KuwaitKG - KyrgyzstanLA - LaosLG - LatviaLE -
LebanonLT - LesothoLI - LiberiaLY - LibyaLS - LiechtensteinLH - LithuaniaLU -
LuxembourgMC - MacauMK - MacedoniaMA - MadagascarMI - MalawiMY - MalaysiaMV -
MaldivesML - MaliMT - MaltaIM - Man, Isle ofRM - Marshall IslandsMR -
MauritaniaMP - MauritiusMX - MexicoMQ - Midway IslandsMD - MoldovaMN - MonacoMG
- MongoliaMJ - MontenegroMH - MontserratMO - MoroccoMZ - MozambiqueWA -
NamibiaNR - NauruBQ - Navassa IslandNP - NepalNL - NetherlandsNC - New
CaledoniaNZ - New ZealandNU - NicaraguaNG - NigerNI - NigeriaNE - NiueNF -
Norfolk IslandCQ - Northern Mariana IslandsNO - NorwayMU - OmanPK - PakistanPS -
PalauLQ - Palmyra AtollPM - PanamaPP - Papua-New GuineaPF - Paracel IslandsPA -
ParaguayPE - PeruRP - PhilippinesPC - Pitcairn IslandsPL - PolandPO - PortugalRQ
- Puerto RicoQA - QatarRO - RomaniaRS - RussiaRW - RwandaTB - Saint BarthelemyRN
- Saint MartinWS - SamoaSM - San MarinoTP - Sao Tome and PrincipeSA - Saudi
ArabiaSG - SenegalRI - SerbiaSE - SeychellesSL - Sierra LeoneSN - SingaporeNN -
Sint MaartenLO - SlovakiaSI - SloveniaBP - Solomon IslandsSO - SomaliaSF - South
AfricaSX - South Georgia and the South Sandwich IslandsSP - SpainPG - Spratly
IslandsCE - Sri LankaSH - St. HelenaSC - St. Kitts and NevisST - St. Lucia
IslandSB - St. Pierre and MiquelonVC - St. Vincent and the GrenadinesSU -
SudanNS - SurinameSV - SvalbardWZ - SwazilandSW - SwedenSZ - SwitzerlandSY -
SyriaTW - TaiwanTI - TajikistanTZ - TanzaniaTH - ThailandTO - TogoTL - TokelauTN
- TongaTD - Trinidad and TobagoTS - TunisiaTU - TurkeyTX - TurkmenistanTK -
Turks and Caicos IslandsTV - TuvaluUG - UgandaUP - UkraineAE - United Arab
EmiratesUK - United KingdomUY - UruguayUZ - UzbekistanNH - VanuatuVE -
VenezuelaVM - VietnamVQ - Virgin IslandsWQ - Wake IslandWF - Wallis and FutunaWI
- Western SaharaYM - Yemen (Aden)ZA - ZambiaZI - Zimbabwe
b
Choose...1 - Model 1 IGA2 - Model 2 IGA
c
d
e
The trustee is...f - U.S.t - Foreign
PART XIII FOREIGN GOVERNMENT, GOVERNMENT OF A U.S. POSSESSION, OR FOREIGN
CENTRAL BANK OF ISSUE
I certify that the entity identified in Part I is the beneficial owner of the
payment and is not engaged in commercial financial activities of a type engaged
in by an insurance company, custodial institution, or depository institution
with respect to the payments, accounts, or obligations for which this form is
submitted (except as permitted in §1.1471-6(h)(2)).
PART XIV INTERNATIONAL ORGANIZATION
Check box 28a or 28b, whichever applies.
I certify that the entity identified in Part I is an international organization
described in section 7701(a)(18).
I certify that the entity identified in Part I:
* Is comprised primarily of foreign governments;
* Is recognized as an intergovernmental or supranational organization under a
foreign law similar to the International Organizations Immunities Act or that
has in effect a headquarters agreement with a foreign government;
* The benefit of the entity's income does not inure to any private person; and
* Is the beneficial owner of the payment and is not engaged in commercial
financial activities of a type engaged in by an insurance company, custodial
institution, or depository institution with respect to the payments,
accounts, or obligations for which this form is submitted (except as
permitted in Regulations §1.1471-6(h)(2)).
PART XV EXEMPT RETIREMENT PLANS
Check box 29a, b, c, d, e, or f, whichever applies.
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 (see Part III if claiming treaty benefits);
* 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.
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
* 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;
* 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 §1.1471-5(b)(2)(i)(A));
* 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 §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
* 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;
* 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 §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 percent 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.
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, or 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 §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 §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 XVI ENTITY WHOLLY OWNED BY EXEMPT BENEFICIAL OWNERS
I certify that the entity identified in Part I:
* Is an FFI solely because it is an investment entity;
* Each direct holder of an equity interest in the investment entity is an
exempt beneficial owner described in Regulations section §1.1471-6 or in an
applicable Model 1 or Model 2 IGA;
* Each direct holder of a debt interest in the investment entity is either a
depository institution (with respect to a loan made to such entity) or an
exempt beneficial owner described in Regulations section §1.1471-6 or an
applicable Model 1 or Model 2 IGA.
* Has provided an owner reporting statement that contains the name, address,
TIN (if any), chapter 4 status, and a description of the type of
documentation provided to the withholding agent for every person that owns a
debt interest constituting a financial account or direct equity interest in
the entity; and
* Has provided documentation establishing that every owner of the entity is an
entity described in §1.1471-6(b), (c), (d), (e), (f) and/or (g) without
regard to whether such owners are beneficial owners.
PART XVII TERRITORY FINANCIAL INSTITUTION
I certify that the entity identified in Part I is a financial institution (other
than an investment entity) that is incorporated or organized under the laws of a
possession of the United States.
PART XVIII 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 XIX 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)x(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;
* Is investing capital into assets with the intent to operate a business other
than that of a financial institution; 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.
x
PART XX EXCEPTED NONFINANCIAL ENTITY IN LIQUIDATION OR BANKRUPTCY
I certify that the entity identified in Part I:
* Filed a plan of liquidation, filed a plan of reorganization, or filed for
bankruptcy on x;
* During the past 5 years has not been engaged 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, 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 three years.
x
PART XXI 501(C) ORGANIZATION
I certify that the entity identified in Part I is a 501(c) organization that:
* Has been issued a determination letter from the IRS that is currently in
effect concluding that the payee is a section 501(c) organization that is
datedx; or
x
PART XXII NON-PROFIT ORGANIZATION
I certify that the entity identified in Part I is a non-profit organization that
meets the following requirements:
* The entity is established and maintained in its country of residence
exclusively for religious, charitable, scientific, artistic, cultural or
educational purposes;
* The entity is exempt from income tax in its country of residence;
* The entity has no shareholders or members who have a proprietary or
beneficial interest in its income or assets;
* Neither the applicable laws of the entity's country of residence nor the
entity's formation documents permit any income or assets of the entity to be
distributed to, or applied for the benefit of, a private person or
non-charitable entity other than pursuant to the conduct of the entity's
charitable activities or as payment of reasonable compensation for services
rendered or payment representing the fair market value of property which the
entity has purchased; and
* The applicable laws of the entity's country of residence or the entity's
formation documents require that, upon the entity's liquidation or
dissolution, all of its assets be distributed to an entity that is a foreign
government, an integral part of a foreign government, a controlled entity of
a foreign government, or another organization that is described in this part
or escheats to the government of the entity's country of residence or any
political subdivision thereof.
PART XXIII PUBLICLY TRADED NFFE OR NFFE AFFILIATE OF A PUBLICLY TRADED
CORPORATION
Check box 37a or 37b, whichever applies.
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 x (name one securities exchange upon which the
stock is regularly traded).
x
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 yand;
* The name of the securities market on which the stock is regularly traded is
z.
y
z
PART XXIV EXCEPTED TERRITORY NFFE
I certify that:
* The entity identified in Part I is an entity that is organized in a
possession of the United States;
* The entity identified in Part I:
* 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; or
* 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; and
* 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.
PART XXV ACTIVE NFFE
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
instructions for the definition of passive income).
PART XXVI PASSIVE NFFE
I certify that the entity identified in Part I is a foreign entity that is not a
financial institution (other than an investment entity organized in a possession
of the United States) and is not certifying its status as a publicly traded NFFE
(or affiliate), excepted territory NFFE, active NFFE, direct reporting NFFE, or
sponsored direct reporting NFFE.
Check box 40b or 40c, whichever applies.
I further certify that the entity identified in Part I has no substantial U.S.
owners (or, if applicable, no controlling U.S. persons), <strong>or</strong>
I further certify that the entity identified in Part I has provided the name,
address, and TIN of each substantial U.S. owner of the NFFE in Part XXIX.
PART XXVII EXCEPTED INTER-AFFILIATE FFI
I certify that the entity identified in Part I:
* Is a member of an expanded affiliated group;
* Does not maintain financial accounts (other than accounts maintained for
members of its expanded affiliated group);
* Does not make withholdable payments to any person other than to members of
its expanded affiliated group;
* Does not hold an account (other than a depository account in the country in
which the entity is operating to pay for expenses) with or receive payments
from any withholding agent other than a member of its expanded affiliated
group; and
* Has not agreed to report under Regulations section §1.1471-4(d)(2)(ii)(C) or
otherwise act as an agent for chapter 4 purposes on behalf of any financial
institution, including a member of its expanded affiliated group.
PART XXVIII SPONSORED DIRECT REPORTING NFFE
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 in line 42.
PART XXIX SUBSTANTIAL U.S. OWNERS OF PASSIVE NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial
U.S. owner of the NFFE. Please see instructions for definition of substantial
U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI
or reporting Model 2 FFI, an NFFE may also use this Part for reporting its
controlling U.S. persons under an applicable IGA.
Add another substantial US owner
PART XXX CERTIFICATION
* The income to which this form relates is:
1. not effectively connected with the conduct of a trade or business in the
United States,
2. effectively connected but is not subject to tax under an income tax
treaty, or
3. the partner's share of a partnership's effectively connected income; and
* 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 the entity on
line 1 is the beneficial owner or any withholding agent that can disburse or
make payments of the income of which the entity on line 1 is the beneficial
owner.
I agree that I will submit a new form within 30 days if any certification
made on this form becomes incorrect.
Signature of individual authorized to sign for beneficial owner
Clear
Print Name
I certify that I have the capacity to sign for the entity identified on line 1
of this form.
Continue
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W-8BEN-E INSTRUCTIONS
IRS W-8BEN-E INSTRUCTIONS
Do NOT use this form for: Instead, use Form: U.S. entity or U.S. citizen or
resident W-9 A foreign individual W-8BEN (Individual) or Form 8233 A foreign
individual or entity claiming that income is effectively connected with the
conduct of trade or business within the U.S. (unless claiming treaty benefits).
W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust
(unless claiming treaty benefits) (see instructions for exceptions) W-8IMY 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 that income is effectively connected U.S. income or
that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or
1443(b) (unless claiming treaty benefits) (see instructions for other
exceptions) W-8ECI or W-8EXP Any person acting as an intermediary (including a
qualified intermediary acting as a qualified derivatives dealer) W-8IMY
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