Identification of Beneficial Owner (continued)

Note: Please complete remainder of the form including signing the form in Part XXX.

• 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.

• 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.

• 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 5% interest in such credit union or cooperative credit organization;
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is 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.

• 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.

• Is an FFI solely because it is an investment entity described in Regulations section 1.1471-5(e)(4);
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities  (determined as if the FFI were a participating FFI) fulfilled by the sponsoring entity identified on line 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% of the equity interests in the FFI and is itself a sponsored FFI).

• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013, pursuant to a trust indenture or similar agreement; and
• Is certified deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the restrictions with respect to its assets and other requirements under Regulations section 1.1471-5(f)(2)(iv)).

• Is a financial institution solely because it is an investment entity described in Regulations section 1.1471-5(e)(4)(i)(A), and
• Does not maintain financial accounts.

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 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.

• Has provided, or will provide, an FFI owner reporting statement that contains:

1. 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);
2. 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 deemedcompliant FFIs, excepted NFFEs, exempt beneficial owners, or U.S. persons other than specified U.S. persons); and
3. 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 Regulations section 1.1471-3(d)(6)(iii) for each person
identified in the FFI owner reporting statement.

• 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:

under the provisions of the applicable IGA or Treasury regulation.

Check box 28a or 28b, whichever applies.

• 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 section 1.1471-6(h)(2)).

Check box 29a, b, c, d, e, or f, whichever applies.

• 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.

• 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

1. 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;
2. Receives at least 50% of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described
   in this part, retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, other retirement funds described in
   an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section 1.1471-5(b)(2)(i)(A));
3. Either does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to retirement, disability, or death (except rollover distributions to accounts described in Regulations section 1.1471-5(b)(2)(i)(A) (referring to retirement and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2 IGA, or to other retirement funds described in this part or in an applicable Model 1 or Model 2 IGA); or
4. Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.

• 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 Regulations section 1.1471-5(b)(2)(i)(A)) are
limited by reference to earned income and compensation of the employee, respectively;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20% of the fund’s assets; and
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities in the
country in which the fund is established or operates.

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.

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.

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

• 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 Regulations section 1.1471-6(b), (c), (d), (e), (f) and/or (g) without regard to whether such owners are beneficial owners.

• 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.

• 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.

• Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on ;
• 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 3 years.

I certify that the entity identified in Part I is a 501(c) organization that:

• Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization (without regard to whether the payee is a foreign private foundation).

• 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 noncharitable 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.

Check box 37a or 37b, whichever applies.

• The entity identified in Part I is a foreign corporation that is not a financial institution; and

• 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 entity identified in Part I is an entity that is organized in a possession of the United States;

• The entity identified in Part I:

1. Does not accept deposits in the ordinary course of a banking or similar business;
2. Does not hold, as a substantial portion of its business, financial assets for the account of others; or
3. 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.

• 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).

Check box 40b or 40c, whichever applies.

• 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 depository accounts 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.

As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see the instructions for a 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.

• Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:
• The entity identified on line 1 of this form is the beneficial owner of all the income or proceeds to which this form relates, is using this form to certify its status for chapter 4 purposes, or is submitting this form for purposes of section 6050W or 6050Y;
• The entity identified on line 1 of this form is not a U.S. person;
• This form relates to: (a) income not effectively connected with the conduct of a trade or business in the United States, (b) income effectively connected with the conduct of a trade or business in the United States but is not subject to tax under an income tax treaty, (c) the partner’s share of a partnership’s effectively connected taxable income, or (d) the partner’s amount realized from the transfer of a partnership interest subject to withholding under section 1446(f); 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.

Disclaimer
These tax forms are provided as a courtesy to our Jotform users. It is up to you to make sure you are filing the right form with the IRS and to fill out the form correctly. Jotform does not file tax forms for you - that is your responsibility. If you have any questions or need any legal or tax advice about which form is appropriate or how to fill in the form, or whether the form is required by the IRS, consult your tax preparer, adviser, and/or attorney.