Part I Identification of Beneficial Owner

Name of individual who is the beneficial owner*

Country of citizenship*

Permanent residence address (DO NOT use P.O. Box or in-care-of address)*

City or Town, State or Province, include Postal Code where appropriate*

Country*

Mailing address (if different from above)

City or Town, State or Province, include Postal Code where appropriate

Country

SSN or ITIN (select which on you have, if either)

SSN ITIN

Without either of these numbers, unless your country has a Tax Treaty with the USA, 30% will be withheld from your royalty payment and paid to the US Internal Revenue Service per IRS regulations.

Enter SSN or ITIN Number here

Want to apply for one, see below

If you DO NOT have a U.S. Social Security Number (SSN) you will need to obtain a ITIN (if you do not already have one). You can get it and assistance if you live outside the USA in most countries. Copy and past link below to see if your country is listed with Agents or see local CPA Firms listed at top of page. https://www.irs.gov/individuals/acceptance-agent-program

Date of Birth*

Enter as Month/Day/Year

Foreign Tax Identification Number (see instructions, pg 5, Line 5)

If you DO NOT have one, leave this field blank

Reference Number(s) (see instructions)

Part II Claim of Tax Treaty Benefits

NOTE: For Chapter 3 purposes ONLY - see instructions.

Residency Certification

Enter Country of Residence Here

Special Rates and Conditions

Article Number

Percentage % Rate of withholding

Explain reason beneficial owners meets the terms of the treaty article

Part III Certification

Declaration

Enter Legal Name Here*

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

NOTE to Authorized Individual

Explain the capacity in which acting (if form is not signed by beneficial owner)

Email*

Date*

Enter as Month/Day/Year

After You Submit Form