This is only
an Example of How to Fill out a W-8BEN Form.
Please Put Your Correct
you see the Red
Writing in this Example!
of the Treasury
of Foreign Status of Beneficial Owner
United States Tax Withholding
Give this form to the withholding
agent or payer. Do not send to the IRS.
not use this form for: Instead, use Form:
● A U.S. citizen or other U.S. person, including a resident alien
● A person claiming that income is effectively connected with the
of a trade or business in the United States W-8ECI
● A foreign partnership, a foreign simple trust, or a foreign grantor
trust (see instructions for exceptions) W-8ECI or 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 that
received effectively connected income or that is
claiming the applicability of section(s) 115(2), 501(c), 892, 895, or
1443(b) (see instructions) W-8ECI or W-8EXP
Note: These entities should use Form W-8BEN if they are claiming treaty
benefits or are providing the form only to
claim they are a foreign person exempt from backup withholding.
● A person acting as an intermediary W-8IMY
Note: See instructions for additional exceptions.
Part I Name
of individual or organization that is the beneficial owner
1. Name of
Individual or Organization that is the beneficial owner:
2. Country of
incorporation or organization
Example: United Kingdom
of beneficial owner: Choose this: Individual
Permanent residence address (street, apt. or suite no., or
rural route). Do not use a P.O. box or in-care-of address.
12902 Down The Road Street Govnowapt
City or town, state or
province. Include postal code where appropriate.
County (Do Not Abbreviate)
Devon SQ2 6RB
address (if different from above) : Leave this Blank please unless
diferent from above
Claim of Tax Treaty Benefits (if applicable)
Check this one and write in your country as the example show
you. This is what most people check and send in.
They do not usually fill out B,C,D, E and #10
9. I certify that (check all that apply):
beneficial owner is a resident of ________United
Kingdom___ within the meaning of the income
tax treaty between the United States and that country.
III Notional Principal Contracts - Leave Blank
Under penalties of perjury, I
declare that I have examined the information on this form and to the
best of my knowledge and belief it is true, correct, and complete. I
further certify under penalties of perjury that:
1 I am the beneficial owner (or am authorized to sign for the
beneficial owner) of all the income to which this form relates,
2 The beneficial owner is not a U.S. person,
3 The income to which this form relates is (a) not effectively
connected with the conduct of a trade or business in the United States,
(b) effectively connected but is
not subject to tax under an income tax treaty, or (c) the
partner’s share of a partnership’s effectively
connected income, and
4 For broker transactions or barter exchanges, the beneficial owner is
an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding
agent that has control, receipt, or custody of the income of which I am
the beneficial owner or
any withholding agent that can disburse or make payments of the income
of which I am the beneficial owner.
Your Name Here________________________Todays Date ______Put
this word: Individual___
Signature of beneficial owner (or individual
authorized to sign for beneficial owner)
Capacity in which acting
After you have printed out the W-8Ben and fill it out,
please fax or mail to:
P.E.E.L. Inc., 146 N. Hamilton Road, Gahanna, Ohio, 43230 or faxed to
You Must To This with in 90 Days of your sign up to womvegas. When it
is received you will get a
note at the top of the Sales Agent Page letting you know it was
received. This can take some time.
So please be patient.
If you do not mail or fax this form in you will not be able to receive
commissions after your 90 days
is up. So please get this form in. Does not take but a few minutes to
fill it out and fax or mail.
Example Created by Georgetta Monroe