Opening My Account: Statement of Acceptance
Opening My Account: Statement of Acceptance
Opening My Account: Statement of Acceptance
27283205
Questrade, Inc.
Account number:
5700 Yonge Street, Unit G1 - Ground Floor, Toronto, ON M2M 4K2
Phone: 416.227.9876 www.questrade.com
OPENING MY ACCOUNT
I authorize Questrade, Inc. (“Questrade”) to open an account in the names of the account holders listed in this agreement. I hereby certify that the
information I have provided to Questrade on my new account application is true and correct.
This statement of acceptance applies to any account type I open with Questrade.
This lien is further explained in the Questrade, Inc. Client Account Agreement in Section 7, Security Interest.
• To pledge all of my assets, held now or in the future in my Questrade account(s), as collateral to secure loans from Questrade and to pay interest
on debt charges, as described in the applicable agreement(s) below.
• That Questrade may use all of the assets in the Questrade account as collateral to secure any amount owed to Questrade by any owner of this
account.
• That Questrade may combine the collateral in this account with the collateral of any other Questrade client.
CREDIT VERIFICATION
I authorize Questrade to inquire from any source (including a credit report) as to my identity (as required by federal law), creditworthiness, and
ongoing eligibility for the account (and the creditworthiness of my spouse if I live in a province that has community property laws) at account opening,
at anytime throughout the life of the account, and thereafter for debt collection or investigative purposes.
QUEBEC RESIDENTS
If you live in Quebec, you are asking us to provide most documents, contracts, and correspondence concerning your account in English only. Si vous
habitez au Québec, vous nous avez demandé de vous procurer, tout document, contrat et correspondence ayant trait à votre compte, et ceci en
anglais uniquement. This request has been in effect throughout the entire Account Application process. Cette demande a été mise en vigueur, tout au
long de la demande de ce compte.
Statement of Acceptance 1 of 3
© Questrade is a registered trademark of Questrade, Inc., licensed to Questrade Financial Group Inc. Last modified date: October 27, 2018
All rights reserved. Member of the Investment Industry Regulatory Organization of Canada and the Canadian Investor Protection Fund. OAA002EN-0003
NO SUITABILITY DISCLOSURE
I ACKNOWLEDGE AND AGREE THAT, IN THE COURSE OF PROVIDING SERVICES TO ME, NEITHER QUESTRADE NOR ITS INVESTMENT
REPRESENTATIVES PROVIDES ADVICE OR RECOMMENDATIONS REGARDING THE PURCHASE OR SALE OF ANY SECURITY, OR MAKES ANY
DETERMINATION OF MY GENERAL INVESTMENT NEEDS AND OBJECTIVES OR THE SUITABILITY REGARDING THE PROPOSED PURCHASE OR SALE
OF ANY SECURITY, AND I AM RESPONSIBLE FOR MY INVESTMENT DECISIONS AND TRANSACTIONS AS WELL AS FOR ANY PROFITS OR LOSSES
THAT MAY RESULT. I FURTHER ACKNOWLEDGE AND AGREE THAT, IN THE COURSE OF PROVIDING SERVICES TO ME, NEITHER QUESTRADE
NOR ITS INVESTMENT REPRESENTATIVES PROVIDES ME WITH ANY LEGAL, TAX OR ACCOUNTING ADVICE REGARDING THE PROFITABILITY OF
ANY SECURITY OR INVESTMENT OR ANY DECISION IN RESPECT THEREOF, NOR DOES QUESTRADE NOR ITS INVESTMENT REPRESENTATIVES
CONSIDER MY FINANCIAL SITUATION, INVESTMENT KNOWLEDGE, INVESTMENT OBJECTIVES AND RISK TOLERANCE WHEN ACCEPTING
ORDERS FROM ME. I WILL NOT SOLICIT OR RELY UPON ANY SUCH ADVICE FROM QUESTRADE OR ANY OF ITS EMPLOYEES AND AGREE THAT
QUESTRADE WILL HAVE NO LIABILITY THEREFORE WHATSOEVER. IN MAKING INVESTMENT DECISIONS WITH RESPECT TO TRANSACTIONS IN
OR FOR MY ACCOUNT(S) OR ANY OTHER MATTER, I WILL CONSULT WITH AND RELY UPON MY OWN ADVISORS AND NOT QUESTRADE.
I have received the booklet titled account agreements and disclosures documents available at http://media.questrade.com/downloads/accounts/
AGMT001EN.pdf. Below is a list of documents applicable to my account.
I have read and understood the following documents and I agree to be bound by the terms and conditions contained therein:
* Privacy Policy;
Please initial x
Muhammad Farooq
Statement of Acceptance 2 of 3
© Questrade is a registered trademark of Questrade, Inc., licensed to Questrade Financial Group Inc. Last modified date: October 27, 2018
All rights reserved. Member of the Investment Industry Regulatory Organization of Canada and the Canadian Investor Protection Fund. OAA002EN-0003
SUMMARY OF ACCOUNT
I AGREE:
By making my/our first account(s) transaction, I am agreeing to this Statement of Acceptance and the terms of all applicable agreements, disclosures
and amendments.
Signature x
Muhammad Farooq Date
Signature x
Muhammad Farooq Date
Approved by Date
Statement of Acceptance 3 of 3
© Questrade is a registered trademark of Questrade, Inc., licensed to Questrade Financial Group Inc. Last modified date: October 27, 2018
All rights reserved. Member of the Investment Industry Regulatory Organization of Canada and the Canadian Investor Protection Fund. OAA002EN-0003
CORPORATE TRADING AUTHORIZATION
ORDER EXECUTION ACCOUNT ONLY
Certified copy of a resolution duly passed by the directors of “the “Corporation” authorizing the establishment and maintenance
of one or more Securities trading accounts with Questrade, Inc. (“Questrade”)
RESOLVED THAT
1. The Corporation establish and maintain an account (or accounts) (“Accounts”), which may include a margin account, with Questrade for buying,
selling and generally dealing with (“trading”) Securities.
be and is hereby authorized on behalf on the Corporation from time to time to:
(a) instruct Questrade in writing, orally (including by telephone) or by electronic means with respect to any trading in Securities and any other
transactions in the Accounts;
(b) give instructions with respect to the delivery or transfer of Securities and to sign and deliver receipts for Securities or to instruct Questrade
either in writing, orally (including by telephone) or by electronic means to deliver any Securities to any person;
(c) sign on behalf of the Corporation all contracts, agreements, releses, powers of attorney and other documents required by Questrade in
connection with the operation of the Accounts and any trading of Securities;
(d) operate the Accounts on such margin(s) as may be advised by Questrade to the Corporation from time to time, and in connection there-
with to authorize Questrade to conduct trading of Securities on the credit of the Corporation and to sign, on behalf of the Corporation,
margin agreements with Questrade; and
(e) create a security interest in any Securities in favour of Questrade to secure repayment of all obligations and indebtedness, present or future,
of the Corporation to Questrade.
3. Questrade may honour instructions received by it pursuant to this resolution, and in particular may honour oral (including telephone) instructions
or electronic (including telefax) instructions purporting to be given by any of the persons authorized hereunder without the necessity of any
further verification or inquiry by Questrade.
4. Questrade be furnished with a copy, certified by the Secretary of the Corporation and, where required by law, under the Corporation’s seal,
of this resolution, and with a list of all persons authorized by this resolution to act for the Corporation and with written notice of any changes
which may take place in such list from time to time (any such notice to be binding on Questrade only from the time when its receipt is duly
acknowledged in writing by Questrade), and with specimens of the signatures of all persons so authorized; and that this resolution shall remain
in force and be binding upon the Corporation until a copy, certified by the Secretary and, where required by law, under the Corporation’s
seal, of a resolution of the directors of the Corporation replacing or repealing this resolution shall have been received by Questrade and duly
acknowledged by it in writing.
5. In this resolution “Securities” shall have the meaning attributed to it in the Securities Act of Ontario, as amended from time to time, and “trading”
shall include trading any interest in Securities.
Signature: x
Signature: x
Signature: x
Signature: x
Signature: x
hereby certify that the following are its officers and directors, with samples of their signatures, namely:
OFFICERS
Muhammad Farooq
1. Name (please print): Signature x
Title:
Title:
Title:
Title:
Title:
DIRECTORS
Muhammad Farooq
1. Name (please print): Signature x
BENEFICIAL OWNERS
Hereby certify that the following persons are beneficial owners of the above entity and each has 10% or more interest in the entity.
I acknowledge that a copy of valid photo identification of each person listed under Director and Beneficial Owners will be required, along with an
one($1) dollar cheque (made payable to Questrade and written on those individuals’ personal, pre-printed cheques.) I understand that a pre-printed
void cheque and a bill payment can be used instead of writing a $1 cheque.
Percentage held:
Signature x
HN242174
ID number:
Percentage held:
Signature x
ID number:
Percentage held:
Signature x
ID number:
Percentage held:
Signature x
ID number:
X
Secretary signature Date
Note: if there are additional Officers, Directors, Beneficial Owners, please attach a separate page with their Name, Signature, Title, and when
applicable ID type and ID number and percentage held.
The undersigned Secretary of the Corporation hereby certifies that this is a true copy of a resolution of the directors of the Corporation passed
in accordance with the Corporation’s bylaws, constating documents, any unanimous shareholders’ agreement made by the shareholders of the
Corporation and all other laws governing the Corporation, as amended from time to time, and that this resolution is now in full force and effect, and
that there are no provisions in the Memorandum of Association, Articles of Incorporation, bylaws of the Corporation or other constating documents
of the Corporation or in any unanimous shareholders’ agreement which restrict or limit the powers of the Corporation to trade in Securities, borrow
money upon the credit of the Corporation, or to give a security interest in any property or assets of the Corporation, present or future.
18 November 19
x
SECRETARY SIGNATURE (CORPORATE SEAL WHERE REQUIRED BY LAW) DATE
Corporate Certificate 1 of 1
© Questrade, Inc. All rights reserved. Member of IIROC and the Canadian Investor Protection Fund. Last modified: October 27, 2018
QUESTRADE is a registered trademark of Questrade, Inc. TRDE022EN-0003
SHAREHOLDER REGISTRY
Note: if a shareholder is a non-individual, please provide the breakdown of the corporation/entity/trust by adding additional Share Registry
document. Use each document to disclose the owners of just one Entity.
x
Signature Date
Shareholder Registry 1 of 1
PERSONAL GUARANTEE
ORDER EXECUTION ACCOUNT ONLY
In consideration of Questrade, Inc. (“Questrade”) establishing or maintaining one or more accounts for the client named on the reverse side (the
“Customer”) or otherwise giving credit to the Customer, the undersigned individual (the “Guarantor”) hereby unconditionally guarantees jointly
and severally with the Customer timely payment to Questrade of: (a) all debit balances existing in any account maintained with Questrade by the
Customer, whether alone or with others; and (b) all other liabilities owing to Questrade by the Customer, whether alone or with others, whether as
principal, guarantor or surety, whether absolute or contingent and whether matured or not (such debit balances and liabilities being referred to herein
as the “Liabilities”). The Guarantor further agrees as follows:
CONTINUING GUARANTEE
This Guarantee is a continuing guarantee which covers all present and future Liabilities and this Guarantee will survive any incidental, temporary or
intermittent closing out, reopening or renumbering of any of the Customer’s accounts.
PAYMENTS TO QUESTRADE
The Guarantor will, upon any demand therefore, pay to Questrade the amount of all of the Liabilities, or such part thereof as may have been
demanded, together with interest, calculated daily and compounded monthly, from the date of demand until payment. The interest rate or rates in
respect of amounts owed in Canadian dollars shall be the rate equal from time to time to Royal Bank of Canada’s prime interest rate per annum plus
3% per annum, and in respect of amounts owed in United States dollars the rate equal from time to time to Royal Bank of Canada’s U.S. dollar call
loan rate per annum plus 3% per annum. For the purpose of this Guarantee, Royal Bank of Canada’s prime interest rate means the annual rate of
interest announced from time to time by Royal Bank of Canada as a reference rate then in effect for determining interest rates on Canadian dollar
commercial loans in Canada, and Royal Bank of Canada’s U.S. dollar call loan rate shall mean the call loan rate announced by Royal Bank of Canada
from time to time as a reference rate then in effect for determining interest rates on U.S. dollar call loans in Canada. Any amount which Questrade
states is owing by the Customer shall be accepted by the Guarantor as conclusive evidence that such amount is owing by the Customer to Questrade.
Questrade shall be entitled to make more than one demand under this Guarantee and no demand shall in any way terminate or extinguish this
Guarantee.
The Guarantor waives notice of, any modifications to the terms of any present or future agreement between the Customer and Questrade, the types
of Securities traded by the Customer and the Customer’s trading pattern. The Guarantor confirms that Questrade may deal with and accept orders for
the Customer’s accounts without notice to the Guarantor. The Guarantor also waives notice of the condition of the Customer’s accounts at any time
and from time to time, including notice of any failure by the Customer to make timely payments of the Liabilities, and the Guarantor waives any right
to automatically receive copies of any confirmations, statements or other communications sent by Questrade to the Customer. The Guarantor shall
be entitled to receive from Questrade on request written confirmation from time to time of the Customer’s liability to Questrade in respect of the
account or accounts to which this Guarantee relates, provided that Questrade has received the written consent of the Customer for such provision of
information.
TERMINATION OF GUARANTEE
The Guarantor may terminate this Guarantee by sending a written notice to Questrade by registered mail addressed to the attention of Questrade’s
Chief Compliance Officer at its head office in Ontario. By giving such notice, the Guarantor shall not, except for any transactions executed by
Questrade within a reasonable time after receipt of such notice for the purpose of closing out positions existing at such time, be liable to Questrade
for any Liabilities arising on or after the trading day immediately following the day on which such notice is received. The Guarantor shall continue to
be liable to Questrade for any Liabilities arising from transactions executed on or before the day of receipt of such notice.
WAIVER OF DEFENCES
The Guarantor’s liability to Questrade will not be released, discharged, limited, reduced or otherwise affected by Questrade
(a) granting any extension or other indulgence or any release or discharge to the Customer or any other guarantor or surety;
(b) taking, giving up or abstaining from perfecting any security or taking advance of, exercising or otherwise dealing with any security held
by Questrade;
(c) accepting any compositions from or otherwise dealing with the Customer or any other guarantor or surety;
(d) supplying any monies received from the Customer or others or from any security against the Liabilities in any manner Questrade sees fit;
(e) failing to exhaust its recourse against the Customer or any other guarantor or surety at any time prior to requiring or enforcing payment
from the G uarantor under this Guarantee; or
Personal Guarantee 1 of 3
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QUESTRADE is a registered trademark of Questrade, Inc. AGMT004EN-0001
(f ) acting, or failing to act, in any manner which might otherwise operate as a discharge, whether partial or absolute, of the Guarantor’s
obligations under this Guarantee; nor by:
(g) any right of set-off, counterclaim, appropriation, application or other demand or right the Customer or Guarantor may have;
(h) any irregularity, defect or informality in any obligation, document or transaction relating to the Customer or its accounts;
(i) any acts done, omitted, suffered or permitted by Questrade in connection with the Customer, its accounts, the Liabilities or any other
guarantees or security held in respect thereof including any renewals, extensions, waivers, releases, amendments, compromises or
indulgences agreed to by Questrade and including the provision of information by Questrade to the Guarantor in accordance with
section 3 above;
( j) the incapacity, bankruptcy or other fundamental change of or affecting the Customer; provided that in the event the Guarantor shall be
released for any reason from this Guarantee the Guarantor shall remain liable as principal debtor in respect of the Liabilities.
The Guarantor hereby renounces all benefits of division and discussion, and waives any rights of subrogation until all Liabilities are paid
in full.
Any notice or communication to the Guarantor may be given by prepaid mail, telegraph or telex to any address of record of the Guarantor with
Questrade or may be delivered personally to the Guarantor or to any such address of record and shall be deemed to have been received, if mailed,
on the second business day after mailing or, if sent by telegram or telex, on the day sent or, if delivered, when delivered. Nothing in this section shall
be interpreted as requiring Questrade to give any notice to the Guarantor, which is not otherwise required to be given to Questrade.
GENERAL
(a) This Guarantee shall remain in effect notwithstanding any change in the name of the Customer or any change of control in, or any
continuation or amalgamation of the Customer.
(b) This Guarantee is in addition to all other guarantees (whether or not in the same form as this Guarantee) held or which Questrade may
here after hold.
(c) There are no representations, collateral agreements or conditions with respect to this Guarantee or affecting the Guarantor’s liabilities
herre under other than as contained herein.
(d) This Guarantee shal l be construed in accordance with the laws of the jurisdiction in which the Customer’s Account is maintained or,
where the Customer has more than one Account, this Guarantee shall be construed separately with respect to each Account in
accordance with the laws of the jurisdiction in which each such Account is maintained. This Guarantee shall ensure to the benefit of and
be binding upon Questrade and the Guarantor and their respective heirs, personal representatives, successors and assigns.
(e) Whenever this Guarantee entitles Questrade to alternative courses of action, Questrade shall be entitled to choose any, none or all of such
alternatives in its sole and unfettered discretion.
(f ) The headings used in this Guarantee are for convenience of reference only and shall not in any way affect the interpretation of this
Guarantee.
(g) In this Guarantee, where the singular is used it shall include the plural.
DEFINED TERM
For the purposes of this Guarantee “Securities” includes shares, share certificates, scrip certificates, warrants, rights, bonds, debentures, notes and
any other securities of any kind whatsoever, commodities and future contracts, options on securities and options on commodities and future contracts.
ACKNOWLEDGEMENT
The Guarantor acknowledges that the Guarantor has read this Guarantee, that the Guarantor understands the legal effect and binding nature of this
Guarantee and that the Guarantor has executed and delivered this Guarantee voluntarily.
GUARANTEED CUSTOMER
The Customer whose accounts are guaranteed pursuant to the foregoing terms and conditions is:
27283205
One of the customer’s guaranteed accounts: account number
Personal Guarantee 2 of 3
© Questrade, Inc. All rights reserved. Member of IIROC and the Canadian Investor Protection Fund. Last modified: 28 August 2013
QUESTRADE is a registered trademark of Questrade, Inc. AGMT004EN-0001
SIGNED, SEALED AND DELIVERED in the presence of:
X
Witness signature Witness (please print)
Muhammad Farooq
X
Guarantor signature Guarantor (please print)
Note: Questrade recommends that the Guarantor obtain independent legal advice before signing this Guarantee. Witness must be an individual who
is not related or associated with the Guarantor or account holder.
(TO BE COMPLETED WHEN ANY ASSETS OF THE PERMANENT ADDRESS OF THE GUARANTOR ARE SITUATE IN THE
PROVINCE OF ALBERTA.)
THE GUARANTEES ACKNOWLEDGEMENT ACT, (ALBERTA) CERTIFICATE OF NOTARY PUBLIC
addressed to Questrade, Inc., a copy of which is attached hereto, appeared in person before me and acknowledged that he or she, as the case
may be, had executed such guarantee and that I have satisfied myself by examination of him or her that he or she is aware of the contests of the
guarantee and he or she understands it.
GIVEN at this day of
(City/Town) (Day) (Month) (Year)
under my hand and seal of office.
x
A NOTARY PUBLIC IN AND FOR
STATEMENT OF GUARANTOR
I am the person named in this certificate.
x
GUARANTOR SIGNATURE
Personal Guarantee 3 of 3
© Questrade, Inc. All rights reserved. Member of IIROC and the Canadian Investor Protection Fund. Last modified: 28 August 2013
QUESTRADE is a registered trademark of Questrade, Inc. AGMT004EN-0001
IRS TREATY STATEMENT
FOR ENTITIES – INSTRUCTIONS
Section references are to the Internal Revenue Code (“IRC”) unless otherwise noted.
GENERAL INSTRUCTIONS
For definitions of terms used throughout these instructions, see the definitions section later in this form.
This form is used by non-U.S. entities to document their status for purposes of chapter three (withholding of tax on no-resident aliens and foreign
corporations, sections 1441 to 1464) and chapter four (taxes to enforce reporting on certain foreign accounts, sections 1471 to 1474) of the IRC, as
well as for certain other code provisions. None of the information in this form should be construed as tax or legal advice. If you have any questions
about the contents of the form or what particular information to input, consult an accountant or a lawyer.Non-U.S. persons are subject to U.S. tax at a
30% rate (the foreign-person withholding rate) on income they receive from U.S. sources that consists of any of the following:
• Interest (including certain original issue discount (OID)
• Dividends
• Rents
• Royalties
• Premiums
• Annuities
• Compensation for, or in expectation of, services performed
• Substitute payments in a securities lending transaction
• Other fixed or determinable annual or periodical gains, profits, or income
Please note that the above is subject to change by US Regulatory authorities and specific tax advice should be sought from a professional. This tax
applies to the gross amount paid and is generally collected by withholding under section 1441 or 1442 of the IRC on that amount. A payment is
considered to have been made whether it is made directly to the beneficial owner or to another person (intermediary, agent, or partnership) for the
benefit of the beneficial owner.
A withholding agent or payer of income may rely on a properly completed entity treaty statement form to apply a reduced rate of, or exemption from,
withholding. You must provide this form to do the following:
• Claim that you are the beneficial owner or a partner in a partnership for income applicable to the entity treaty statement form subject to
section 1446 of the IRC
• If applicable, claim a reduced rate of, or exemption from, withholding as a resident of a foreign country that the U.S. has an income tax treaty
with and that is eligible for treaty benefits
Note: send the entity treaty statement form to Questrade before you receive any income. If you do not send this form as requested, your
income may be withheld at a 30% rate (foreign-person withholding rate) or the backup withholding rate. If you own the income with one
or more other persons, the income will be treated by the withholding agent as owned by a foreign person that is a beneficial owner of a
payment only if an entity treaty statement is provided by the owners. An account will be treated as a U.S. account for chapter four purposes
by an FFI requesting this form if any of the account holders is a specified U.S. person or a U.S.-owned foreign entity (unless the account is
otherwise accepted from U.S. account status for chapter four purposes).
Change in circumstances: if there are any changes to the information you provided in the entity treaty statement form, send us the updated info
within 30 days of the changes.
Amounts subject to withholding under chapter three: an amount from sources within the United States that is fixed or determinable annual or
periodical (FDAP) income. FDAP income is all income included in gross income, including interest (as well as OID), dividends, rents, royalties, and
compensation. See regulations section 1.1441-2 for all exclusions.
Beneficial owner: The person who is required under U.S. tax principles to include the payment in gross income on a tax return for payments other
than those for which a reduced rate of, or exemption from, withholding is claimed. A person is not a beneficial owner of income, however, to the
extent that person is receiving the income as a nominee, agent, or custodian, or to the extent that the person’s participation in a transaction is
disregarded. In the case of amounts paid that do not constitute income, beneficial ownership is determined as if the payment were income.
Chapter 3: sections 1441 through 1464 of the IRC (withholding of tax on nonresident aliens and foreign corporations).
Chapter 4: sections 1471 through 1474 of the IRC (taxes to enforce reporting on certain foreign accounts).
Chapter 4 status: status as a U.S. person, specified U.S. person, foreign individual, participating FFI, deemed-compliant FFI, restricted distributor,
exempt beneficial owner, nonparticipating FFI, territory financial institution, excepted NFFE, or passive NFFE. See regulations section 1.1471-1(b) for
the definitions of these terms.
Specified U.S. person: any U.S. person other than a person identified in regulations section 1.1473-1(c).
• Owns, directly or indirectly, more than 10% (by vote or value) of the stock of any foreign corporation
• Owns, directly or indirectly, more than 10% of the profits or capital interests in a foreign partnership
• Is treated as an owner of any portion of a foreign trust under sections 671 through 679
• Holds, directly or indirectly, more than a 10% beneficial interest in a trust
U.S. person: defined in section 7701(a)(30) and including domestic partnerships, corporations, and trusts.
SPECIFIC INSTRUCTIONS
Permanent residence address in the country where you claim to be a resident for purposes of that country’s income tax. If you are giving an entity
treaty statement to claim a reduced rate of, or exemption from, withholding under an income tax treaty, you must determine residency in the manner
required by the treaty. If you do not have a tax residence in any country, use the address where you maintain your principal residence.
Line 4: mailing address (should it differ from the address shown on line three).
Line 5: mailing address (should it differ from the address shown on line three).
If you do not have a U.S. TIN, apply for one on form SS-4, application for employer identification number, if you are required to obtain a U.S. TIN.
• Claiming an exemption from withholding under section 871(f) for certain annuities received under qualified plans
• Claiming benefits under an income tax treaty and have not provided a foreign TIN on line 5a
• Dividends and interest from actively traded stocks and debt obligations
• Dividends from any redeemable security issued by an investment company registered under the investment company act of 1940
Line 5a: for the purposes of this form, you may use your BIN as a TIN.
If you are providing this form to document yourself with respect to a financial account that you hold at a U.S. office of a financial institution, you must
provide the TIN issued to you by the jurisdiction in which you are a tax resident unless:
Line 6: check the box that represents your classification under U.S. tax principles. You may not use this form if you are partnership, simple trust, or
grantor trust (see form W-8IMY).
Note: if you are documenting your foreign status (or making a claim of treaty benefits for reduced withholding) use form W-8BEN. In general, if you
are a foreign entity receiving a withholdable payment, you should provide this form when requested to avoid withholding consequences.
Line 7a: country of residency if you are claiming a reduced rate of, or exemption from, withholding under an income tax treaty. Check the box to
confirm that the entity stated in line one is in fact a resident of the stated country.
Line 7b: an entity that is claiming a reduced rate of, or exemption from, withholding under an income tax treaty must check the box to certify that it:
• Derives the item of income for which the treaty benefit is claimed, and
• Meets the limitation on benefits provisions contained in the treaty, if any.
An item of income may be derived by either the entity receiving the item of income or by the interest holders in the entity or, in certain circumstances,
both. An item of income paid to an entity is considered to be derived by the entity only if the entity is not fiscally transparent under the laws of the
entity’s jurisdiction with respect to the item of income. An item of income paid to an entity shall be considered to be derived by the interest holder in
the entity only if:
• The interest holder is not fiscally transparent in its jurisdiction with respect to the item of income, and
• The entity is considered to be fiscally transparent under the laws of the interest holder’s jurisdiction with respect to the item of income. An
item of income paid directly to a type of entity specifically identified in a treaty as a resident of a treaty jurisdiction is treated as derived by a
resident of that treaty jurisdiction.
Limitation on benefits treaty provisions. If you are a resident of a foreign country that has entered into an income tax treaty with the United States
that contains a limitation on benefits (LOB) article, you must complete one of the checkboxes in line 14b. You may only check a box if the limitation on
benefits article in that treaty includes a provision that corresponds to the checkbox on which you are relying to claim treaty benefits. A particular
treaty might not include every type of test for which a checkbox is provided. For example, “Company that meets the derivative benefits test” is
generally not available to a company resident in a treaty country that is not a member of the EU, EEA, or NAFTA. In addition, each treaty LOB article
that contains a specific test listed below may have particular requirements that must be met that differ from the requirements in another treaty with
regard to the same test. Accordingly, you must check the relevant treaty LOB article for the particular requirements associated with each test. In
general, only one LOB checkbox is required to claim a treaty exemption, even if more than one checkbox would suffice to claim the benefits of the
treaty for that item of income.
Each of the tests is summarized below for the general convenience of taxpayers but may not be relied upon for making a final determination that you
meet an LOB test. Rather you must check the text of the LOB article itself to determine which tests are available under that treaty and the particular
requirements of those tests. See Table 4, Limitation on Benefits, at www.irs.gov/Individuals/International-Taxpayers/Tax-Treaty-Tables, for a summary
of the major tests within the Limitation on Benefits article that are relevant for documenting any entity’s claim for treaty benefits. See www.irs.gov/
Businesses/International-Businesses/United-StatesIncome-Tax-Treaties- - -A-to-Z for a current list of treaties in force.
• Government—this test is met if the entity is the Contracting State, political subdivision, or local authority.
• Tax-exempt pension trust or pension fund—this test generally requires that more than half the beneficiaries or participants in the trust or
fund be residents of the country of residence of the trust or fund itself.
• Other tax-exempt organization—this test generally requires that more than half the beneficiaries, members, or participants of religious,
charitable, scientific, artistic, cultural, or educational organizations be residents of the country of residence of the organization.
• Publicly-traded corporation—this test generally requires the corporation’s principal class of shares to be primarily and regularly traded on a
If an entity is claiming treaty benefits on its own behalf, it should complete Form W-8BEN-E. If an interest holder
in an entity that is considered fiscally transparent in the interest holder’s jurisdiction is claiming a treaty benefit, the interest holder should complete
Form W-8BEN (if an individual) or Form W-8BEN-E (if an entity) on its own behalf as the appropriate treaty resident, and the fiscally transparent entity
should associate the interest holder’s Form W-8BEN or Form W-8BEN-E with a Form W-8IMY completed by the fiscally transparent entity (see Hybrid
entities under Special Instructions, later).
Note: An income tax treaty may not apply to reduce the amount of any tax on an item of income received by an entity that is treated as a domestic
corporation for U.S. tax purposes. Therefore, neither the domestic corporation nor its shareholders are entitled to the benefits of a reduction of U.S.
income tax on an item of income received from U.S. sources by the corporation.
TIP: If you are an entity that derives the income as a resident of a treaty country, you may check this box if the applicable income tax treaty does not
contain a “limitation on benefits” provision.
Line 7c: if you are a foreign corporation claiming treaty benefits under an income tax treaty enforced before January 1st, 1987 (and that has not since
been renegotiated) on either U.S.-sourced dividends paid to you by another foreign corporation, or on U.S. source interest paid to you by a U.S. trade
or business of another foreign corporation, you are generally a qualified resident of a treaty country. See section 884 for clarification and applicable
rules.
A foreign corporation may be a qualified resident of a country if any of the following apply:
Note: if you are claiming treaty benefits under an income tax treaty enforced after December 31st, 1986, check box 7b instead of box 7c.
Line 8: complete only if you are claiming treaty benefits that require that you meet conditions not covered in line seven or if you fit one of these
examples:
• Exempt organizations claiming treaty benefits under treaties with Canada, Mexico, Germany, and the Netherlands
Line 9: check the one box that represents your classification under U.S. tax principles.
NON-PROFIT ORGANIZATION
Line 10: check the box to confirm that you are a non-profit organization and meet the requirements of this status.
Line 11: check this box to confirm that you are an active NFFE and meet all of the requirements for this status, including the assets and passive
income test. For purposes of applying this test, passive income includes dividends, interest, rents, royalties, annuities, and certain other forms of
passive income. See Regulations section 1.1472-1(c)(1)(iv)(A) and 1.1472-1(c)(1)(iv)(B) for exceptions.
Line 12a: check this box to confirm that you are a passive NFFE who is not a financial institution and who is not certifying your status as a publicly
traded NFFE, NFFE affiliate of a publicly traded company, accepted territory NFFE, active NFFE, direct reporting NFFE, or sponsored direct reporting
NFFE.
If you are an NFFE that may qualify as an active NFFE (or other NFFE described in another part of this form), you may still check line 40a and disclose
your substantial U.S. owners or certify that you have no substantial U.S. owners (see instructions to lines 40b and 40c below).
Line 12b: check this box to confirm that you have no substantial U.S. owners.
Line 12c: check this box if you do not check the box or make the certification on line 40b. Identify each of your substantial U.S. owners by their name,
address, and TIN in the box below.
27283205
Account number:
3. Permanent residence address (street, apt. or suite no., or rural route): ______________________________________________________________________
_______________________________________________________________________________________________________________________________________
Do not use a P.O. box or in-care-of address (other than a registered address).
a) The beneficial owner is resident of____________________________ within the meaning of the income tax treaty between the United
States and that country.
b) 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 (check only one; see instructions)
c) The beneficial owner is claiming treaty benefits for 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).
9. Entity Status (Must check one box only and complete corresponding certification below)
Non-profit organization
10. I certify that the entity identified in is a non-profit organization that meets the following requirements:
i. The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or
educational purposes.
ii. The entity is exempt from income tax in its country of residence.
iii. The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets.
iv. 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 section or escheats to the government of the entity’s
country of residence or any political subdivision thereof.
ii. Less than 50% of such entity’s gross income for the preceding calendar year is passive income; and
iii. 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).
12. a) 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 non-financial entity (or affiliate), excepted territory non-
financial entity, active non-financial entity, direct reporting non-financial entity, or sponsored direct reporting non-financial entity
b) I further certify that the entity identified has no substantial U.S. owners, or
c) I further certify that the entity identified has provided the name, address, and TIN of each substantial U.S. owner of the non
financial entity (below)
As required, provide the name, address, and TIN of each substantial U.S. owner of the non-financial entity. (A substantial U.S. Owner owns over 10%
of the entity)
Certification
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true,
correct, and complete. I further certify under penalties of perjury that:
i. The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to
certify its status for FATCA purposes.
ii. The entity identified on line 1 of this form is not a U.S. person.
iii. 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
iv. 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 certify that I have the capacity to sign for the entity identified on line 1 of this form.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
x
Name (please print)
x
Signature of individual authorized to sign for beneficial owner Date