Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding and Reporting

Transcription

1 Form W-8MY (Rev. April 2014) Department of the Treasury nternal Revenue Servie Do not use this form for: A A A Certifiate of Foreign ntermediary, Foreign Flow-Through Entity, or Certain U.S. Branhes for United States Ta Withholding and Reporting Setion referenes are to the nternal Revenue Code. nformation aout Form W-8MY and its separate instrutions is at Give this form to the withholding agent or payer. Do not send to the RS. OMB No nstead, use Form: enefiial owner solely laiming foreign status or treaty enefits m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m W-8BEN or W-8BEN-E hyrid entity laiming treaty enefits on its own ehalf m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m W-8BEN-E A disregarded entity with a single foreign owner that is the enefiial owner of the inome to whih this form relates. nstead, A foreign government, international organization, foreign entral ank of issue, foreign ta-eempt organization, foreign private U.S. A foreign person laiming that inome is effetively onneted with the ondut of a trade or usiness in the United States m m m m m m m m m m m m m m m m m m m W-8EC the single foreign owner should use m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m W-8BEN, W-8EC, or W-8BEN-E foundation, or government of a U.S. possession laiming the appliaility of setion(s) 115(2), 501(), 892, 895, or 1443() m m m m m m m m m m m m m m m m m W-8EXP entity or U.S. itizen or resident m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m W-9 foreign person doumenting themselves for purposes of setion 6050W m m m m m m m m m m m m m m m m m m m m m m m m m m m W-8BEN, W-8BEN-E, or W-8EC Part dentifiation of Entity 1 Name of individual or organization that is ating as intermediary 2 Country of inorporation or organization Aon Canada ntermediaries GP Canada 3 Name of disregarded entity (if appliale) 4 Chapter 3 Status: Qualified intermediary. Complete Part. Nonqualified intermediary. Complete Part V. Territory finanial institution. Complete Part V. U.S. ranh. Complete Part V. Withholding foreign partnership. Complete Part V. 5 Chapter 4 Status: Nonpartiipating FF (inluding a limited FF or limited ranh). Complete Part X (if appliale). Partiipating FF. Reporting Model 1 FF. Reporting Model 2 FF. Registered deemed-ompliant FF (other than a reporting Model 1 FF or sponsored FF that has not otained a GN). Territory finanial institution. Complete Part V. Sponsored FF that has not otained a GN (other than a ertified deemed-ompliant sponsored, losely held investment vehile). Complete Part X. Certified deemed-ompliant nonregistering loal ank. Complete Part X. Certified deemed-ompliant FF with only low-value aounts. Complete Part X. Certified deemed-ompliant sponsored, losely held investment vehile. Complete Part XV. Certified deemed-ompliant limited life det investment entity. Complete Part XV. Withholding foreign trust. Complete Part V. Nonwithholding foreign partnership. Complete Part V. Nonwithholding foreign simple trust. Complete Part V. Nonwithholding foreign grantor trust. Complete Part V. Owner-doumented FF. Complete Part X. Restrited distriutor. Complete Part XV. Foreign entral ank of issue. Complete Part XV. Nonreporting GA FF. Complete Part XV. Eempt retirement plans. Complete Part XX. Eepted nonfinanial group entity. Complete Part XX. Eepted nonfinanial start-up ompany. Complete Part XX. Eepted nonfinanial entity in liquidation or ankrupty. Complete Part XX. Pulily traded NFFE or NFFE affiliate of a pulily traded orporation. Complete Part XX. Eepted territory NFFE. Complete Part XXV. Ative NFFE. Complete Part XXV. Passive NFFE. Complete Part XXV. Diret reporting NFFE. Sponsored diret reporting NFFE. Complete Part XXV. 6 Permanent residene address (street, apt. or suite no., or rural route). Do not use a P.O. o or in-are-of address (other than a registered address). 20 Bay Street, Suite 2400 City or town, state or provine. nlude postal ode where appropriate. Country Toronto, M5J-2N9 Canada 7 Mailing address (if different from aove) City or town, state or provine. nlude postal ode where appropriate. 8 U.S. tapayer identifiation numer, if required Country Q-EN WP-EN WT-EN EN SSN or TN 9 GN (if appliale) 10 Referene numer(s) (see instrutions) Aon Benfield Canada ULC For Paperwork Redution At Notie, see separate instrutions. Form W-8MY (Rev ) 3W

2 Form W-8MY (Rev ) Page 2 Part Disregarded Entity or Branh Reeiving Payment. (Complete only if disregarded entity or ranh of an FF in a ountry other than the FF's ountry of residene.) 11 Chapter 4 Status (FATCA status) of disregarded entity or ranh reeiving payment. Limited ranh. Reporting Model 1 FF. U.S. Branh. Partiipating FF. Reporting Model 2 FF. 12 Address of ranh (street, apt. or suite no., or rural route). Do not use a P.O. o or in-are-of address (other than a registered address). City or town, state or provine. nlude postal ode where appropriate. 13 GN (if any) Part Qualified ntermediary Chapter 3 Status Certifiations Country 14 a (All qualified intermediaries hek here) ertify that the entity identified in Part (or ranh, if relevant): d e f Part V 15 a d s a qualified intermediary and is not ating for its own aount with respet to the aount(s) identified on line 10 or in a withholding statement assoiated with this form; and Has provided or will provide a withholding statement, as required, for purposes of hapters 3 and 4 that is sujet to the ertifiations made on this form. Chek all that apply: ertify that the entity identified in Part of this form is not providing a withholding statement assoiated with this form eause it assumes primary withholding responsiility for purposes of hapters 3 and 4, and either: Primary Form 1099 reporting and akup withholding responsiility; or Reporting responsiility as a partiipating FF or registered deemed-ompliant FF with respet to aounts that it maintains and that are held y speified U.S. persons as permitted under Regulations setions ()(4)(i) or ()(4)(ii) in lieu of Form 1099 reporting. ertify that the entity identified in Part of this form assumes primary withholding responsiility under hapters 3 and 4 with respet to payments made to eah aount identified on this line 14 (or on an attahment to this form) ertify that the entity identified in Part of this form assumes primary Form 1099 reporting and akup withholding responsiility with respet to payments made to eah aount identified on this line 14d or on an attahment to this form or reporting responsiility as a partiipating FF or registered deemed-ompliant FF with respet to aounts that it maintains and that are held y speified U.S. persons as permitted under Regulations setions ()(4)(i) or ()(4)(ii) in lieu of Form 1099 reporting ertify that the entity identified in Part of this form does NOT assume primary Form 1099 reporting and akup withholding responsiility and is using this form to transmit Forms W-9 with respet to eah aount(s) held y a U.S. non-eempt reipient identified on this line 14e or in a withholding statement assoiated with this form f the entity identified on Part of this form has alloated or will alloate a portion of a payment to a hapter 4 withholding rate pool of U.S. payees on a withholding statement assoiated with this form (hek all that apply): (i) (ii) ertify that the entity meets the requirements of Regulations setion ()(4)(iii) with respet to any aount holder of an aount it maintains that is inluded in a withholding rate pool of U.S. payees provided on a withholding statement assoiated with this form. To the etent the entity is providing a withholding statement that inludes a hapter 4 withholding rate pool of U.S. payees that are aountholders of an intermediary or flow-through entity reeiving a payment from the entity identified on line 1, ertify that the entity on line 1 has otained or will otain doumentation suffiient to estalish eah suh intermediary or flowthrough entity's status as a partiipating FF, registered deemed-ompliant FF, or FF that is a qualified intermediary. ertify that the entity identified in Part of this form is ating as Qualified Seurities Lender with respet to payments assoiated with this form that are U.S. soure sustitute dividends reeived from the withholding agent. Nonqualified ntermediary Chek all that apply: (All nonqualified intermediaries and qualified intermediaries that are not ating in their apaity as suh hek here) ertify that the entity identified in Part of this form is not ating as a qualified intermediary with respet to eah aount(s) for whih this form is provided and is not ating for its own aount. ertify that the entity identified in Part of this form is using this form to transmit withholding ertifiates and/or other doumentation and has provided, or will provide, a withholding statement, as required. ertify that the entity identified in Part of this form meets the requirements of Regulations setion ()(4)(iii) with respet to any aount holder of an aount it maintains that is inluded in a withholding rate pool of U.S. payees provided on a withholding statement assoiated with this form. ertify that the entity identified in Part of this form is ating as a Qualified Seurities Lender with respet to payments assoiated with this form that are U.S. soure sustitute dividends reeived from the withholding agent. Form W-8MY (Rev ) 3W

3 Form W-8MY (Rev ) Page 3 Territory Finanial nstitution Part V 16 a ertify that the entity identified in Part is a finanial institution (other than an investment entity that is not also a depository institution, ustodial institution, or speified insurane ompany) that is inorporated or organized under the laws of a possession of the United States. Chek whihever o applies: further ertify that the entity identified in Part is using this form as evidene of its agreement with the withholding agent to e treated as a U.S. person for purposes of hapters 3 and 4 with respet to any payments assoiated with this withholding ertifiate. further ertify that the entity identified in Part : s using this form to transmit withholding ertifiates and/or other doumentation for the persons for whom it reeives a payment; and Has provided or will provide a withholding statement, as required. Part V Certain U.S. Branhes 17 a ertify that the entity identified in Part is reeiving payments that are not effetively onneted with the ondut of a trade or usiness in the United States. Chek whihever o applies: ertify that the entity identified in Part is a U.S. ranh of a foreign ank or insurane ompany desried in Regulations setion ()(2)(iv)(A) that is a partiipating FF (inluding a reporting Model 2 FF), registered deemed-ompliant FF (inluding a reporting Model 1 FF), or NFFE that is using this form as evidene of its agreement with the withholding agent to e treated as a U.S. person with respet to any payments assoiated with this withholding ertifiate. ertify that the entity identified in Part : s using this form to transmit withholding ertifiates and/or other doumentation for the persons for whom the ranh reeives a payment; and Has provided or will provide a withholding statement, as required. Part V Withholding Foreign Partnership (WP) or Withholding Foreign Trust (WT) 18 ertify that the entity identified in Part is a withholding foreign partnership or a withholding foreign trust that is ompliant with the terms of its WP or WT agreement. Part V Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust 19 Part X 20 ertify that the entity identified in Part : s a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and that the payments to whih this ertifiate relates are not effetively onneted, or are not treated as effetively onneted, with the ondut of a trade or usiness in the United States; and s using this form to transmit withholding ertifiates and/or other doumentation and has provided or will provide a withholding statement, as required for purposes of hapters 3 and 4, that is sujet to the ertifiations made on this form. Chapter 4 Status Certifiations Nonpartiipating FF with Eempt Benefiial Owners ertify that the entity identified in Part is using this form to transmit withholding ertifiates and/or other doumentation and has provided or will provide a withholding statement that indiates the portion of the payment alloated to one or more eempt enefiial owners. Part X 21 a Sponsored FF That Has Not Otained a GN Name of sponsoring entity: Chek whihever o applies. ertify that the entity identified in Part : s an FF solely eause it is an investment entity; s not a Q, WP, or WT; and Has agreed with the entity identified aove (that is not a nonpartiipating FF) to at as the sponsoring entity for this entity. ertify that the entity identified in Part : s a ontrolled foreign orporation as defined in setion 957(a); s not a Q, WP, or WT; s wholly owned, diretly or indiretly, y the U.S. finanial institution identified aove that agrees to at as the sponsoring entity for this entity; and Shares a ommon eletroni aount system with the sponsoring entity (identified aove) that enales the sponsoring entity to identify all aount holders and payees of the entity and to aess all aount and ustomer information maintained y the entity inluding, ut not limited to, ustomer identifiation information, ustomer doumentation, aount alane, and all payments made to aount holders or payees. Form W-8MY (Rev ) 3W

4 Form W-8MY (Rev ) Page 4 Part X Owner-Doumented FF Note. This status only applies if the U.S. finanial institution, partiipating FF, reporting Model 1 FF, or reporting Model 2 FF to whih this form is given has agreed that it will treat the FF as an owner-doumented FF. The owner-doumented FF must make the ertifiations elow. 22 a ertify that the FF identified in Part : Does not at as an intermediary; Does not aept deposits in the ordinary ourse of a anking or similar usiness; Does not hold, as a sustantial portion of its usiness, finanial assets for the aount of others; s not an insurane ompany (or the holding ompany of an insurane ompany) that issues or is oligated to make payments with respet to a finanial aount; s not affiliated with an entity (other than an FF that is also treated as an owner-doumented FF) that aepts deposits in the ordinary ourse of a anking or similar usiness, holds, as a sustantial portion of its usiness, finanial assets for the aount of others, or is an insurane ompany (or the holding ompany of an insurane ompany) that issues or is oligated to make payments with respet to a finanial aount; and Does not maintain a finanial aount for any nonpartiipating FF. Chek whihever o applies. ertify that the FF identified in Part : Has provided, or will provide, an FF owner reporting statement (inluding any appliale owner doumentation) that ontains: (i) The name, address, TN (if any), hapter 4 status, and type of doumentation provided (if required) of every individual and speified U.S. person that owns a diret or indiret equity interest in the owner-doumented FF (looking through all entities other than speified U.S. persons); (ii) The name, address, TN (if any), hapter 4 status, and type of doumentation provided (if required) of every individual and speified U.S. person that owns a det interest in the owner-doumented FF (inluding any indiret det interest, whih inludes det interests in any entity that diretly or indiretly owns the payee or any diret or indiret equity interest in a det holder of the payee) that onstitutes a finanial aount in eess of $50,000 (disregarding all suh det interests owned y partiipating FFs, registered deemed-ompliant FFs, ertified deemed ompliant FFs, eepted NFFEs, eempt enefiial owners, or U.S. persons other than speified U.S. persons); and (iii) Any additional information the withholding agent requests in order to fulfill its oligations with respet to the entity. ertify that the FF identified in Part : Has provided, or will provide, an auditor's letter, signed no more than four years prior to the date of payment, from an independent aounting firm or legal representative with a loation in the United States stating that the firm or representative has reviewed the FF's doumentation with respet to all of its owners and det holders identified in Regulations setion (d)(6)(iv)(A)(2) and that the FF meets all the requirements to e an owner-doumented FF. The FF identified in Part has also provided, or will provide, an FF owner reporting statement and Form W-9, with appliale waivers, as desried in Regulations setion (d)(6)(iv). Part X Certified Deemed-Compliant Nonregistering Loal Bank 23 ertify that the FF identified in Part : Operates and is liensed solely as a ank or redit union (or similar ooperative redit organization operated without profit) in its ountry of inorporation or organization; Engages primarily in the usiness of reeiving deposits from and making loans to, with respet to a ank, retail ustomers unrelated to suh ank and, with respet to a redit union or similar ooperative redit organization, memers, provided that no memer has a greater than five perent interest in suh redit union or ooperative redit organization; Does not soliit aount holders outside its ountry of organization; Has no fied plae of usiness outside suh ountry (for this purpose, a fied plae of usiness does not inlude a loation that is not advertised to the puli and from whih the FF performs solely administrative support funtions); Has no more than $175 million in assets on its alane sheet and, if it is a memer of an epanded affiliated group, the group has no more than $500 million in total assets on its onsolidated or omined alane sheets; and Does not have any memer of its epanded affiliated group that is a foreign finanial institution, other than a foreign finanial institution that is inorporated or organized in the same ountry as the FF identified in Part and that meets the requirements set forth in this Part X. Part X Certified Deemed-Compliant FF with Only Low-Value Aounts 24 ertify that the FF identified in Part : s not engaged primarily in the usiness of investing, reinvesting, or trading in seurities, partnership interests, ommodities, notional prinipal ontrats, insurane or annuity ontrats, or any interest (inluding a futures or forward ontrat or option) in suh seurity, partnership interest, ommodity, notional prinipal ontrat, insurane ontrat or annuity ontrat; No finanial aount maintained y the FF or any memer of its epanded affiliated group, if any, has a alane or value in eess of $50,000 (as determined after applying appliale aount aggregation rules); and Neither the FF nor the FF's entire epanded affiliated group, if any, have more than $50 million in assets on its onsolidated or omined alane sheet as of the end of its most reent aounting year. Form W-8MY (Rev ) 3W

5 Form W-8MY (Rev ) Page 5 Part XV Certified Deemed-Compliant Sponsored, Closely Held nvestment Vehile 25a Name of sponsoring entity: ertify that the FF identified in Part : s an FF soiety eause it is an investment entity desried in Regulations setion: (e)(4); s not a Q, WP, or WT; Will have all of its due diligene, withholding, and reporting responsilities (determined as if the FF were a partiipating FF), fulfilled y the sponsoring entity identified in line 25a; and Twenty or fewer individuals own all of the det and equity interests in the entity (disregarding det interest owned y U.S. finanial institutions, partiipating FFs, registered deemed-ompliant FFs, and ertified deemed-ompliant FFs and equity interests owned y an entity that owns 100 perent of the equity interests in the FF identified in Part and is itself a sponsored FF). Part XV 26 Part XV Certified Deemed-Compliant Limited Life Det nvestment Entity ertify that the FF identified in Part : Was in eistene as of January 17, 2013; ssued all lasses of its det or equity interests to investors on or efore January 17, 2013 pursuant to a trust indenture or similar agreement; and s ertified deemed-ompliant eause it satisfies the requirements to e treated as a limited life det investment entity (suh as the restritions with respet to its assets and other requirements under Regulations setion (f)(2)(iv)). Restrited Distriutor 27a (All restrited distriutors hek here) ertify that the entity identified in Part : Operates as a distriutor with respet to det or equity interests of the restrited fund with respet to whih this form is furnished; Provides investment servies to at least 30 ustomers unrelated to eah other and less than half of its ustomers are related to eah other; s required to perform AML due diligene proedures under the anti-money laundering laws of its ountry of organization (whih is a FATF-ompliant jurisdition); Operates solely in its ountry of inorporation or organization, has no fied plae of usiness outside of that ountry, and has the same ountry of inorporation or organization as all memers of its affiliated group, if any; Does not soliit ustomers outside its ountry of inorporation or organization; Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its inome statement for the most reent aounting year; s not a memer of an epanded affiliated group that has more than $500 million in total assets under management or more than $20 million in gross revenue for its most reent aounting year on a omined or onsolidated inome statement; and Does not distriute any det or seurities of the restrited fund to speified U.S. persons, passive NFFEs with one or more sustantial U.S. owners, or nonpartiipating FFs. Chek whihever o applies: further ertify that with respet to all sales of det or equity interests in the restrited fund with respet to whih this form is furnished that are made after Deemer 31, 2011, the entity identified in Part : Part XV 28 Has een ound y a distriution agreement that ontained a general prohiition on the sale of det or seurities to U.S. entities and U.S. resident individuals and is urrently ound y a distriution agreement that ontains a prohiition of the sale of det or seurities to any speified U.S. person, passive NFFE with one or more sustantial U.S. owners, or nonpartiipating FF. s urrently ound y a distriution agreement that ontains a prohiition on the sale of det or seurities to any speified U.S. person, passive NFFE with one or more sustantial U.S. owners, or nonpartiipating FF and, for all sales made prior to the time that suh a restrition was inluded in its distriution agreement, has reviewed all aounts related to suh sales in aordane with the proedures identified in Regulations setion () appliale to preeisting aounts and has redeemed or retired any seurities whih were sold to speified U.S. persons, passive NFFEs with one or more sustantial U.S. owners, or nonpartiipating FFs, or will transfer the seurities to a distriutor that is a partiipating FF reporting Model 1 FF, or reporting Model 2 FF. Foreign Central Bank of ssue ertify that the entity identified in Part is treated as the enefial owner of the payment solely for purposes of hapter 4 under Reguations setion (d)(4). Form W-8MY (Rev ) 3W

6 Form W-81MY (Rev ) Page 6 Nonreporting GA FF Part XV 29 ertify that the entity identified in Part : Meets the requirements to e onsidered a nonreporting finanial institution pursuant to an GA etween the United States and ; s entitled to the provisions of the GA eause the entity (or relevant ranh) is onsidered a under the provisions of the appliale GA; and f you are an FF treated as a registered deemed-ompliant FF under an appliale Model 2 GA, provide your GN: Part XX Eempt Retirement Plans Chek whihever o applies. ertify that the entity identified in Part : 30a s estalished in a ountry with whih the United States has an inome ta treaty in fore; s operated prinipally to administer or provide pension or retirement enefits; and s entitled to treaty enefits on inome that the fund derives from U.S. soures (or would e entitled to enefits if it derived any suh inome) as a resident of the other ountry whih satisfies any appliale limitation on enefits requirement. ertify that the entity identified in Part : s organized for the provision of retirement, disaility, or death enefits (or any omination thereof) to enefiiaries that are former employees of one or more employers in onsideration for servies rendered; No single enefiiary has a right to more than 5 of the FF's assets; s sujet to government regulation and provides annual information reporting aout its enefiiaries to the relevant ta authorities in the ountry in whih the fund is estalished or operated; and (i) (ii) s generally eempt from ta on investment inome under the laws of the ountry in whih it is estalished or operates due to its status as a retirement or pension plan; Reeives at least 50 of its total ontriutions from sponsoring employers (disregarding transfers of assets from other plans desried in this part, retirement and pension aounts desried in an appliale Model 1 or Model 2 GA, other retirement funds desried in an appliale Model 1 or Model 2 GA, or aounts desried in Regulations setion ()(2)(i)(A)); (iii) Either does not permit or penalizes distriutions or withdrawals made efore the ourrene of speified events related to retirement, disaility, or death (eept rollover distriutions to aounts desried in Regulations setion ()(2)(i)(A) (referring to retirement and pension aounts), to retirement and pension aounts desried in an appliale Model 1 or Model 2 GA, or to other retirement funds desried in this part or in an appliale Model 1 or Model 2 GA); or (iv) Limits ontriutions y employees to the fund y referene to earned inome of the employee or may not eeed $50,000 annually. ertify that the entity identified in Part : s organized for the provision of retirement, disaility, or death enefits (or any omination thereof) to enefiiaries that are former employees of one or more employers in onsideration for servies rendered; Has fewer than 50 partiipants; s sponsored y one or more employers, eah of whih is not an investment entity or passive NFFE. Employee and employer ontriutions to the fund (disregarding transfers of assets from other plans desried in this part, retirement and pension aounts desried in an appliale Model 1 or Model 2 GA, or aounts desried in Regulations setion ()(2)(i)(A)) are limited y referene to earned inome and ompensation of the employee, respetively; Partiipants that are not residents of the ountry in whih the fund is estalished or operated are not entitled to more than 20 perent of the fund's assets; and s sujet to government regulation and provides annual information reporting aout its enefiiaries to the relevant ta authorities in the ountry in whih the fund is estalished or operates. d e ertify that the entity identified in Part is formed pursuant to a pension plan that would meet the requirements of setion 401(a), other than the requirement that the plan e funded y a trust reated or organized in the United States. ertify that the entity identified in Part is estalished elusively to earn inome for the enefit of one or more retirement funds desried in this part or in an appliale Model 1 or Model 2 GA, aounts desried in Regulations setion ()(2)(i)(A) (referring to retirement and pension aounts), or retirement and pension aounts desried in an appliale Model 1 or Model 2 GA. f ertify that the entity identified in Part : s estalished and sponsored y a foreign government, international organization, entral ank of issue, or government of a U.S. possession (eah as defined in Regulations setion ) or an eempt enefiial owner desried in an appliale Model 1 or Model 2 GA to provide retirement, disaility, or death enefits to enefiiaries or partiipants that are urrent or former employees of the sponsor (or persons designated y suh employees); or s estalished and sponsored y a foreign government, international organization, entral ank of issue, or government of a U.S. possession (eah as defined in Regulations setion ) or an eempt enefiial owner desried in an appliale Model 1 or Model 2 GA to provide retirement, disaility, or death enefits to enefiiaries or partiipants that are not urrent or former employees of suh sponsor, ut are in onsideration of personal servies performed for the sponsor. 3W Form W-8MY (Rev )

7 Form W-8MY (Rev ) Page 7 Part XX Eepted Nonfinanial Group Entity 31 ertify that the entity identified in Part : Part XX s a holding ompany, treasury enter, or aptive finane ompany and sustantially all of the entity's ativities are funtions desried in Regulations setion (e)(5)(i)(C) through (E); s a memer of a nonfinanial group desried in Regulations setion (e)(5)(i)(B); s not a depository or ustodial institution (other than for memers of the entity's epanded affiliated group); and Does not funtion (or hold itself out) as an investment fund, suh as a private equity fund, venture apital fund, leveraged uyout fund or any investment vehile with an investment strategy to aquire or fund ompanies and then hold interests in those ompanies as apital assets for investment purposes. Eepted Nonfinanial Start-Up Company 32 ertify that the entity identified in Part : Part XX Was formed on (or in the ase of a new line of usiness, the date of oard resolution approving the new line of usiness) (date must e less than 24 months prior to date of payment); s not yet operating a usiness and has no prior operating history or is investing apital in assets with the intent to operate a new line of usiness other than that of a finanial institution or passive NFFE; and Does not funtion (or hold itself out) as an investment fund, suh as a private equity fund, venture apital fund, leveraged uyout fund, or any investment vehile whose purpose is to aquire or fund ompanies and then hold interests in those ompanies as apital assets for investment purposes. Eepted Nonfinanial Entity in Liquidation or Bankrupty 33 ertify that the entity identified in Part : Part XX Filed a plan of liquidation, filed a plan or reorganization, or filed for ankrupty on the following date: Has not een engaged during the past 5 years in usiness as a finanial institution or ated as a passive NFFE; s either liquidating or emerging from a reorganization or ankrupty with the intent to ontinue or reommene operations as a nonfinanial entity; and Has provided, or will provide, doumentary evidene suh as a ankrupty filing or other puli doumentation that supports its laim if it remains in ankrupty or liquidation for more than three years. Chek whihever o applies: Pulily Traded NFFE or NFFE Affiliate of a Pulily Traded Corporation 34 a ertify that: The entity identified in Part is a foreign orporation that is not a finanial institution; and The stok of suh orporation is regularly traded on one or more estalished seurities markets, inluding Part XXV ertify that: The entity identified in Part is a foreign orporation that is not a finanial institution; The entity identified in Part is a memer of the same epanded affiliated group as an entity the stok of whih is regularly traded on an estalished seurities market; The name of the entity, the stok of whih is regularly traded on an estalished seurities market, is The name of the seurities market on whih the stok is regularly traded is Eepted Territory NFFE 35 ertify that: The entity identified in Part is an entity that is organized in a possession of the United States; Part XXV The entity identified in Part : (i) (ii) Does not aept deposits in the ordinary ourse of a anking or similar usiness, Does not hold, as a sustantial portion of its usiness, finanial assets for the aount of others, and (iii) s not an insurane ompany (or the holding ompany of an insurane ompany) that issues or is oligated to make payments with respet to a finanial aount; and All of the owners of the entity identified in Part are ona fide residents of the possession in whih the NFFE is organized or inorporated. Ative NFFE 36 ertify that: 3W The entity identified in Part is a foreign entity that is not a finanial institution; Less than 50 of suh entity's gross inome for the preeding alendar year is passive inome; and Less than 50 of the assets held y suh entity are assets that produe or are held for the prodution of passive inome (alulated as a weighted average of the perentage of passive assets measured quarterly). See the instrutions for the definition of passive inome. Form W-8MY (Rev ) ; and

8 Form W-8MY (Rev ) Page 8 Part XXV Passive NFFE 37 ertify that the entity identified in Part : s a foreign entity that is not a finanial institution (this ategory inludes an entity organized in a possession of the United States that engages (or holds itself out as eing engaged) primarily in the usiness of investing, reinvesting, or trading in seurities, partnership interests, ommodities, notional prinipal ontrats, insurane or annuity ontrats, or any interest in suh seurity, partnership interest, ommodity, notional prinipal ontrat, insurane ontrat or annuity ontrat); and s using this form to transmit withholding ertifiates and/or other doumentation and has provided or will provide a withholding statement, as required. Part XXV 38 Sponsored Diret Reporting NFFE Name of sponsoring entity: 39 ertify that the entity identified in Part is a diret reporting NFFE that is sponsored y the entity identified in line 38. Part XXV Certifiation Under penalties of perjury, delare that have eamined the information on this form and to the est of my knowledge and elief it is true, orret, and omplete. Furthermore, authorize this form to e provided to any withholding agent that has ontrol, reeipt, or ustody of the inome for whih am providing this form or any withholding agent that an disurse or make payments of the amounts for whih am providing this form. agree that will sumit a new form within 30 days if any ertifiation made on this form eomes inorret. Sign Here M Signature of authorized offiial 08/15/2014 Date (MM-DD-YYYY) Form W-8MY (Rev ) 3W