Checklist for Monthly Investment Plan (MIP) Account Opening

Transcription

1 Checklist for Monthly Investment Plan (MIP) Account Opening Monthly Investment Plan is a service offered to all clients with a KE Trade Prefunded Trading Account. To open a KE Trade Prefunded Trading Account, please furnish the following documents listed below: a. Individual/Joint Trading Account Application Page 1: Page 2: Products and Services - Tick 'Prefunded Trading' Personal Particulars of Account Applicant Personal Particulars of Joint Account Holder (if applicable) Applicant(s) to sign at the bottom of page Disclose status of Politically Exposed Person (if applicable) Applicant(s) to sign Acknowledgement/Declaration section b. Prefunded Trading Account Product Factsheet Applicant(s) to acknowledge and sign on page 5 (only last page to be returned) c. Electronic Payment for Shares (EPS) Form (Optional) Fill in bank account details for EPS application Applicant to sign at the bottom of page 6 d. Interbank GIRO Application Form (Optional) Fill in bank account details for GIRO application Applicant to sign under 'My signature' in the middle of page 7 e. Risk Warning Statement (for trading in Overseas Listed Investment Products) Applicant(s) to sign on page 10 Note: If you wish to trade in Bursa Malaysia, you will be required to pay SGD5 to open a CDS account f. W8-Ben Form (For trading in U.S. markets) Applicant to sign at the bottom of page 11 g. 2 signed photocopies of your Identity Card (front and back for Singaporeans, PRs and Malaysians) OR passport (for foreigners) If you are unable to come down to our offices and you do not have an existing Maybank Kim Eng account, account opening forms and supporting documents must be certified by one of the following: i. Singapore Embassy; ii. Notary Public officially registered with the country s governmental institution; iii. Advocates & Solicitors (preferably with a branch in Singapore); iv. Justice of Peace; or v. Commissioners for Oaths Maybank Kim Eng Securities Pte Ltd Last Updated: May 2015 Company Reg No N

2 INDIVIDUAL / JOINT TRADING ACCOUNT A photocopy of Identity Card (for Singaporean, Singapore Permanent Resident, and Malaysian) / Passport (for other foreigners) must be attached to this application form. Please select the products you wish to transact in and/or services you wish to engage in below. PRODUCTS AND SERVICES Excluded Investment Products - Listed Shares & Preference Shares, Bonds, Company Warrants & Rights Issue, Business Trusts, Real Estate Investment Trusts, American & Global Depository Receipts Specified Investment Products - Listed Exchange Traded Funds, Exchange Traded Notes, Certificates and Structured Warrants SGX Listed Extended Settlement Contracts Contracts For Difference Leveraged Foreign Exchange MAYBANK KIM ENG SECURITIES PTE LTD (Member of Singapore Exchange Securities Trading Limited) 50 North Canal Road Singapore Tel No.: (65) Co. Reg No N Securities Margin Financing Custodian Depository Securities Borrowing/Lending Futures Prefunded Trading Salutation Gender Full Name (Please underline surname) NRIC/Malaysian IC/Passport No. MAIN APPLICANT Mr/Mrs/Ms/Mdm/Dr* Male / Female* JOINT APPLICANT Mr/Mrs/Ms/Mdm/Dr* Male / Female* Passport Expiry Date (DD/MM/YYYY) (Applicable to Non-Singaporean, Non-Singapore PR & Non-Malaysian) Date of Birth (DD/MM/YYYY) Country of Birth Nationality Singapore Permanent Resident Yes / No* Yes / No* Residential/Permanent Address (P.O. Box No. not permitted. For Non-Singaporean & Non-Singapore PR, please state home country address.) Mailing Address (If different from Residential Address) Refer to Main Applicant Status of Residential Address Contact No. (If outside Singapore, please state name of country, country code & area code.) Own / Family / Rental / Mortgaged* (Mobile) (Home) (Office) Own / Family / Rental / Mortgaged* (Mobile) (Home) (Office) Occupation (If retired, state last position held) Name of Employer (If unemployed/retired, state last employer) Employer Address Gross Annual Income Level under $30,000 $30,001 - $50,000 $50,001 - $100,000 $100,001 - $300,000 Above $300,000 under $30,000 $30,001 - $50,000 $50,001 - $100,000 $100,001 - $300,000 Above $300,000 Source of Funds (For Investment) Salary Commission Gift/investment return Own business Others: Salary Commission Gift/investment return Own business Others: * Delete accordingly Signature of Main Applicant Sign here Signature of Joint Applicant, if any Sign here 1

3 MAIN APPLICANT JOINT APPLICANT Are you a foreign tax resident^? If yes, please list the country or countries in which you are a tax resident. (i) (ii) Yes Country Country ; ; No Foreign TIN Foreign TIN (i) (ii) Yes Country Country ; ; No Foreign TIN Foreign TIN Marital Status Single / Married / Other* Single / Married / Other* Spouse s Name Spouse s NRIC/Passport No. Are you related to any director, employee or remisier of Maybank Kim Eng? No / Yes* (if yes, please state name of employee and relationship) Do you have existing account(s) with other broking firms? No / Yes* (if yes, please name the firms) No / Yes* (if yes, please state name of employee and relationship) ^ If you are a U.S. tax resident, please state your foreign tax identification number (TIN), and provide us with a completed Form W-9. A U.S. citizen or resident (including a U.S. green card holder) is considered a U.S. tax resident even if he or she is a tax resident of another jurisdiction. * Delete accordingly JOINT APPLICANT S RELATIONSHIP WITH MAIN APPLICANT (if applicable): CPF/SRS DETAILS (Please select and provide details if applicable) CPF AIS : DBS OCBC UOB A/c No: SRS Agent Bank : DBS OCBC UOB A/c No: FINANCIAL ADVISORY (Not available for Accredited, Expert and Overseas investors) Yes No, I/we wish to proceed without receiving any advice from Maybank Kim Eng. In choosing this option, I/we have decided to act on my/our own accord. Therefore, it is my/our responsibility to ensure the suitability of the product selected. I/We will not be able to rely on section 27 of the Financial Advisers Act, Chapter 110 of Singapore (the FAA ) Recommendation by Licensed Financial Adviser to file a civil claim in the event I/we allege that I/we have suffered a loss. POLITICALLY EXPOSED PERSON ( PEP ) PEP means (a) a natural person who is or has been entrusted with prominent functions whether in Singapore or in a foreign country (b) immediate family members of such a person or (c) close associates of such a person. "Prominent public functions" include the roles held by a head of state, a head of government, government ministers, senior civil servants, senior judicial or military officials, senior executives of state owned corporations, or senior political party officials Please provide details as follows, if you or your immediate family member(s) has/have been entrusted with prominent public functions OR is/are close associate(s) of such a person: Name: Relationship to client: Occupation: Employer/ Country: PERSONAL DATA PROTECTION CONSENT I/We confirm that I/we understand and accept the Personal Data Protection Consent terms in the Acknowledgement and Declaration section of this Application Form and agree that Marketing Messages may be sent to my/our telephone contact number(s) by: Voice call (including calls through third party applications such as Viber or Tango) Text message (SMS / MMS, including messages through third party applications such as Whatsapp or Line) Fax ACKNOWLEDGEMENT AND DECLARATION BY APPLICANT(S) In addition to the consent I/we give above, I/we confirm that I/we understand and accept the Acknowledgement and Declaration section of this Application Form. Signature of Main Applicant Sign here Sign here Sign here Sign here Signature of Joint Applicant, if any Signature of Witness Signature of Notary public, If any Date Date Date Date FOR OFFICIAL USE ONLY TR Name/Code: TR Signature: Date: CDP Account Number : DA Sub-Account : Account Number: Special Code: Date A/C opened : Remarks: Input By : Signature: Walk-In: Yes No Input Checked By : Signature: 2

4 ACKNOWLEDGEMENT AND DECLARATION BY APPLICANT(S) I/We confirm that I/we understand and accept:- a. the Terms & Conditions of Maybank Kim Eng Securities Pte Ltd ( Maybank Kim Eng T&C ) (as may be changed from time to time) and understand that the Maybank Kim Eng T&C shall govern my/our relationship, trading accounts, margin accounts, Internet or mobile trading, custodial or other services of Maybank Kim Eng; and b. the risks associated with trading of various financial instruments in Part VII. Risk Disclosure Statement of Maybank Kim Eng T&C. I/We acknowledge that the Maybank Kim Eng T&C is available on (or any other website notified to me/us) and that a printed copy of the Maybank Kim Eng T&C is available upon by/our request. I/We accept that Maybank Kim Eng reserves the unconditional right to decline this Application wihtout giving any reason whatsoever. I/We am/are aware that Maybank Kim Eng s trading representatives may operate from outside Maybank Kim Eng s office premises, which might affect customer service and there may be risks of delay in trade processing, outages and unauthorised trading. I/We agree to place trade orders only with such trading representatives, and I/we shall be responsible for monitoring my/our accounts for any unauthorised trading and direct all complaints, if any, to Maybank Kim Eng for investigation. account(s) applied for. employees or its trading representatives. (FOR JOINT ACCOUNT HOLDERS) trading and settlement instructions), authorisation, request, act, admission, agreement or settlement of whatever nature in respect of the operation of the joint account or any transaction given by either one of us shall be binding on the other joint account holder and Maybank Kim Eng may act on the same. operation of our joint account and our respective individual trading or other accounts with Maybank Kim Eng including the monitoring of our aggregate exposure. TAX COMPLIANCE others in evading tax. or tax citizens of; tax and regulatory agency or authority or any party (located in or outside Singapore) for the purpose of enabling Maybank Kim Eng to comply with any legal, tax or regulatory obligation under any applicable laws (including the Foreign Account Tax Compliance Act ( FATCA ) or any similar law in any jurisdiction). account of any tax or levy in any jurisdiction where Maybank Kim Eng is required to do so by any government agency, revenue authority or any party in any jurisdiction Eng s compliance with FATCA or any tax or regulatory obligations under any applicable law. PERSONAL DATA PROTECTION CONSENT Eng; parties stated in the Maybank Kim Eng T&C, whether in Singapore or elsewhere, for the Purposes, in a manner consistent with Maybank Kim Eng Privacy Policy on the Maybank Kim Eng website, or to the extent necessary under the applicable law. 3

5 Prefunded Trading Account Product Factsheet Multi-markets trading access Enjoy access into Singapore, United States, Hong Kong and Malaysia markets via KE Trade Online & Mobile, as well as 18 other global markets via your Trading Representative. Low online commission Enjoy attractive online brokerage rates for Singapore and foreign markets. Refer to table below. Multi-currency trust account Maintain cash in 5 different currencies SGD, USD, HKD, MYR 1, AUD. Hassle-free account management Corporate actions for both Singapore and foreign shareholdings including cash offers, bonus share issues, dividend payouts and share custody will be handled by us. No minimum deposit required Deposit only the cash value of the securities you wish to purchase. Online Offline Commission Rate Minimum Commission Commission Rate Minimum Commission Up to S$50, % Singapore All values 0.18% SGD 18 Above S$50,000 & up to S$100, % SGD 40 Above S$100, % United States All values 0.20% USD 20 All values 0.50% USD 30 Hong Kong All values 0.20% HKD 100 All values 0.40% HKD 100 Malaysia All values 0.20% MYR 60 All values 0.50% MYR 80 Brokerage rates shall be levied in accordance with Maybank Kim Eng s prevailing rates. A copy of our rates can be obtained from 1 Maintaining cash in MYR is only applicable to non-malaysian clients. 4

6 Prefunded Trading Account Terms and Conditions: 1. Custody 1.1 All securities purchased through the Prefunded Trading Account ( PTA ) will be held in custody in a segregated Maybank Kim Eng Securities Pte. Ltd. ( MKES ) sub-account. 2. Trading Limits 2.1 You may purchase securities up to the value of the cash collateral value placed in your PTA trust account with MKES ( the Trust Account ). 2.2 Only securities held in custody with MKES may be sold through the PTA. 3. Settlement 3.1 On the due date, funds will be deducted from your Trust Account for payment for outstanding contracts, while proceeds from sales of securities will be credited back to your Trust Account. 3.2 If there are insufficient funds in the settlement currency elected, other currencies will be converted in the following order to make up any currency shortfall in the balance for settlement:- (1) SGD, (2) USD, (3) HKD, (4) MYR, (5) AUD. 4. Other Fees and Charges 4.1 Other fees and charges shall be levied in accordance with MKES s prevailing rates. A copy of the charges can be obtained from our website DECLARATION I/We hereby confirm I/We have read the terms and conditions ( the Terms ) for this Prefunded Trading Account and that I/We fully understand, accept and agree to the Terms and that the Terms are in addition to MKES general terms and conditions of business. I/We acknowledge and accept that my/our personal data will be collected, used, processed and disclosed in a manner compliant with the applicable law or with the General Terms and Conditions of Maybank Kim Eng Securities Pte Ltd. Main Applicant / 1 st Corporate Authorised Signatory* Joint Applicant (if applicable) / 2 nd Corporate Authorised Signatory* X Signature Name: NRIC/Passport No: Date: X Signature Name: NRIC/Passport No: Date: * For Corporate application, two Authorised Signatories and Company Stamp are required. For Official Use Only Signature Verified / Sighted By : Date : 5

7 ELECTRONIC PAYMENT FOR SHARES Main Applicant Full Name (as in NRIC / Passport) Main Applicant NRIC/Passport No./Malaysian IC Joint Applicant Full Name (as in NRIC / Passport) Joint Applicant NRIC/Passport No./Malaysian IC I/We hereby request and authorize MAYBANK KIM ENG (i) from time to time to pay all sales proceeds and contra gains due to me arising from the transactions effected through the above trading account (the "Account") to the bank account (the "designated Bank Account") below; and (ii) to link the designated Bank Account with the Account in order for me/us to make payment from time to time for purchases or contra losses due to MAYBANK KIM ENG arising from transaction effected through the Account from the designated Bank Account. I/We acknowledge and agree: a. that I/we have read Clause 5 (Electronic Payment for Shares ( EPS ) Service) contained in PART I of the TERMS AND CONDITIONS OF MAYBANK KIM ENG SECURITIES PTE. LTD. ( MAYBANK KIM ENG T&C ) and hereby confirm that the same shall be binding on me whenever payments are made to the designated Bank Account by MAYBANK KIM ENG or whenever payments are made by me/us to MAYBANK KIM ENG from the designated Bank Account through the EPS service; b. that the authorisations herein shall continue to be in force until I/we expressly revoke them by giving 3 weeks notice in writing delivered to MAYBANK KIM ENG or the closure of the designated Bank Account, whichever is earlier. MAYBANK KIM ENG may in its absolute discretion terminate the EPS service by giving me/us written notice at my/our last known address; or in the case of closure of MAYBANK KIM ENG, the Participating Bank may in its absolute discretion terminate the EPS service; and c. and consent to the disclosure by MAYBANK KIM ENG to the Participating Bank and to any relevant person of all or any of the information in relation to or concerning the transactions effected through the Account such as the contract or contra statement numbers, amounts due thereunder, the Account number and such information as may be necessary or appropriate or that may arise in order to effect, or as a result of, the payments to the designated Bank Account by MAYBANK KIM ENG or the payments by me/us to MAYBANK KIM ENG from the designated Bank Account through the EPS service. Participating Bank: Maybank DBS/POSB OCBC UOB Citibank Bank Account No: Signature of Main Applicant Sign here Signature of Joint Applicant, if any Sign here Date Date

8 For Monthly Investment Plan Only INTERBANK GIRO APPLICATION FORM (OPTIONAL) DIRECT DEBIT AUTHORISATION Please complete PART 1 of this form and return to Maybank Kim Eng. Part 1: For Applicant's Completion (fill in the spaces indicated with a ) Name of Bank: Name of Billing Organisation ("BO"): MAYBANK KIM ENG SECURITIES PTE LTD Branch: Maybank Kim Eng Trading A/C No.: Bank Account Name: Maybank Kim Eng A/C Holder s Name: Bank Account Number: NRIC / Passport Number: (a) I/We hereby instruct you to process the BO's instructions to debit my/our account. (b) You are entitled to reject the BO's debit instruction if my/our account do/does not have sufficient funds and charge me/us a fee for so doing. You may also, at your discretion, allow the debit even if this results in an overdraft on the account and impose charges accordingly. (c) This authorisation will remain in force until terminated by your written notice sent to my/our address last known to you or upon receipt of my/our written revocation through the BO. (d) The BO is responsible for informing you upon the expiry of this authorization and to ensure no deductions are made thereafter. My/Our Company Stamp/Signature(s)/Thumbprint(s): My/Our Contact Tel: Date: (As in Bank s records) Note: For thumbprints, please go to bank branch with your identification document. Part 2: For Billing Organisation's Completion Bank Branch BO's Account No BO's Customer Ref No Bank Branch Account No to be debited Part 3: For Financial Institution s Completion To: MAYBANK CAPS-KOVAN 996B Upper Serangoon Road Singapore This application is hereby REJECTED (please tick) for the following reason(s): [ ] Signature/Thumbprint # differs from Financial Institution s records [ ] Wrong account number [ ] Signature/Thumbprint # incomplete/unclear # [ ] Amendments not countersigned by customer [ ] Account operated by signature/thumbprint # [ ] Others: Name of Approving Officer Authorised Signature Date # Please delete where inapplicable

9 RISK WARNING STATEMENT FOR OVERSEAS-LISTED INVESTMENT PRODUCTS Risk Warning An overseas-listed investment product* is subject to the laws and regulations of the jurisdiction it is listed in. Before you trade in an overseas-listed investment product or authorise someone else to trade for you, you should be aware of: The level of investor protection and safeguards that you are afforded in the relevant foreign jurisdiction as the overseas-listed investment product would operate under a different regulatory regime. The differences between the legal systems in the foreign jurisdiction and Singapore that may affect your ability to recover your funds. The tax implications, currency risks, and additional transaction costs that you may have to incur. The counterparty and correspondent broker risks that you are exposed to. The political, economic and social developments that influence the overseas markets you are investing in. These and other risks may affect the value of your investment. You should not invest in the product if you do not understand or are not comfortable with such risks. *An overseas-listed investment product in this statement refers to a capital markets product that is listed for quotation or quoted only on overseas securities exchange(s) or overseas futures exchange(s) (collectively referred to as overseas exchanges ). 1. This statement is provided to you in accordance with paragraph 29D of the Notice on the Sale of Investment Products [SFA04-N12]. 2. This statement does not disclose all the risks and other significant aspects of trading in an overseas-listed investment product. You should undertake such transactions only if you understand and are comfortable with the extent of your exposure to the risks. 3. You should carefully consider whether such trading is suitable for you in light of your experience, objectives, risk appetite, financial resources and other relevant circumstances. In considering whether to trade or to authorise someone else to trade for you, you should be aware of the following: Differences in Regulatory Regimes (a) Overseas markets may be subject to different regulations, and may operate differently from approved exchanges in Singapore. For example, there may be different rules providing for the safekeeping of securities and monies held by custodian banks or depositories. This may affect the level of safeguards in place to ensure proper segregation and safekeeping of your investment products or monies held overseas. There is also the risk of your investment products or monies not being protected if the custodian has credit problems or fails. Overseas markets may also have different periods for clearing and settling transactions. These may affect the information available to you regarding transaction prices and the time you have to settle your trade on such overseas markets. (b) Overseas markets may be subject to rules which may offer different investor protection as compared to Singapore. Before you start to trade, you should be fully aware of the types of redress available to you in Singapore and other relevant jurisdictions, if any. (c) Overseas-listed investment products may not be subject to the same disclosure standards that apply to investment products listed for quotation or quoted on an approved exchange in Singapore. Where disclosure is made, differences in accounting, auditing and financial reporting standards may also Version Oct

10 affect the quality and comparability of information provided. It may also be more difficult to locate up-to-date information, and the information published may only be available in a foreign language. Differences in legal systems (d) In some countries, legal concepts which are practiced in mature legal systems may not be in place or may have yet to be tested in courts. This would make it more difficult to predict with a degree of certainty the outcome of judicial proceedings or even the quantum of damages which may be awarded following a successful claim. (e) The Monetary Authority of Singapore will be unable to compel the enforcement of the rules of the regulatory authorities or markets in other jurisdictions where your transactions will be effected. (f) The laws of some jurisdictions may prohibit or restrict the repatriation of funds from such jurisdictions including capital, divestment proceeds, profits, dividends and interest arising from investment in such countries. Therefore, there is no guarantee that the funds you have invested and the funds arising from your investment will be capable of being remitted. (g) Some jurisdictions may also restrict the amount or type of investment products that foreign investors may trade. This can affect the liquidity and prices of the overseas-listed investment products that you invest in. Different costs involved (h) There may be tax implications of investing in an overseas-listed investment product. For example, sale proceeds or the receipt of any dividends and other income may be subject to tax levies, duties or charges in the foreign country, in Singapore, or in both countries. (i) Your investment return on foreign currency-denominated investment products will be affected by exchange rate fluctuations where there is a need to convert from the currency of denomination of the investment products to another currency, or may be affected by exchange controls. (j) You may have to pay additional costs such as fees and broker s commissions for transactions in overseas exchanges. In some jurisdictions, you may also have to pay a premium to trade certain listed investment products. Therefore, before you begin to trade, you should obtain a clear explanation of all commissions, fees and other charges for which you will be liable. These charges will affect your net profit (if any) or increase your loss. Counterparty and correspondent broker risks (k) Transactions on overseas exchanges or overseas markets are generally effected by your Singapore broker through the use of foreign brokers who have trading and/or clearing rights on those exchanges. All transactions that are executed upon your instructions with such counterparties and correspondent brokers are dependent on their respective due performance of their obligations. The insolvency or default of such counterparties and correspondent brokers may lead to positions being liquidated or closed out without your consent and/or may result in difficulties in recovering your monies and assets held overseas. Political, Economic and Social Developments (l) Overseas markets are influenced by the political, economic and social developments in the foreign jurisdiction, which may be uncertain and may increase the risk of investing in overseas-listed investment products. Version Oct

11 ACKNOWLEDGEMENT OF RECEIPT OF RISK WARNING STATEMENT MAIN ACCOUNT HOLDER I acknowledge that I have received a copy of the Risk Warning Statement and understand its contents. JOINT ACCOUNT HOLDER I acknowledge that I have received a copy of the Risk Warning Statement and understand its contents. (Signature) Full Name (as in NRIC / Passport): (Signature) Full Name (as in NRIC / Passport): NRIC/Passport No.: NRIC/Passport No.: Date: Date: I/We acknowledge and accept that my/our personal data will be collected, used, processed and disclosed in a manner compliant with the applicable law or with the General Terms and Conditions of Maybank Kim Eng Securities Pte Ltd. Please submit this Acknowledgement Slip to: Customer Services Department, Maybank Kim Eng Securities Pte Ltd 9 Temasek Boulevard #12-00 Suntec Tower 2 Singapore FOR OFFICIAL USE ONLY Signature(s) Verified By: Input By: Checked By: Signature/Date: Signature/Date: Signature/Date: Version Oct

12 Form W-8BEN (Rev. February 2014) Department of the Treasury Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals) For use by individuals. Entities must use Form W-8BEN-E. Information about Form W-8BEN and its separate instructions is at Give this form to the withholding agent or payer. Do not send to the IRS. OMB No Do NOT use this form if: Instead, use Form: You are NOT an individual W-8BEN-E You are a U.S. citizen or other U.S. person, including a resident alien individual W-9 You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal services) W-8ECI You are a beneficial owner who is receiving compensation for personal services performed in the United States or W-4 A person acting as an intermediary W-8IMY Part I Identification of Beneficial Owner (see instructions) 1 Name of individual who is the beneficial owner 2 Country of citizenship 3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. City or town, state or province. Include postal code where appropriate. Country 4 Mailing address (if different from above) City or town, state or province. Include postal code where appropriate. Country 5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions) 7 Reference number(s) (see instructions) 8 Date of birth (MM-DD-YYYY) (see instructions) Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions) 9 I certify that the beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country. 10 Special rates and conditions (if applicable see instructions): The beneficial owner is claiming the provisions of Article of the treaty identified on line 9 above to claim a % rate of withholding on (specify type of income): Explain the reasons the beneficial owner meets the terms of the treaty article:. Part III 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 am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or am using this form to document myself as an individual that is an owner or account holder of a foreign financial institution, The person named on line 1 of this form is not a U.S. person, 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 applicable income tax treaty, or (c) the partner s share of a partnership's effectively connected income, The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the United States and that country, 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 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. I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect. Sign Here Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Print name of signer Capacity in which acting (if form is not signed by beneficial owner) For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev )