W-8BEN-E

Transkript

W-8BEN-E

W-8BEN-E – Potvrzení skutečného vlastníka o svém statusu pro účely FATCA (právnické subjekty)
A. Přečtěte si tuto část a s ní související pokyny, abyste měli jistotu, že vyplňujete správný
formulář W.
Formulář W-8BEN-E musí být vyplněn správně, bez provádění jakýchkoliv změn.
Pokud při vyplňování uděláte chybu, začněte znovu s novým formulářem.
Nepoužívejte kapalné odstraňovače překlepů ani jiné opravné nástroje.
B. ČÁST I (Identifikace skutečného vlastníka) (Strana 1 formuláře)
Všechny formuláře musí být vyplněny v anglickém jazyce.
Form
W-8BEN-E
(February 2014)
Certificate of Status of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
Department of the Treasury
Internal Revenue Service
OMB No. 1545-1621
▶ For use by entities. Individuals must use Form W-8BEN. ▶ Section references are to the Internal Revenue Code.
▶ Information about Form W-8BEN-E and its separate instructions is at www.irs.gov/formw8bene.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form for:
Instead use Form:
A
• U.S. entity or U.S. citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . .
• A foreign individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . W-9
W-8BEN (Individual)
.
.
.
. W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions)
.
. W-8IMY
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private
foundation, or government of a U.S. possession claiming that income is effectively connected U.S. income or that is claiming
the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions) . . . .
• Any person acting as an intermediary .
Part I
.
.
.
.
.
.
.
.
.
Identification of Beneficial Owner
1
Name of organization that is the beneficial owner
3
Name of disregarded entity receiving the payment (if applicable)
4
Chapter 3 Status (entity type) (Must check one box only):
.
.
.
.
.
.
.
B
.
.
.
.
.
.
.
.
.
W-8ECI or W-8EXP
.
.
Corporation
Disregarded entity
Partnership
Grantor trust
Complex trust
Estate
Government
Central Bank of Issue
Tax-exempt organization
Private foundation
Nonreporting IGA FFI (including an FFI treated as a registered
deemed-compliant FFI under an applicable Model 2 IGA).
Complete Part XII.
Participating FFI.
Reporting Model 1 FFI.
Foreign government, government of a U.S. possession, or foreign
central bank of issue. Complete Part XIII.
International organization. Complete Part XIV.
Exempt retirement plans. Complete Part XV.
Sponsored FFI that has not obtained a GIIN. Complete Part IV.
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
Territory financial institution. Complete Part XVII.
Certified deemed-compliant nonregistering local bank. Complete
Part V.
Nonfinancial group entity. Complete Part XVIII.
Excepted nonfinancial start-up company. Complete Part XIX.
Certified deemed-compliant FFI with only low-value accounts.
Complete Part VI.
Excepted nonfinancial entity in liquidation or bankruptcy.
Complete Part XX.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
501(c) organization. Complete Part XXI.
Certified deemed-compliant limited life debt investment entity.
Complete Part VIII.
Publicly traded NFFE or NFFE affiliate of a publicly traded
corporation. Complete Part XXIII.
Certified deemed-compliant investment advisors and investment
managers. Complete Part IX.
Excepted territory NFFE. Complete Part XXIV.
Active NFFE. Complete Part XXV.
Passive NFFE. Complete Part XXVI.
Nonprofit organization. Complete Part XXII.
Řádek 2 Země vzniku společnosti nebo organizace
Řádek 3Název subjektu z daňového hlediska spojeného se svým vlastníkem (Disregarded Entity), který je
příjemcem platby (v příslušném případě)
Řádek 4 Status podle kapitoly 3 (typ subjektu) (zaškrtněte pouze jedno políčko):
Řádek 5 Status podle kapitoly 4 (status FATCA)
Řádek 6Adresa trvalého sídla.
Uveďte kompletní adresu v prvním řádku a město nebo obec, stát či provincii, včetně poštovního kódu
(PSČ), ve 2. řádku, a „zemi“ v poli Země (Country).
NEPOUŽÍVEJTE:
v adrese pro finanční správu USA
(Financial Institution US) poštovní schránku
(PO Box) ani adresu třetí strany
zřízenou pro účely přeposílání pošty.
Sponsored direct reporting NFFE. Complete Part XXVIII.
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).
Řádek 8Identifikační číslo plátce daně USA (Taxpayer Identification Number – TIN), v případě potřeby
Zadejte identifikační číslo zaměstnavatele (Employer Identification Number – EIN), máte-li jej.
Platné číslo EIN musí být vždy tvořeno 9 číslicemi.
Číslo EIN nesmí:
(1) obsahovat jiné znaky než číslice,
(2) obsahovat méně než nebo více než devět číslic,
(3) obsahovat devět stejných číslic, nebo
(4) obsahovat devět po sobě jdoucích číslic (ve vzestupném nebo sestupném pořadí).
Řádek 9Zaškrtněte políčko 9a „GIIN“ a zadejte globální identifikační číslo zprostředkujícího subjektu (GIIN), nebo
zaškrtněte políčko 9b „Foreign TIN“ a zadejte identifikační číslo plátce daně v jiné zemi (Foreign TIN), máte-li
jej.
okud globální identifikační číslo zprostředkujícího subjektu (GIIN) nemáte a chcete o něj co nejdříve požádat, nebo
P
pokud jste o něj již požádali, uveďte v poli „GIIN“ text „Applied For“ (Žádost podána). Číslo GIIN nám v takovém
případě musíte předložit ve lhůtě do 60 dnů.
Country
Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
U.S. taxpayer identification number (TIN), if required
9a
GIIN
Country
b
Foreign TIN
© HSBC Bank plc 2014. Všechna práva vyhrazena.
Cat. No. 59689N
Řádek 10 Nechejte prázdné.
10 Reference number(s) (see instructions)
Note. Please complete remainder of the form including signing the form in Part XXIX.
For Paperwork Reduction Act Notice, see separate instructions.
Řádek 7Poštovní adresa, včetně „země“ v poli Země (Country)
Uveďte poštovní adresu pouze v případě, že je odlišná od adresy trvalého sídla.
Poznámka:Pokud bude uvedena poštovní adresa v USA, bude vyžadováno písemné vysvětlení/zdůvodnění uvedení poštovní adresy v USA.
Pokud se bude země lišit od země adresy trvalého sídla, bude vyžadováno písemné vysvětlení.
Excepted inter-affiliate FFI. Complete Part XXVII.
Direct reporting NFFE.
8
No
Nonparticipating FFI (including a limited FFI or an FFI related to a
Reporting IGA FFI other than a registered deemed-compliant FFI
or participating FFI).
Restricted distributor. Complete Part XI.
Řádek 1 Celý název organizace, která je skutečným vlastníkem
Yes
Chapter 4 Status (FATCA status) (Must check one box only unless otherwise indicated). (See instructions for details and complete the
certification below for the entity's applicable status).
Owner-documented FFI. Complete Part X.
7
. W-8IMY
Simple trust
Registered deemed-compliant FFI (other than a reporting Model 1
FFI or sponsored FFI that has not obtained a GIIN).
6
.
2 Country of incorporation or organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If "Yes" complete Part III.
5
.
Form
W-8BEN-E
(2-2014)
Poznámka: P
řečtěte si pokyny k formuláři W-8BEN-E ohledně
toho, kdo je považován za skutečného vlastníka.
Page 2
Form W-8BEN-E (2-2014)
Part II
Disregarded Entity or Branch Receiving Payment. (Complete only if disregarded entity or branch of an
FFI in a country other than the FFI's country of residence.)
Page 2
Form
(2-2014)
11 W-8BEN-E
Chapter
4 Status (FATCA status) of disregarded entity or branch receiving payment
Part II
12
11
Form
Disregarded
Entity or Branch Receiving
Payment.
(Complete only if disregarded
entity or branch of an
Limited
Branch.
Reporting
Model 1 FFI.
U.S. Branch.
FFI in a FFI.
country other than the FFI's country
residence.)
Participating
Reportingof
Model
2 FFI.
Address4ofStatus
disregarded
or of
branch
(street, entity
apt. ororsuite
no.,receiving
or rural payment
route). Do not use a P.O. box or in-care-of address (other than a
Chapter
(FATCAentity
status)
disregarded
branch
registered
Limited address).
Branch.
U.S. Branch.
W-8BEN-E
Participating FFI.
C. ČÁST II (Strana 2 formuláře)
Subjekt z daňového hlediska spojený se svým vlastníkem (Disregarded Entity) nebo pobočka přijímající platbu.
(Vyplňte pouze v případě, pokud je subjekt z daňového hlediska spojený se svým vlastníkem (Disregarded Entity)
nebo pobočka zahraniční finanční instituce (FFI) v jiné zemi, než je země sídla zahraniční finanční instituce (FFI).)
C
Certificate of Status
of Beneficial Owner for
United States Tax Withholding and Reporting (Entities)
City
state or province.
Include
postal
code
where
appropriate.
No. 1545-1621
(February
2014)or town,
12
Address
of disregarded
entity or
branch
(street,
apt.
or suite
no., or rural route). Do not use a P.O. box or in-care-of OMB
address
(other than a
▶ For use by entities. Individuals must use Form W-8BEN. ▶ Section references are to the Internal Revenue Code.
registered
address). ▶ Information about Form W-8BEN-E and its separate instructions is at www.irs.gov/formw8bene.
Department
of the Treasury
▶ Give this form to the withholding agent or payer. Do not send to the IRS.
Internal Revenue Service
Country
Do NOT use this form for:
Instead use Form:
• U.S.
13 entity
GIINor
(if U.S.
any) citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-9
• APart
foreign
. .Treaty
. . Benefits
. . . . (if .applicable).
. . . . (For
. . chapter
. . . 3 purposes
. . . . only)
. . . . . . . . W-8BEN (Individual)
III individual
Claim. of. Tax
Country
• A14foreign
individual
or entity
that income is effectively connected with the conduct of trade or business within the U.S.
I certify
that (check
allclaiming
that apply):
(unless claiming treaty benefits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
beneficial owner is a resident of
within the meaning of the income tax
13 a GIINThe
(if any)
• A foreign partnership,
a foreign
simple
trust,and
or athat
foreign
grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . . W-8IMY
between
States
country.
Part III treaty
Claim
of the
TaxUnited
Treaty
Benefits
(if applicable).
(For chapter 3 purposes only)
b I certify
• 14
A foreign
government,
international
organization,
central
of issue,
foreign
tax-exempt
organization,
foreignand,
private
Thethat
beneficial
owner
derives
the itemforeign
(or items)
of bank
income
for which
the
treaty benefits
are claimed,
if applicable, meets the
(check
all
that apply):
foundation,
or beneficial
government
of atreaty
U.S.
possession
claiming
incomeonisbenefits
effectively
connected
U.S. income or that is claiming
requirements
of
the
provision
withthat
limitation
(see
instructions).
The
owner
is
a resident
of dealing
a
the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions) . . . .
W-8ECI or W-8EXP
c
The(2-2014)
beneficial
is claiming
benefits
for dividends received from a foreign corporation or interest from a U.S. trade or business
treaty
between owner
the United
States treaty
and that
country.
Form W-8BEN-E
Page 2
• Any personofacting
as an
intermediary
. .qualified
. . resident
. . . status
. . (see
. instructions).
. . . . . . . . . . . . . . . . . . . . W-8IMY
a foreign
corporation
and .meets
b
The Disregarded
beneficial ownerEntity
derivesor
the
item (orReceiving
items) of income
for which
the treatyonly
benefits
are claimed,entity
and, iforapplicable,
meets
Part
II
Branch
Payment.
(Complete
if
disregarded
branch
of
an the
Part Special
I requirements
Identification
of Beneficial
Owner
rates andofconditions
(if applicable—see
instructions):
The
beneficial
is claiming the provisions of Article
15
the treaty
provision
dealing
with
limitation
on
benefits
(seeowner
instructions).
FFI
in
a
country
other
than
the
FFI's
country
of
residence.)
1
Name
organization
is the
beneficial
2 Country
of incorporation
or organization
of the of
treaty
identifiedthat
on line
14a
above toowner
claim a
.
% rate
of withholding
on (specify
of income):
The beneficial
owner is
claiming
treaty benefits
forordividends
received
from
a foreign corporation
ortype
interest
from a U.S. trade or business
11c Chapter
4 Status (FATCA
status)
of disregarded
entity
branch receiving
payment
Explain
reasons
the beneficial
ownerqualified
meets the
termsstatus
of the (see
treatyinstructions).
article:
of a the
foreign
corporation
and meets
resident
Limited
Branch. entity receiving the payment (if applicable)
U.S. Branch.
3
Name
of disregarded
Special
rates andFFI.
conditions (if applicable—see instructions):
beneficial
15
Participating
ReportingThe
Model
2 FFI. owner is claiming the provisions of Article
Part of
IVthe treaty
Sponsored
FFI
Has to
Not
Obtained
a GIIN % rate of withholding on (specify type of income):
identified on
lineThat
14a
above
claim
a or suite
12
Address of disregarded
entity
or branch
(street,
apt.
no., or rural route). Do not use a P.O. box or in-care-of address (other than a.
Corporation
4
Chapter
3sponsoring
Status
(entity
type) (Must
checkmeets
one box
Disregarded entity
Partnership
16
Name
ofthe
entity:
Explain
reasons
beneficial
owner
the only):
terms of the treaty article:
registered
address).the
Simple
trust box applies. Grantor trust
Complex trust
Estate
Government
17
Check
whichever
Central
Bank
of Issue
Tax-exempt
organization
I certify
that the
entity
in Part
I: Obtained
Part IV
Sponsored
FFIidentified
That
Has
Not
a GIIN Private foundation
City or town,
state or province.
Include
postal
code where appropriate.
If• you
disregarded
entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
Is anentered
solely
because
16
Name
ofFFI
sponsoring
entity:it is an investment entity;
claim?
complete
Part
Yes
No
• Is notIfwhichever
a"Yes"
QI, WP,
or
WT;
and III.
17
Check
box
applies.
Country
5
Chapter
4 Status
(FATCA
status)
(Must
check one box only unless otherwise indicated). (See instructions for details and complete the
• Has
agreed
with
the
entity
identified
I certify that the entity identified
in above
Part I: (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
certification
below
for
the
entity's
applicable
status).
I certify that the entity identified in Part I:
•GIIN
Is an(ifFFI
13
any)solely because it is an investment entity;
FFIcorporation
(including aas
limited
FFIinorsection
an FFI 957(a);
related to a
Nonreporting IGA FFI (including an FFI treated as a registered
• IsNonparticipating
a controlled foreign
defined
Is not aClaim
QI, WP,of
or Tax
WT; and
Part •III
Treaty
(if applicable).
(For
3 purposes only)
IGA or
FFIWT;
other
than a Benefits
registered deemed-compliant
FFI chapter
deemed-compliant FFI under an applicable Model 2 IGA).
• IsReporting
not a QI, WP,
•I certify
Has
with the
identified above (that is not a nonparticipating FFI)
to act asPart
theXII.
sponsoring entity for this entity.
14
that (check
all entity
that apply):
or agreed
participating
FFI).
Complete
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
beneficial
a resident
IThe
certify
that theowner
entityisidentified
in of
Part I:
a
entity;
and
Participating
FFI.
Foreign government, government of a U.S. possession, or foreign
• Is atreaty
controlled
foreign
corporation
defined
in section 957(a);
between
the United
Statesasand
that country.
central bank
of issue.
Complete
XIII.
Reporting
Model 1electronic
FFI.
• Shares
a common
account system with the sponsoring entity (identified
above)
that enables
thePart
sponsoring
entity to identify all
QI, WP, orowner
WT; derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the
b • Is not
Thea beneficial
account
holders
and2payees
of the entity and to access all account and customer
information
maintained
by Part
the entity
Reporting
Model
FFI.
International
organization.
Complete
XIV. including, but not
the treaty
dealing
on
benefits (see
instructions).
•limited
Is requirements
wholly
owned,ofdirectly
or provision
indirectly,
by thewith
U.S.limitation
financial
institution
identified
above
thatand
agrees
to act as made
the sponsoring
for this
to, customer
identification
information,
customer
documentation,
account
balance,
all payments
to accountentity
holders
or
Exempt
retirement
plans.
Complete
Part
XV.
Registered
deemed-compliant
FFI
(other
than
a
reporting
Model
1
and
c entity;
The
beneficial owner is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business
payees.
FFI or sponsored FFI that has not obtained a GIIN).
Entity wholly owned by exempt beneficial owners. Complete Part XVI.
of a foreign
corporation
andaccount
meets qualified
(see instructions).
• Shares
a common
electronic
system resident
with thestatus
sponsoring
entity (identified above) that enables the sponsoring entity to identify all
Partaccount
V Sponsored
Certified
Deemed-Compliant
Nonregistering
Bank
FFI
that
has notofobtained
a GIIN.
Complete
IV. Local
Territory financial
institution.
Complete
Part
XVII.including, but not
holders
and
payees
entity
and to
access Part
all account
and customer
information
maintained
the
entity
Special rates
and
conditions
(if the
applicable—see
instructions):
The beneficial
owner is claiming
the provisions
ofby
Article
15
18
Nonfinancial
groupand
entity.
Complete Part
XVIII.
Certified
deemed-compliant
I certify
that
the FFI
ininformation,
Part to
I: claimlocal
limited
to, customer
identification
customer
documentation,
account
balance,
all payments
made
to account holders .or
of the
treaty
identified
onidentified
line 14anonregistering
above
a bank. Complete
% rate
of withholding
on (specify
type of income):
Part V. and is licensed solely as a bank or credit union (or similar cooperative
payees.
Excepted
nonfinancial
start-up
company.
Complete
Part
XIX. of
•
Operates
credit
organization
operated
without
profit)
in its
country
Explain the reasons the beneficial owner meets the terms of the treaty article:
incorporationdeemed-compliant
or organization; FFI with only low-value accounts.
Excepted nonfinancial entity in liquidation or bankruptcy.
Part V Certified
Certified Deemed-Compliant
Nonregistering Local Bank
Complete
Part
VI.
Complete
Part
XX.
• Engages
primarily in the
business
of receiving
deposits from
and making loans to, with respect to a bank, retail customers unrelated to such
Part IV
Sponsored
ThatinHas
Obtained
a GIIN
18
I certify
that the FFIFFI
identified
Part Not
I:
bank
and, with
respect to a credit
union or similar
credit organization,
provided
that Part
no member
has a greater than five
501(c) members,
organization.
Complete
XXI.
Certified
deemed-compliant
sponsored,
closelycooperative
held investment
16
of sponsoring
entity: solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of
•Name
Operates
and
is
percent
interest
in licensed
such
credit
vehicle.
Complete
Part
VII. union or cooperative credit organization;
Nonprofit organization. Complete Part XXII.
17
Check whichever
box applies.
incorporation
or organization;
• Does
not
solicit
account
holders
outside
its
country
of
organization;
Certified
deemed-compliant
limited
life debt
entity.
Publicly traded NFFE or NFFE affiliate of a publicly traded
I certifyprimarily
that
the in
entity
identified
in
I: investment
•• Engages
thebusiness
businessoutside
of Part
receiving
fromthis
andpurpose,
making loans
to,place
with Complete
respect
toPart
a bank,
retail
customers
unrelated
Complete
Part
VIII. of
XXIII.
Has
no fixed
place
such deposits
country (for
acorporation.
fixed
of business
does
not
include
a location
that to
is such
not
• Is an
FFI with
solely
because
it is
an investment
entity;cooperative credit organization, members, provided that no member has a greater than five
bank
and,
respect
a
credit
unionthe
or similar
advertised
todeemed-compliant
the
publicto
and
from
which
FFI performs
solely administrativeExcepted
support functions);
territory NFFE. Complete Part XXIV.
Certified
investment
advisors
and
investment
percent
in or
such
• Is not interest
a QI, WP,
WT;credit
and union or cooperative credit organization;
managers.
Complete
Part
IX.
• Has no more than $175 million in assets on its balance sheet and, if it is aActive
member
of an
expanded
affiliated
NFFE.
Complete
Part
XXV. group, the group has no more
Has agreed
withaccount
the entity
identified
above
is not
aorganization;
nonparticipating FFI) to act as the sponsoring entity for this entity.
••than
Does
not million
solicit
holders
its (that
country
$500
in totalFFI.
assets
onoutside
its consolidated
orof
combined
balance sheets;
andNFFE. Complete Part XXVI.
Owner-documented
Complete
PartI:X.
Passive
I certify
thatplace
the entity
identified
in Part
•• Has
no
of business
such
countrygroup
(for this
a fixed
place
of business
does
include
a location that is not
Does
notfixed
have
any member
of itsoutside
expanded
affiliated
that purpose,
is a foreign
financial
institution,
other
than not
a foreign
Restricted
distributor.
Complete
Part
XI.
Excepted
inter-affiliate
FFI.
Complete
Part financial
XXVII. institution that
•is Is
a controlled
foreign
corporation
as defined
section
957(a);
advertised
to theor
public
and
from
the
FFIinperforms
solely
administrative
support
functions);
incorporated
organized
in thewhich
same
country
as
the FFI
identified
in Part I and
that meets
the requirements set forth in this Part V.
Direct reporting NFFE.
•
Is
not
a
QI,
WP,
or
WT;
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more
Form W-8BEN-E
(2-2014)
Sponsored
direct
Part XXVIII.
• Is wholly
owned,
directly
or indirectly,
by the U.S.
institution
identified
above
that reporting
agrees toNFFE.
act asComplete
the sponsoring
entity for this
than
$500 million
in total
assets
on its consolidated
or financial
combined
balance sheets;
and
6
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).
•entity;
Does and
not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that
is
or organized
in the
same system
country with
as the
identified in
Part(identified
I and that above)
meets the
set forth in this
Part
• incorporated
Shares a common
electronic
account
theFFI
sponsoring
entity
thatrequirements
enables the sponsoring
entity
to V.
identify all
City
or town,
stateand
or province.
postal
code
where appropriate.
Country
account
holders
payees ofInclude
the entity
and
to access
all account and customer information maintained
by the entity including, but not
limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or
payees.address (if different from above)
7
Mailing
D
E
Příklad
Part V
18
8
Certified Deemed-Compliant Nonregistering Local Bank
I certify that the FFI identified in Part I:
Tuto část vyplňujte pouze v případě, pokud jste rezidentem v zemi, která podepsala smlouvu týkající se zdanění,
a máte nárok na výhody vyplývající z této smlouvy, tj. pokud máte pevný nebo stanovitelný, roční nebo pravidelný
(FDAP) příjem, například z výplat dividend, a platba pochází ze zdrojů na území USA. Pokud máte nejasnosti ohledně
oprávněnosti vašeho nároku na výhody na základě smluv týkajících se zdanění, doporučujeme vám vyhledat
pomoc nezávislého daňového poradce.
Řádek 14a zaškrtněte políčko a zadejte „zemi“ (Country) rezidentství
Řádek 14a NEBO 14c zaškrtněte jedno z políček, podle potřeby.
Řádek 15 Speciální sazby a podmínky (pouze v příslušném případě – viz pokyny).
E. ČÁSTI IV až XXVIII
Zbývající části formuláře (části IV až XXVIII) obsahují speciální potvrzení týkající se statusu podle kapitoly 4, podle
údajů, které jste zaškrtli v části I, na řádku 5.
V této části formuláře musíte vyplnit pouze potvrzení platná pro váš status podle kapitoly 4.
Příklad:
Pokud subjekt zvolit v části I, na řádku 5, možnost „Místní banka neregistrující, certifikovaná jako uznanávyhovující“ (Certified deemed-compliant nonregistering local bank),
musí subjekt vyplnit část V formuláře W-8BEN-E.
Country
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of
U.S.
taxpayer identification
number (TIN), if required
10 Reference number(s) (see instructions)
b
Foreign TIN
9a
GIIN
incorporation
or organization;
• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to such
Note. Please
complete
remainder
theorform
the form in
Part XXIX.
bank and,
with respect
to a credit of
union
similarincluding
cooperativesigning
credit organization,
members,
provided that no member has a greater than five
percent Reduction
interest in such
credit union
cooperative
credit organization;
For Paperwork
Act Notice,
see or
separate
instructions.
Cat. No. 59689N
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more
than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that
is incorporated or organized in the same country as the FFI identified in Part I and that meets the requirements set forth in this Part V.
D. ČÁST III (Vyžádání si výhod na základě smluv týkajících se zdanění) (v příslušném případě). (Pouze pro
účely kapitoly 3)
Form
W-8BEN-E
(2-2014)
Povšimněte si, že nadpisy sekcí, které mají být vyplněny, odpovídají statusu podle kapitoly 4 (status FATCA)
vybranému v části l, na řádku 5, a že část l, řádek 5, rovněž obsahuje odkaz na sekci, která má být vyplněna,
např. v tomto příkladu část V.
Page 8
Part XXVIII
42
Sponsored Direct Reporting NFFE
Name of sponsoring entity:
I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 42.
43
Part XXIX
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:
• 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 chapter 4
purposes, or is a merchant submitting this form for purposes of section 6050W,
Page 8
• The entity identified on line 1 of this form is not a U.S. person,
Sponsored
Reporting
NFFEconnected with the conduct of a trade or business in the United States, (b) effectively connected but is
Part XXVIII
• The income
to which thisDirect
form relates
is: (a) not effectively
not
subject
to
tax
under
an
income
tax
treaty,
or
(c)
the
partner’s
share
of
a
partnership's
effectively
connected
income,
and
Name of sponsoring entity:
42
F
43
that the entity
identified
in Part
is a directowner
reporting
NFFE foreign
that is person
sponsored
by the
entity
identified in line 42.
• ForI certify
broker transactions
or barter
exchanges,
theI beneficial
is an exempt
as defined
in the
instructions.
Certification
Part XXIX I authorize
Furthermore,
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
ownerpenalties
or any withholding
that that
can Idisburse
or makethe
payments
of the
of which
onmy
lineknowledge
1 is the beneficial
owner.
Under
of perjury,agent
I declare
have examined
information
onincome
this form
and tothe
theentity
best of
and belief
it is true, correct, and complete. I further
certify
under
of perjury
I agree
that penalties
I will submit
a newthat:
form within 30 days if any certification on this form becomes incorrect.
1
2
3
▲
• 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 chapter 4
purposes, or is a merchant submitting this form for purposes of section 6050W,
Sign Here
Print Name
of this
individual
sign for beneficial owner
Date (MM-DD-YYYY)
• The entity identifiedSignature
on line 1 of
form isauthorized
not a U.S.toperson,
• 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
4
not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, and
I certify that I have the capacity to sign for the entity identified on line 1 of this form.
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
F. ČÁST XXIX (Potvrzení) (Strana 8 formuláře)
Musíte mít oprávnění k podpisu jménem subjektu uvedeného na řádku 1.
1. Podepište formulář
2. Na řádek pod podpisem napište tiskacím písmem své jméno.
3. Ve formuláři vyplňte datum ve formátu MM/DD/RRRR.
4. Zde zaškrtněte „Potvrzuji, že mám oprávnění k podpisu jménem subjektu uvedeného na řádku 1 tohoto formuláře“ (I
certify that I have the capacity to sign for the entity identified on Line 1 of the form).
Poznámka: Tento formulář nelze podepsat na základě plné moci obhájce (Power of Attorney – POA), pokud v této plné
moci není výslovně uvedeno, že zástupce/obhájce je oprávněn podepisovat jménem klienta dokumenty týkající se
daní nebo daňové formuláře (a pokud není nebo již nebyla taková plná moc předložena), nebo případně pokud není
předložen formulář IRS 2848.
Part XXXI authorize
Substantial
U.S.
Owners
of Passive
NFFE
Furthermore,
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 canthe
disburse
make payments
ofof
theeach
income
of which the
entity
on line
1 is NFFE.
the beneficial
As required
by Part XXVI,
provide
name,oraddress,
and TIN
substantial
U.S.
owner
of the
Pleaseowner.
see instructions for definition of
owner.a new form within 30 days if any certification on this form becomes incorrect.
I substantial
agree that I U.S.
will submit
▲
Sign Here
Name
Signature of individual authorized to sign for beneficial owner
Address
TIN
Print Name
Date (MM-DD-YYYY)
I certify that I have the capacity to sign for the entity identified on line 1 of this form.
Part XXX
Substantial U.S. Owners of Passive NFFE
As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for definition of
substantial U.S. owner.
Name
Address
TIN
G.Část XXX Podstatní vlastníci pasivního nefinančního zahraničního subjektu (NFFE) z USA
(Vyplňte, pouze pokud jste vyplnili část XXVI a pokud je to váš případ.)
Vyplňte jméno, adresu a číslo TIN každého z podstatných vlastníků NFFE z USA.
Definice podstatného vlastníka z USA (substantial U.S. owner) viz pokyny k formuláři W-8BEN-E.
G
Form
Form
W-8BEN-E
W-8BEN-E
(2-2014)
(2-2014)
* HSBC nemůže poskytovat daňové poradenství. Pokud potřebujete
jakoukoli pomoc, obraťte se na nezávislého daňového poradce.

W-8BEN-E

Transkript

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