Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697749269203.pdf (Georgia)
F",,W-8BEN'E (Rev.

July 201 7) Certificate of Status of Beneficial Owner for United States TaxWithholding and Reporting (Entities) > For use by 6ntfs8.

lndlvldual8 must use Form W{BEN.

> Secdon referencos are to the lnternal Revenue Code.

lnstructlons and tho latost lnformaflon, > Go to www.i/s.govlFormWSBENEfor Give thls form to the wlthholdlng agent or payer.

Do not eend to the lRS.

Department of the Treasury lnternal Revenua Servics Do NOT use this form for: .
U.S. entlty or U.S. cltlzen or resldent .

A foreign lndividual ' 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-gECl ' A forelgn partnershlp, a foreign slmple trust, or a forelgn grantor trust (unless claimlng treaty benefits) (see instructions for exceptions) .
W-BlMy 'Aforeign government, internatlonal organlzatlon, foreign central bank of issue, foreign tax-exempt organlzatlon, foreign private foundation, or government of a U.S. possession claiming that income is effectively connected U,S, lncome or that ls clalming the applicablllty of section(s) 115(2), 501(c),892,895'or1443(b)(unlessclaimingtreatybenefits)(seelnstructionsforotherexceptionS) ' Any person acting as an intermediary (including a qualified intermediary acting as a qualified derivatives dealer) lnstead use Form: W-9 W-BBEN (lndividual) or Form 8293 .
W-glMy OMB No.
1545-1621 1 Name of organization that is the beneficial owner JSC'VTB Bank (Georgia)" of Beneficial Owner 3 Name of disregarded entity receiving the payment (if applicable, see instructions) 2 Country of incorporation or organization GEORGIA 4chapter3Status(entitytype)(Mustcheckoneboxonly):ECorporation E Simple trust E Central Bankof lssue E Tax-exemptorganization E Privatefoundation E lnternational organization lf you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty claim?
lf "Yes" complete Part lll.

E Complex trust E Grantor trust E Estate tr Government E Yes nNo 5 Chapter 4 Status (FATCA status) (See lnstructions for details and complete the certification below for the entity's applicable status.)

n Nonparticipating FFI (including an FFI related to a Reporting IGA !

Nonreporting tcA FFl.

complete part xll.

FFI other than a deemed'compliant FFl, participating FFl, or exempt beneficial owner).
I Foreign government, government of a U.S. possession, or foreign n Partlcipating FFl.

E neporting Model 1 FFl, E ReportingModel 2FFl.

I Registered deemed-compliant FFI(other than a reporting Model 1 fl ferritory nnancial institution.

Complete part XVll.

cenhal bank of lssue.

Complete part Xlll.

E lnternattonal organizallon.

Complete Part xlv.

E Exempt retirement ptans.

complete part XV.

E Entitywhollyo,vnedbyexemptbeneflcial owners.Completepartxvl.
FFI' sponsored FFI' or nonreportlng IGA FFI covered in Part Xll)' E Excepted nonfinanclal group enflty.

complete part XVlll, seeinstructions tr Excepted nonfinancial start-up company, complete partxlx.

E Excepted nonfinancial entity in liquidagon or bankruptcy, E Sponsored FFl.

Complete Part lV.

E CertitteO deemert-compliant nonregisterlng local bank.

Complete Comftete Part XX, E CertifieO deemed-compliant FFI with only low-value accounts.

E ruonpiont organlzation.

Complete part XXll.


E sot(c) organization.

Complete part xxl.

Partv.

complete Part vl' D CertiRed deemed-compllant sponsored, closely held investment corporation.

Complete Part XXlll.

vehicle' complete Part Vll' E CertifieO deemed-compliant Complete Partvlll.

llmited llfedebt investment entity.

E Active NFFE.

comptete part xxv.

E passiveNFFE.

Comptete partxxvl.

tr Excepted territory NFFE.

complete pan xxv.


D Certain investment entitles that do not maintaln financlal accounts.

E ExcepteO inter-affiliate FFl.

Complete part XXVll.

E euuttcty traded NFFE or NFFE affitiate of a pubticly traded complete Part lX' E Owner-documented FFl.

Complete part X. E oirect reporting NFFE.

!

SponsoreO direct reporting NFFE.

Complete part XXVlll.

Permanent residence address (skeet, apt.

orsuite no., orrural route).


Do not use a P.O, box orln-care.of address (otherthan a registered address).

#14, G.Chanturia street, QlV or town, state or province.

lnclude postal code where appropriate.

Tbilisi ,0108 Country GEORGIA 7 Mailing address (if different from above) City or town, state or province.

lnclude postal code where appropriate.


8 U.S. taxpayer identification number (TlN), if required 10 Reference numbe(s) (seeinstructions) Country b Foreign TIN 202906427 remainder of the form For Papenvork Reduction Act Noflce, sse separate lnstructions.

the form in Part XXX.

Cat.

No.

59689N rorm W-8BEN-E (Rev.

7-2017) Form W-8BEN-E (Rev.7-2017) page2 branch of an FFlin a country other than the FFI's country of residence.

See instructions.)
See instructions.)

11 Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment n Branch treated as nonparticipating FFl, E Participating FFl.

E Reporting Model 1 FFl.

E Reporting Model 2 FFl.

E u.s.

Branch.

12 Address of disregarded entity or branch (street, apt.

or suite no., or rural route).

Do not use a P.O.

box or ln-carE-of address (other than a registered address).

City or town, state or province.

lnclude postal code where appropriate.


Counky 13 GllN (if any) I certify that (check all that appty): a !

Thebeneficial owner is a resident of treaty between the United States and that country.
meaning of the income tax E The beneficial owner derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requhements of thetreaty.provlslon deallngwith limitation on benefits, Thefollowing aretypes of limitatlon on beneflts provisions that may be included in an applicable tax treaty (check only one; see instructions): I Government E Tax exempt penslon trust or penslon fund E Company that meets the derivative benefits test E Other tax exempt organlzation E euUncry traded corporatlon EsubsidiaryofapubllclytradedcorporationEotner(speclryArticleandparagraph): E The beneficial owner ls clalming treaty benefits for U,S.
source dlvldends received from a foreign corporation or lnterest from a U.S. trade E Company with an ltem of income that meets active trade or buslness test E Favorable discreflonary determlnation by the U.S, competent authorlty recelved E Company that meels the ownership and base eroslon test or business of a foreign corporation and meets qualified resident status (see lnstructions), 15 Speclal rates and condltlons (lf applicablFsee instructions): The beneficial owner ls claiming the provlslons of Arlicle and paragraph of the keaty identified on line 14a above to claim a Explain the additional conditions in the Article tre uef,ffiiEiJffiffiEts to be etigibte for the rate of withhotding: .% rate of withholding on (specify type of income): 16 Name of sponsoring entity: 17 Check whichever box applies.
E I cenify that the entity identified in part t; .

ls an investment entity; ' ls not a Ql' WP (except to the extent permltted in the withholding forelgn partnership agreement), or WT; and ' Has agreed with the entlty identified above (that is not a nonparticlpating FFI) to act as the sponsoring entity for this entity.

E tcertity that the entity identlfied in Part t: .

ls a controlled foreign corpoatlon as defined in section g57(a); .
ls not a Ql, WP, or WT; ' ls !frollyowned, directly or indlrectly, by the U.S, financial institutlon identified above that agrees to act as the sponsorlng entityfor this entity;and ' shares a common electronic €ccount system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all account holders and payees of the entity and to access all account ani customer lnformalion maintained Oy tfre enti-ty lnciuding, but'not limited to' customer identlflcatlon lnformation, customer documentation, account balance, and all payments made to account holders or payees.
rorm W-8BEN-E (Rev.

7-2017) Form W-BBEN-E (Rev.
7-2017) lcertify that the FFI identified in Part l: ' Operates and is licensed solety as a bank or credit union (or simllar cooperative credit organization operated without profit) in its country of incorporation or organlzation; ' Engages prlmarily ln the buslness of recelving deposits from and maklng loans to, with respect to a bank, retail customers unrelated to such bank and, wlth respect to a credit unlon or similar cooperatlve credlt orginlzatlon, members, provided that no member has a greater than b% lnterest in such credlt union or cooperaflve credit organizailon; .
Does not sollcit account holders outslde lts country of organization; ' Has no fixed place of buslness oulslde such counlry (for this purpose, a fixed place of business does not include a location that is not advertised to the public and from whlch 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 ln total assets on lts consolldated 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 ln Part iand that meets the requirements set forth in this part.
lcertify that the FFI identified in part l: ' .ls .not engaged primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, notional principal contracts, insurance or annuity contracts, or any interesi (includingl futures or forward contract or option) in such security, partnership interest, commodity, notional principal contract, insurance contract oi annuity contract; ' No financial account malntained by the FFI or any member of its expanded affiliated group, if any, has a balance or value in excess of $50,000 (as determined after applying applicable account aggregation rules); and ' Neither the FFI nor the entire expanded affiliated group, if any, of the FFl, have more than $s0 million in assets on its consolidated or combined balance sheet as of the end of its most recent accounting year.
20 21 Name of sponsoring entity: E lcertify that the entity idlntified in part t: ' ls an FFlsolely because it is an investment entity described in Regulations section 1,1471-S(e)(4); .
ls not a Ql, WP, or WT; ' Will have all of its due diligence, withholding, and reporting responsibilities (determined as if lhe FFI were a participating FFI) futfiled by the sponsoring entity identified on line 20; and ' 20 or fewer individuals own all of the debt and equity interests in the entity (disregarding debt interests owned by U.S. financial institutions, participating FFls, registered deemed'compliant FFls,'and certified oeemed-iomptiant FFls and eluity interests bwneo by in entity if that entity owns 100To ot the equity lnterests in the FFI and ls itself a sponsored FFI).
22 E lcertify that the entity identified in part t:- .

Was in existence as of January 12, 2013; ' lssued all classes of its debt or equity interests to investors on or beforeJan uary 17,2013, pursuant to a trust indenture or similaragreement; and ' ls certified deemed'compliant because it satisfies the requirements to be treated as a limited life debt investment entity (such as the restrictions with respect to its assets and other requirements under Regulations section 1,1471-s(f)(2)(iv).
E tcertity that the entity id"ntitied in part l: ' ls a financial institution solely because it is an investment entity described ln Regulations section 1.1471-s(e)(4XiXA), and .

Does not maintain financial accounls.

Note:ThiSstatusonlyappliesiftheU.S.financialinstitution,pa treat the FFI as an owner-documented FFI(see instructions for eligibility requirements).

ln addition, the FFI must make the certifications below.
24a E 14[ owner-aocumented FFls check here) I cerflfy that the FFI ldentifled in part l: .
Does not act as an lntermediary; ' Does not accept deposits in the ordlnary course of a banklng or similar buslness: ' Does not hold, as a substantial portlon of lts business, financlal assets for the account of others; ' ls not an lnsurance company (or the holdlng company of an insurance company) that issues or ls obllgated to make payments with respect to a flnanclal account; ' ls not owned by or in an 919andeo affiliated group with an entity that accepts deposits in the ordinary course of a banking or similar business, holds, as a substantial portion of lts business, financial assets for the account of others, or is an insurance company (orthe holding company of an insurance company) lhat issues or ls obligated to make payments with respect to a financial account; .
Does not maintain a flnanclal account for any nonparticipating FFI; and ' Does.

not..have any specified U.s. persons that own an equity interest or debt interest (other than a debt interest that is not a financial account or that has a balance or value not exceeding gS0,000) in tlre FFI other than ihose id"niin.J onin" fFf o*ner reporting statement.

Porm W-8BEN-E (Rev.

7-2017) Form W-8BEN-E (Rev.

7-2017) Page 4 Check box 24b or 24c, whlchever applles.

b E lcertify that the FFI identified in Part l: .
Has provided, or will provide, an FFI owner reporting statement that contains: (l) The name, address, TIN (lf any), chapter 4 status, and type of documentatlon provided (if required) of every individual and specifled U.S. person that owns a direct or indirect equity interest in the owner-documented FFI (looking through all entities other than specified U.S. persons); (ll) The name, address, TIN (if any), and chapter 4 status of every individual and speclfied U.S. person that owns a debt interest in the owner-documented FFI (lncludlng any indirect debt interest, which lncludes debt lnterests ln any entlty that dlrectly or lndlrectly owns the payee or any dlrect or lndlrect equlty lnterest in a debt holder of the payee) that constitutes a flnanclal account ln excess of $50,000 (disregarding all such debt lnterests owned by participating FFls, reglstered deemed-compliant FFls, cerlified deemed- compliant FFls, excepted NFFES, exempt beneficial owners, or U,S, persons other than specifled U.S. persons); and (lll) Any additional informatlon the withholding agent requests ln order to fulfill its obligations with respect to the entity.
'Has provided, or will provide, valid documentation meeting the requirements of Regulatlons section 1.1471-3(dx6)(iii) for each person identified in the FFI owner reporting statement.
c n t certify that the FFI ldentifled in Part I has provided, or will provide, an audito/s letter, signed within 4 years of the date of payment, from an independent accounting firm or legal representative with a location in the United States stating that the firm or representative has reviewed the FFI's documentation with respect to all of its owners and debt holders identified in Regulations section 1.1471-3(d)(6)(iv)(A)(2), and that the FFI meets all the requlrements to be an owner-documented FFl.
The FFI ldentifled ln Part I has also provlded, or will provide, an FFI owner reportlng statement of lts owners that are specified U.S. persons and Form(s) W-9, with applicable walvers.

Check box 24d lf appllcable (optional, see instructions).

a E t certify that the entity ldentlfled on line 1 ls a trust that does not have any contlngent beneflciaries or designated classes with unidentified beneficiaries.

25a l-J (Allrestricted distributors check here) lcertify that the entity identified in Part l: .
Operates as a distributor with respect to debt or equity interests of the restricted fund with respect to wtrich this form is furnished; ' ProMdes investment services to at least 30 customers unrelated to each other and less than half of its customers are related to each other; ' ls required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization (which is an FATF- compliant Jurlsdlction); ' Operates solely in its country of lncorporation or organizatlon, has no fixed place of business outslde of that country, and has the same country of incorporation or organization as all members of its affiliated group, if any; .
Does not solicit customers outside its country of incorporation or organization; ' Has no more than $175 mllllon ln total assets under management and no more than $7 mllllon ln gross revenue on its income statement for the most recent accounting year; .
ls not a member of an expanded afflllated group that has more than gS00 million in total assets under management or more than $20 mlllion in gross revenue for its most recent accounting year on a combined or consolidated lncom€ statement; and ' Does not distribute any debt or securitles of the restricted fund to specified U,S, persons, passlve NFFESwith one or more substantlal U,S.

owners, or nonpartlclpatlng FFls.
Gheck box 25b or 25c, whlchever applles, lfurther certify that with respect to all sales of debt or equity interests in the restricted fund with respect to which this form is furnished that are made after December 31,2011, the entlty identifled ln Part l: U E nas been bound by a dlstrlbution agreement that contained a general prohibition on the sale of debt or securities to U.S. enilfles and U.S. resident lndividuals and is currently_ bound by a distrlbution agreement that contalns a prohibltion of the sale of debt or securities to any specified U.S. person, passlve NFFE with one or more substantld U.S. owners, or nonparilclpailng FFl.
c E ts currently bountt by a distributlon agreement that contains a prohibition on the sale of debt or securities to any specitied U.S. person, passive NFFE with one or more substantial U.S. owners, or nonparticipating FFI and, for all sales made prior to the time that such a restriction was lncluded in its distributlon agreement, has reviewed all accounts related to such sales in accordance with the procedures ldentlfled in Regulations sectlon 1.1471-4(c) applicable to preexistlng accounts and has redeemed or retlred any, or caused lhe restricted fund to transfer the securitles to a dlstrlbutor that is a participating FFI or reportlng Model 1 FFI securities whlch were sold to specifled U.S. persons, passlve NFFEs with one or more substantial U.S, owners, or nonparlicipating FFls.
(Rev.7-2017) Form W-8BEN-E (Rev.

7-2017) I certify that the entity identified in Part l: .

Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable lGAbetween the United States and The applicable IGA is a !

n,looet 1 IGA or a n uooet 2 IGA; and under the provisions of the applicable IGA or Treasury regulations is treated as a (if applicable, see instructions); .
lf you are a trustee documented trust or a sponsored entity, provide the name of the trustee or sponsor.

The trustee is: f] U.s. !


Foreign I certify that the entity identified in Part I is the beneficial owner of the payment, and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institulion, or deposltory institutlon with respect to the payments, accounts, or obligations for which this form is submitted (except as permitted in Regulations section 1.1471-6(h)(2)).

Check box 28a or 28b, whlcheverapplleo.


28a n I certify that the entlty ldentified ln Part I is an international organization descrlbed in section 7701(aX1S).

b n I certify that the entity ldentlfled ln Part l: .

ls comprised primarily of forelgn governments; .

ls recognized as an intergovernmental or supranational organization under a foreign law slmllar to lhe lnternational Organlzations lmmunities .. Act or that has ln effect a headquarters agreement wilh a foreign governmenti .
The benefit of the entltys income does not inure to any private person; and .

ls the beneficial owner of the payment and is not engaged in commercial financial activitles of a type engaged in by an insurance company, custodlal lnstitution, or deposltory lmtltutlon with respect to the payments, accounts, or obligatlons for which this form ls submitted (except as permltted ln Regulations section 1.1471-6(hX2)).

Gheck box 29a, b, c, d, e, or f, whlchever applles.
29a E I certlfy that the entlty identified ln Part l: .

ls established in a country wlth whlch the Unlted States has an income tax heaty in force (see Part lll lf claiming treaty benefits); .

ls operated prlncipally to administer or provlde penslon or retirement benefits; and .
ls entltled to treaty beneflts on lncome that the fund derives from U,S, sources (or would be entitled to beneflts if it derived any such income) as a resident of the other country vfilch satisfles any applicable limitation on beneflts requlrement.

b D I certlfy that the entity identified ln Part l: .
ls organized for the provision of retlrement, disability, or death benefits (or any combination thereoo to beneficiaries that are former employees o, one or more employers in consideration for services rendered; .

No single beneficiary has a right to more than 5% of the FFI's assets; .
ls subject to government regulatlon and provides annual information reporting about its beneficlarles to the relevant tax authorities in the country in wtrich the fund is established or operated; and (l) ls generally exempt from tax on investment income under the laws of the country in which it ls established or operates due to its status as a retirement or pension plan; (ll) Receives at least 50o/o of its total contributions from sponsoring employers (disregarding transfers of assets from other plans described in this part, retirement and penslon accounts described in an applicable Model 'l or Model 2 lGA, other retlrement funds described in an applicable Model 1 or Model 2 lGA, or accounts described in Regulations section 1.1471-5(bX2)(i)(e)); (lll) Elther does not permlt or penallzes dlstrlbutions or withdrawals made before the occurrence of speclfled events related to retirement, disability, ordeath (exceptrolloverdistrlbutions to accounts described in Regulationssectlon 1.1471-5(bX2)0XA) (refaringto retiremenl and pension accounts), to retirement and pension accounts described in an applicable Model 1 or Model 2 lGA, or to other retirement funds described in this part or in an applicable Model 1 or Model 2 IGA); or (lv) Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually, c E t certify that the entity ldentifled ln Part l: .
ls organized for the provision of retlrement, disability, or death benefits (or any combinatlon thereoO to beneficiaries that are former employees of one or more employers in consideration for services rendered; .

Has fewer than 50 partlclpants; .

ls sponsored by one or more employers each of which is not an investment entity or passive NFFE; .
Employee and employer contrlbutlons to the fund (disregarding transfers of assets frorn other plans described ln thls part, retirement and pension accounts descrlbed in an appllcable Model 1 or Model 2 lGA, or accounts described ln Regulations section 1.1471-5(bX2Xi)(A)) are limited by reference to earned income and compensation of the employee, respectlvelyi .

Participantsthatarenotresidentsofthecountryinwhichthefundisestablishedoroperatedarenotentitledtomorethan20%ofthefund'sassets; .
ls subject to government regulation and provides annual lnformation reporting about lts beneficiariee to the relevant tax authorities in the country in which thefund is established or operates.

and rorm W-8BEN-E (Rev.

7-2017) Form W-8BEN-E (Rev.

7-2017) tr f ..,rtity tnat the entity identified in part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other than the requirement that the plan be funded by a trust created or organized in the United States.
fl t certify that the entity identified in pa( I is established exclusively to earn income for the beneflt of one or more retirement funds described in this part or in an applicable Model 1 or Model 2lGA, or accounts described in Regulatlons section 1.1471's(bX2XiXA) (eferringto retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 lGA.

E I certify that the entity identified in Part l: .
ls established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described in an appllcable Model 'l or Model 2 lGAto provide retirement, disability, or death benefits to beneficiarles or participants that are current or former employees of the sponsor (or persons designated by such employees); or .
ls established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S' possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described ln an applicable Model 1 or Model 2 lGAto provide retirement, disability, or death beneflts to beneficiaries or participants that are not current or former employees of such sponsor, but are in consideration of personal services performed for the sponsor.
lcertify that the entity identified in Part l: .

ls an FFlsolely because lt is an lnvestment entity; .

Eachdirect holder of an equity lnterest in the investment entity is an exempt beneficial owner described ln Regulations section 1.1471-6 or in an appllcable Model 1 or Model 2 IGA; .
Each direct holder of a debt Interest ln the lnvestment entity ls either a deposltory institution (wlth respect to a loan made to such entity) or an exempt beneficial owner described in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 lGA.

.
.

Has provided an owner reporling statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the lype of documentation provided to the withholding agent for every person that owns a debt interest constitutlng a financial account or direct equity interest in the entlty; and .
Has provided documentation establlshlng that every owner of the entity is an entity described ln Regulatlons section '1.1471-6(b), (c), (d), (e), (f) and/or (g) wlthout regard to whether such owlers are beneficlal or/ners.

lcertify that the entity identified in Part I is a financial institution (otherthan an investment entity) that ls incorporated or organized under lcertify that the entity identified in Part l: .
ls a holding company, treasury center, or captive finance company and substantially all of the entity's activities are functions described in Regulations section 1.

1 471 -s(eXs)(lXC) through (E) ; .
ls a member of a nonfinancial group described in Regulations section 1.1471-s(eXsXiXB); - ls not a depository or custodial institution (other than for members of the entity's expanded affiliated group); and - Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or any investment vehicle with an investment strategy to acquire or fund companies and then hold interests in those companies as capital assets for inveslment purposes.
33 E lcertify that the entity ldentified ln Part l: .

Was formed on (or, in the case of a new llne of business, the date of board resolution approving the new line of business) (date must be less than 24 months prlor to date of payment); .

ls not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of business other than that of a financlal lnstitutlon or passive NFFE; .
ls investing capital lnto assets with the lntent to operate a business other than that of a financial institution; and .

Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or any or fund companies and then hold interests in those companies as capital assets for investment purposes.

investment vehicle whose is to I certify that the entity identified in Part l: .
Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on .

Durlng the past 5 years has not been engaged in business as a financlal lnstltution or acted as a passlve NFFE; .

ls elther liquidailng or emerglng from a reorganlzatlon or bankruptcy with the intent to contlnue or recommence operations as a nonflnanclal entitf and .
Has, or will provlde, documentary evldence such as a bankruptcy fillng or other public documentation that supports lts clalm if it remains in bankruptcy or liquidation for more than 3 years.

rorm W-8BEN-E (Rev.

7-2017) Form W-8BEN-E (Rev.

7-2017) I certify that the entity identlfied in Part I is a 501(c) organization that: .

Has been issued a determlnaflon letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organlzation that is dated_;or .
Has provided a copy of an oplnlon from U.S, counsel certiffing that the payee ls a section 501(c) organlzation (without regard to whether the payee is a foreign private an n 36 E lcertify that the entity identified in Part I is a nonprofit organization that meets the following requirements.

.

The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes; .
The entity is exempt from income tax in lts country of residence; .

The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets; .
Neither the applicable laws of the entity's country of residence nor the entity's formation documents permit any income or assets of the entity to be distributed to, or applied for the benefit of, a private person or noncharitable entity other than pursuant to the conduct of the entity's charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property which the entity has purchased; and .
The applicable laws of the entity's country of residence or the entity's formalion documents require that, upon the entity's liquidation or dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled entity of a foreign government, or another organization that is described in this part or escheats to the government of the entity's country of residence or any political subdivision thereof.
Chock box 37a or 37b, whlchever applles.

37a n lcertlfythat: .

The entity identified in Part I is a foreign corporation that is not a financial institution; and .

The stock of such corporation ls regularlytraded on one or more establlshed securities markets, lncluding (name one securities exchange upon which the stock is regularly traded).

b E lcertifythat: .

The entity identified in Part I is a foreign corporation that is not a financial institution; .
The entity identified in Part I is a member of the same expanded affiliated group as an entity the stock of which is regularly traded on an established securities market; .

The name of the entity, the stock of which is regularly traded on an established securities market, is .

The name of the securities market on whlch the stock is regularly haded is ; and I cerlify that: .

The entity identified in Part I is an entlty that ls organized in a possesslon of the United States; .
The entity identified ln Part l: (l) Does not accept deposlts ln the ordlnary course of a banking or similar business; (ll) Does not hold, as a substantlal portlon of lts business, flnancial assets for the account of others; or (lll) ls not an insurance company (or the holding company of an insurance company) that issues or ls obligated to make payments with respect to a financlal account; and .
All of the owners of the entity ldentifled In Part I are bona fide residents of the possesslon in which the NFFE ls organized or incorporated, 39 I certify that: .

The entity identified in Part I is a forelgn entity that is not a financial institution; .

Less than 50% of such entity's gross income for the preceding calendar year is passive income; and .
Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income (calculated as a of the of passive assets measured quarterly) (see instructions for the definition of passive income).
40a I certify that the entity identified in Part I is a foreign entity that is not a financial institution (other than an investment entity organized in a possession of the United States) and ls not certifying its status as a publicly traded NFFE (or affiliate), excepted territory NFFE, active NFFE, direct reporting NFFE, or sponsored direct reporting NFFE.

Check box 40b or 40c, whlchever applles.


O n tfurtner certify that the entity ldentlfled ln Part I has no substantial U.S. owners (or, if appllcable, no controlling U.S, persons); or c E lfurther certify that the entity ldentifled ln Part I has provided lhe name, address, and TIN of each substantial U.S. owner (or, if applicable, controlling U.S. person) of the NFFE ln Part XXIX.

rorm W-8BEN-E (Rev.

7-2017) Page 8 41 42 43 E tcertify that the entity ldentlfied ln Part l: .
ls a member of an expanded affiliated group; .

Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group); .

Does not make Wthholdable payments to any person other than to members of its expanded afliliated group; .

Does not hold an account (other than deposltory accounts ln the country in which the entlty ls operating to pay for expenses) with or receive payments from anywithholding agent other than a member of its expanded affiliated group; and .
Has not agreed to report under Regulations section 1.1471-4(dX2XiiXC) or otherwise act as an agent for chapter 4 purposes on behalf of anyfinancial institutlon, including a member of lts expanded afflllated group.

Name of sponsoring entity: I that the entity identified in Part I is a direct NFFE that is the identified on line 42.

As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE, Pleasesee the instructions for a definition of substantial U.S. owner.
lf providing the form to an FFltreated as a reporting Model 1 FFI or reporting Model 2 FFl, an NFFE may also use this part for reporling its controlllng U.S. persons under an applicable lGA.

on 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 per,iury that: ' The entiV 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; .
The entity identified 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 lax under an income tax treaty, or (c) the partner's share of a partnership's effectively connected income; 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 the entity on line 'l is the beneficial owner or any withholding agent that can disburse or make payments of the income of which the entity on linqlis the beneflcial owner.

I agroe that I will submit a nEw form wlthln 30 days lf any thls form ,n Sign Here ) Signature of individual beneficial 0.1.f ) .2,1 .
Date (MM-DD-YYYY) M I certifythatl to slgn for the entity on llne'l of rorm W-8BEN-E (Rev.

7-2017)