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Global Stock Plan Services Substitute Form W-8BEN (for use by individuals only)
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding
PLEASE PRINT OR TYPE ALL APPLICABLE INFORMATION IN ENGLISH
General Instructions: This form may be completed only by or for a nonresident alien individual. If you are a U.S. citizen or an alien resident in the United States for tax purposes,
do not use this form. Instead, complete a Form W-9. Failure to submit this form will result in maximum tax being applied to dividends and gross proceeds from the sale of stock.
• Beneficial Owner. A beneficial owner of income is generally the person who is required under U.S. tax principles to include the payment in gross income on a tax return.
A person that receives income as a nominee, agent, custodian, or other intermediary or a conduit is not a beneficial owner.
• Permanent Residence Address. A permanent residence address is the address in the country where the beneficial owner claims to be a resident for purposes of that
country’s income tax.
• Please visit www.irs.gov for complete instructions.
You MUST complete this box with either Global ID or PUID:
Company
Company Name
Global ID # (9 digits)
PUID # (up to 12 digits)
Stock Symbol
3-Digit Company #
(Optional)
PART I — IDENTIFICATION OF BENEFICIAL OWNER
1. N
ame of individual who is
the beneficial owner
First Name
ermanent residence
3. P
address (DO NOT USE A
P.O. BOX OR IN CARE
OF ADDRESS)
Street, Apartment or Suite No., or Rural Route
4. M
ailing Address (if different
from above)
Street, Apartment or Suite No., or Rural Route
City or Town
City or Town
5. U.S. Taxpayer Identification
Number (if any):
Middle Name/Initial
State or Province
State or Province
6. Foreign Tax ID number
Last Name
2. Country of Citizenship
Postal Code
Country (do not abbreviate)
Postal Code
Country (do not abbreviate)
7. Reference number
8. Date of birth (MM-DD-YYYY)
PART II — CLAIM OF TAX TREATY BENEFITS (if applicable)
I certify that (check all that apply):
9. The beneficial owner is a resident of
(See instructions for a complete list of treaty countries.)
within the meaning of the income tax treaty between the United States and that country.
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:
1. 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,
2. The person named on line 1 of this form is not a U.S. person,
3. The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not
subject to tax under an income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income,
4. 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
5. 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.
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Date
Capacity in which signing (if not beneficial owner)
Sign Here
AFFIDAVIT OF UNCHANGED STATUS. Under penalties of perjury, I declare that I have examined and signed the above Form W-8BEN and that the information and
certifications contained therein remained the same and unchanged since January 1 of current year or to the date the account was opened, whichever is later, and were
true, correct and complete for that time.
Capacity in which signing (if not beneficial owner)
Sign Here
© 2017 Morgan Stanley Smith Barney LLC. Member SIPC.
Global Stock Plan Services Substitute Form W-8BEN
GSPSFW8 (02/2017)
PAGE 1 of 1
NY CS 8786192 02/17
COMPLETED FORMS MUST BE FAXED OR MAILED TO (by fax) +1 (614) 467-4471
(by overnight courier) Morgan Stanley, Global Stock Plan Services, 4343 Easton Commons, Suite 300, Columbus, OH 43219
(by regular mail) Morgan Stanley, Global Stock Plan Services, P.O. Box 182616, Columbus, OH 43218-2616