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Click here to open Form W-8 IMY instructions from the IRS web site in a new window.

Part 1: Identification of Entity

1 User Name * : (Account that log in AVOP)

2 Name of individual or organization that is acting as intermediary: * :

3 Country of incorporation or organization * :

4 Type of entity:

Qualified intermediary. Complete Part II.	Nonqualified intermediary. Complete Part III.
U.S. branch. Complete Part IV.	Withholding foreign partnership. Complete Part V.
Withholding foreign trust. Complete Part V.	Nonwithholding foreign partnership. Complete Part VI.
Nonwithholding foreign simple trust. Complete Part VI.	Nonwithholding foreign grantor trust. Complete Part VI.

5 Permanent residence address. Do not use a P.O. Box.

Street Address * :
City * :
State, province or region:
Zip or postal code, if appropriate:
Country * :

6 Mailing address (if different from above)

Street Address:
City:
State, province or region::
Zip or postal code, if appropriate::
Country:

7 U.S. Taxpayer Identification Number, if required (see instructions)

SSN or ITIN EIN QI-EIN

8 Foreign Tax Identifying Number, if any (optional)

9 Reference number(s) (see instructions)

Part 2: Qualified Intermediary

10a		(All qualified intermediaries check here) I certify that the entity identified in Part I:
		Is a qualified intermediary and is not acting for its own account with respect to the account(s) identified on line 8 or in a withholding statement associated with this form and
		Has provided or will provide a withholding statement, as required
b		(If applicable) I certify that the entity identified in Part I has assumed primary withholding responsibility under Chapter 3 of the Code with respect to the account(s) identified on this line 9b or in a withholding statement associated with this form

c		(If applicable) I certify that the entity identified in Part I has assumed primary Form 1099 reporting and backup withholding responsibility as authorized in its withholding agreement with the IRS with respect to the account(s) identified on this line 9c or in a withholding statement associated with this form

Part 3: Nonqualified Intermediary

11a		(All nonqualified intermediaries check here) I certify that the entity identified in Part I is not a qualified intermediary and is not acting for its own account.
b		(If applicable) I certify that the entity identified in Part I is using this form to transmit withholding certificates and/or other documentary evidence and has provided or will provide a withholding statement, as required.

Part 4: Certain United States Branches

Note: You may use this Part if the entity identified in Part I is a U.S. branch of a foreign bank or insurance company and is subject to certain regulatory requirements (see instructions).

12		I certify that the entity identified in Part I is a U.S. branch and that the payments are not effectively connected with the conduct of a trade or business in the United States.
Check box 12 or box 13, whichever applies:
13		I certify that the entity identified in Part I is using this form as evidence of its agreement with the withholding agent to be treated as a U.S. person with respect to any payments associated with this certificate.
14		I certify that the entity identified in Part I:
		Is using this form to transmit withholding certificates or other documentary evidence for the persons for whom the branch receives a payment and
		Has provided or will provide a withholding statement, as required.

Part 5: Withholding Foreign Partnership or Withholding Foreign Trust

15		I certify that the entity identified in Part I:
		Is a withholding foreign partnership or a withholding foreign trust and
		Has provided or will provide a withholding statement, as required.

Part 6: Nonwithholding Foreign Partnership, Simple Trust, or Grantor Trust

16		I certify that the entity identified in Part I:
		Is a nonwithholding foreign partnership, a nonwithholding foreign simple trust, or a nonwithholding foreign grantor trust and that the payments to which this certificate relates are not effectively connected, or are not treated as effectively connected, with the conduct of a trade or business in the United States and
		Has provided or will provide a withholding statement, as required.

Part 7: 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. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income for which I am providing this form or any withholding agent that can disburse or make payments of the income for which I am providing this form.

Signature of authorized official (Typing in your name acts as your signature): * :

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