Part VII – Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle

Line 20. Enter the name of your sponsoring entity that has agreed to fulfill the due diligence, reporting, and withholding obligations of the entity identified on line 1 as if the entity on line 1 were a participating FFI. You must also enter the GIIN of your sponsoring entity on line 9a.

Line 24d. Check the box if you do not have any contingent beneficiaries or designated classes with unidentified beneficiaries. While this certification is not required, an owner reporting statement provided by an owner-documented FFI will remain valid indefinitely for chapter 4 purposes absent a change in circumstances with respect to offshore obligations (as defined in Regulations section 1.6049-5(c)(1)) only if this certification is provided and the account balance of all accounts held by the owner-documented FFI with the withholding agent does not exceed $1,000,000 on the later of June 30, 2014, or the last day of the calendar year in which the account was opened, and the last day of

Line 21. If you are a sponsored, closely held investment vehicle, you must check the box to certify that you meet all of the requirements for this certified deemed-compliant status.