Part III — Qualification Statement for Chapter 4 Status

You are not required to complete a chapter 4

TIP qualification statement if you are not the payee of

a withholdable payment or are not an accountholder holding an account with an FFI requesting this form.

Line 16. Check this box to indicate that you are treated as a nonreporting FFI under an applicable IGA (and as defined in the IGA). You must identify the applicable IGA by entering the name of the jurisdiction that has the applicable IGA in effect with the United States. You must also provide the withholding agent with the class of entity described in Annex II of the IGA applicable to your status. If you are an FFI treated as a registered deemed-compliant FFI under an applicable Model 2 IGA, you must provide your GIIN in the space provided.

Line 17. Check this box if you are a territory financial institution. By checking this box, you are certifying to the statement in line 17.

Line 18. Check this box if you are a foreign government, government of a U.S. territory, or foreign central bank of issue as defined for purposes of chapter 4 (see

-8- Instructions for Form W-8EXP (Rev. 10-2023)

The affidavit must be based on information from your latest accounting year, identify the type of section 501(c) (3) organization (for example, charitable, religious, educational), and be signed by one of your principal

Regulations section 1.1471-6). By checking this box, you are certifying to the statement made in line 18.

Line 19. Check the applicable box if you are an exempt retirement plan of a foreign government as defined for purposes of chapter 4. By checking one of these boxes, you are certifying to the statement made in either line 19a or line 19b, as applicable.

Line 20. Check this box if you are a 501(c) organization other than an insurance company described in section 501(c)(15). By checking this box, you are certifying to the statement made in line 20.

Line 21. Check box 21a if you are passive NFFE. If you do not have any substantial U.S. owners, check box 21b. If you have any substantial U.S. owners, you must provide a statement with the information set forth on line 21c.

Line 22. Check this box if you are a sponsored direct reporting NFFE. Provide the name of your sponsoring entity in the space provided. By checking this box, you are certifying to the statement made in line 22.