! your jurisdiction — 1021 Inst W-8IMY (PDF)

CAUTION benefits as described in these instructions. Instead,

you must include the withholding certificates or documentary evidence of the owners claiming treaty benefits and provide an allocation on the withholding statement.

QDD branch of a U.S. person. If you are a foreign branch of a U.S. person that is acting as a QDD and you receive a payment that otherwise would be subject to withholding except for the U.S. person’s status as a U.S. person, you may associate this Form W-8IMY with a Form W-9 from the U.S. person.

Withholding statement of a QI. As a QI, you must provide a withholding statement to each withholding agent from which you receive reportable amounts or withholdable payments if you have not assumed primary withholding responsibility under chapter 3 and chapter 4 with respect to the payment for one or more accounts (as indicated otherwise on line 15a), or if you are receiving a reportable amount on behalf of a U.S. non-exempt recipient, you have not assumed primary Form 1099 reporting and backup withholding responsibility for the payment. You must also provide a withholding statement for an amount realized or a PTP distribution for which you have not assumed primary withholding responsibility. The withholding statement becomes an integral part of the Form W-8IMY and, therefore, the certification statement that you sign in Part XXIX of the form applies to the withholding statement as well as to the form. If you are a QDD, see also QDD withholding statement, later.

A QI withholding statement must also:

Designate those accounts for which you act as a QI;
Designate those accounts for which you are assuming primary withholding and reporting responsibility under chapter 3 and chapter 4;
If you receive an amount realized or a PTP distribution, designate those accounts for which you are assuming primary withholding and reporting responsibility for either such amount;
If applicable, designate those accounts or payments for which you are acting as a QSL with respect to any U.S. source substitute dividends; and
For any account for which you are not assuming primary withholding and reporting responsibility, provide information to allocate the payment, as applicable, to chapter 3 withholding rate pools, chapter 4 withholding rate pools, or other pools of payees permitted under the chapter 4 regulations. See Regulations section 1.1471-3(c)(3)(iii)(B)(2) (with respect to a chapter 4 withholding rate pool). You mus t, however, provide information to allocate the payment to the

specific partners receiving the payment (rather than including any part of the payment in any chapter 3 withholding rate pool) when you act as a disclosing QI for a payment of an amount realized or PTP distribution.

For chapter 4 purposes. If you are a QI and you receive a withholdable payment, you must provide a withholding statement which satisfies the requirements of an FFI withholding statement or chapter 4 withholding statement (if you are not an FFI) when you do not assume primary withholding responsibility under chapter 3 and chapter 4 and Form 1099 reporting and backup withholding responsibility for the payment.

If you are a QI that is an FFI you may provide an FFI withholding statement to allocate the payment to chapter 4 withholding rate pools (as applicable) or other pool of payees permitted on an FFI withholding statement under the chapter 4 regulations. See Regulations section 1.1471-3(c) (3)(iii)(B)(2). You may also provide on the withholding statement a single pool of nonparticipating FFIs, a single pool of recalcitrant account holders of yours or of or another intermediary that is a participating FFI or registered deemed-compliant FFI, and, if you do not assume primary Form 1099 and backup withholding responsibility, a chapter 4 withholding rate pool of U.S. payees. A chapter 4 withholding rate pool of U.S. payees may include:

If you are a reporting Model 1 FFI, an account holder that is not withheld on under chapter 3, chapter 4, or section 3406 that you report as a U.S. account pursuant to the Model 1 IGA because the account has U.S. indicia and you have not obtained appropriate documentation to treat the account as held by other than a specified U.S. person;
If you are a reporting Model 2 FFI, an account holder that is not withheld on under chapter 3, chapter 4, or section 3406 that you report as an account holder of a non-consenting U.S. account as described in the Model 2 IGA;
If you are a non-U.S. payor (as described in Regulations section 1.6049-5(c)(5)) that is a participating FFI (including a reporting Model 2 FFI), registered deemed-compliant FFI, or reporting Model 1 FFI, an account holder not withheld on under chapter 4 or section 3406 who you report under chapter 4 or an applicable IGA (including the account holder’s TIN).

Additionally, a chapter 4 withholding rate pool of U.S. payees may be provided in the above-described cases for a payment of an amount realized for which a withholding statement is provided for purposes of section 1446(f) that allocates some amount of the payment to a U.S. person. See, For a payment of an amount realized, later, and Example 5 and Example 6 , later.

An FFI withholding statement must also identify each intermediary or flow-through entity that is receiving a payment on behalf of a payee and include such entity’s chapter 4 status and GIIN (if applicable), excluding any intermediary or flow-through entity that is an account holder or interest holder in another QI, WP, or WT. An FFI withholding statement of a QI may combine withholding rate pool information provided by such an entity to the QI with withholding rate pools comprised of accounts that the QI maintains.

If you are a QI that is not an FFI and that does not assume primary withholding responsibility under chapter 3 and chapter 4, you must provide, for a withholdable payment, a chapter 4 withholding statement that contains the name, address, TIN (if any), entity type (if applicable), and chapter 4 status of each payee, the amount allocated to each payee, a

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valid withholding certificate or other documentation sufficient to establish the payee’s chapter 4 status. However, a chapter 4 withholding statement may include pooled information for payees that are nonparticipating FFIs that hold accounts that you maintain or hold accounts with an intermediary or flow-through entity receiving the payment from you. You may also provide another pool of payees as permitted under the chapter 4 regulations for a chapter 4 withholding statement. See Regulations section 1.1471-3(c) (3)(iii)(B).

For chapter 3 purposes. In the case of a reportable amount that is a withholdable payment, any portion of the payment for which you are acting as a QI that is not allocated to a chapter 4 withholding rate pool or a U.S. non-exempt recipient (including for backup withholding purposes) must be allocated to a chapter 3 withholding rate pool or pool of U.S. exempt recipients, if it is not required to be separately reported. The chapter 3 withholding rate pool may be established by any reasonable method agreed upon by you and the withholding agent. For example, you may agree to establish a separate account for a single chapter 3 withholding rate pool or you may agree to divide a payment made to a single account into portions allocable to each chapter 3 withholding rate pool. You must provide the chapter 3 withholding rate pool information that is required for the withholding agent to meet its withholding and reporting obligations. A withholding agent may request any information reasonably necessary to withhold and report payments correctly.

For a payment of an amount realized. In the case of a payment of an amount realized, you must provide chapter 3 withholding rate pool information with respect to the foreign transferors receiving the payment for your broker to meet its withholding and reporting obligations (except when you act as a disclosing QI). See Regulations section 1.1446(f)-4(a) (7)(iii). The chapter 3 withholding rate pool information you provide on a withholding statement may be properly adjusted to take into account the withholding required on a transferor that is a foreign partnership for which you permit a modified amount realized. With respect to U.S. transferors receiving an amount realized, and regardless of whether you act as a disclosing QI, you must allocate the payment to each such transferor to the extent of the amount that may not be allocated to a chapter 4 withholding rate pool of U.S. payees (to the extent permitted for chapter 4 purposes).

For a PTP distribution. In the case of a PTP distribution, you must provide to the PTP or nominee from which you receive the distribution chapter 3 withholding rate pool information and chapter 4 withholding rate pool information (when permitted for chapter 4 purposes) for your foreign partners with respect to the amounts subject to withholding on the distribution (except when you act as a disclosing QI). For determining the amounts to include in each withholding rate pool, the QI must rely on the allocation of each amount subject to withholding on the distribution as determined by the PTP or nominee that pays the distribution to the QI. When acting as a disclosing QI for a PTP distribution, you must provide with respect to each partner an allocation of the income attributable to the distribution that is subject to withholding under section 1446(a) or (f) (and, for an amount subject to chapter 3 or 4 withholding, an allocation of such amount to each beneficial owner or payee). See Withholding statement, earlier, for the requirements of a withholding statement provided by an intermediary for a PTP distribution. Regardless of whether you act as a disclosing QI, you must

allocate the amounts subject to withholding on the distribution to each U.S. partner.

Form 1099 reporting. If you do not assume primary Form 1099 reporting and backup withholding responsibility, you must provide payee-specific information for each U.S. non-exempt recipient account holder (other than those U.S. payees included in a chapter 4 withholding rate pool of U.S. payees (described in Regulations section 1.6049-4(c)(4)(iii)) or when the alternative procedure is used. The pools are based on valid documentation that you obtain or, if a payment cannot be reliably associated with valid documentation, the applicable presumption rules.

$10 on behalf of C, a U.S. exempt recipient that is not a specified U.S. person and is an indirect account holder of the QI (who beneficially owns the payment through an account with another participating FFI);
$20 on behalf of D, a U.S. non-exempt recipient that is a specified U.S. person who is an indirect account holder of the QI (that beneficially owns the payment through an account with a certified deemed-compliant FFI described in Regulations section 1.1471-5(f)(2)); and
$10 each on behalf of two nonresident alien individuals who are account holders of the QI, one of whom is entitled to a 15% rate of withholding under an applicable income tax treaty.

The dividend payment is both a withholdable payment under chapter 4 and a reportable amount under chapter 3. The QI assumes primary withholding and reporting responsibility under chapter 3 and chapter 4 as well as primary Form 1099 reporting and backup withholding responsibility. As a result, the QI is not required to provide a withholding statement allocating the payment to specific payees or withholding rate pools. The QI will provide Form W-8IMY and check the boxes on lines 14, 15a, and 15f.

Example 2. The facts are the same as Example 1, except QI is a non-U.S. payor under Regulations section 1.6049-5(c)(5) and does not assume primary Form 1099 and backup withholding responsibility but reports the accounts of A and B as U.S. accounts under Regulations section 1.1471-4(d). The QI must provide a withholding statement allocating $20 of the payment to D, $10 to C, and $10 to a chapter 4 withholding rate pool of U.S. payees. The QI need not allocate any portion of the payment specifically to A or B because the QI is a non-U.S. payor that is permitted to include A and B in a chapter 4 withholding rate pool of U.S. payees under Regulations section 1.6049-4(c)(4)(i). For payments made on or after April 1, 2017, see the instructions for Part IV of this form for when a withholding statement includes an allocation of a payment of an amount subject to chapter 3 withholding that is made to a pool of U.S. payees.

Example 1. A QI that is a participating FFI receives a $100 payment of U.S. source dividends on an account for which it acts as a QI held with the withholding agent for the following recipients:

$20 to NPFFI, a nonparticipating FFI that is an account holder of the QI;
$10 each on behalf of two recalcitrant account holders of the QI ($20 total), each with U.S. indicia (as described in Regulations section 1.1441-7(b)(5)) associated with the account;
$5 each on behalf of A and B, U.S. individual account holders of the QI that the QI reports as U.S. accounts pursuant to its chapter 4 reporting obligations as a participating FFI ($10 total);

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The QI must also provide a Form W-9 (or alternatively, name and TIN) for D. A Form W-9 is not required for C. The QI will provide Form W-8IMY and check the boxes on lines 14, 15a, and 15g and 15h.

Example 3. The facts are the same as Example 1, except the QI is a U.S. payor and does not assume primary Form 1099 and backup withholding responsibility. Because the QI is a U.S. payor, it is not permitted, under Regulations section 1.6049-4(c)(4)(i) and (iii), to include A and B in a chapter 4 withholding rate pool of U.S. payees. The QI must provide a withholding statement allocating $5 of the payment to A, $5 of the payment to B, $10 of the payment to C, and $20 of the payment to D along with Forms W-9 (or name and TIN) for A, B, and D. The QI will provide Form W-8IMY and check the boxes on lines 14 and 15a.

Example 4. The facts are the same as Example 1, except the QI is a non-U.S. payor that does not assume primary withholding and reporting responsibility under chapter 3 and chapter 4. The QI also does not assume primary Form 1099 and backup withholding responsibility.

If the QI does not assume primary withholding and reporting responsibility under chapter 3 and chapter 4 as well as primary Form 1099 reporting and separate backup withholding responsibilities, the QI will provide an FFI withholding statement with the following pools:

information specified in Regulations section 1.1446(f)-4(c)(2) (ii)(C) for QI to determine a modified amount realized of $10 (one-half of the $20 is allocable to partners of F who are nonresident alien individuals and one-half allocable to a U.S. partner of F (USP)), and QI does not report F’s account as a U.S. account for purposes of chapter 4 reporting;

To USP, for the $10 of the $20 of amount realized by F that is allocable to USP.

The QI will complete Form W-8IMY and check the box on line 14. As QI does not assume primary withholding responsibility under section 1446(f) for the amount realized, QI must not check the box on line 15b but should check the boxes on lines 15g and 15h because it has not assumed Form 1099 reporting and backup withholding responsibility. QI does not account for any of the account holders of N on its withholding statement as withholding applies to N at the 10% rate on the payment regardless of the statuses of N’s account holders receiving the payment. See Regulations section 1.1446(f)-4(a)(2) for this withholding requirement. See Withholding statement for amount realized or PTP distribution in Part IV, later, however, for when N (as an NQI) would be permitted to provide to QI allocation information and beneficial owner withholding certificates for the account holders of N receiving the amount realized from the sale. With respect to grantor trust H, the withholding is determined with respect to grantor G, rather than H, as G is the transferor of the PTP interest. With respect to foreign partnership F, the withholding statement includes the $10 allocable to F’s foreign partners in a chapter 3 withholding rate pool at the 10% rate as these partners did not claim any exception to withholding based on an income tax treaty. With respect to USP, QI discloses the identity of USP on the withholding statement because it does not assume primary Form 1099 reporting and backup withholding responsibility and does not report the account of USP for purposes of QI’s chapter 4 requirements as a participating FFI. QI must also provide the documentation permitted for section 1446(f) purposes to support USP’s non-foreign status. With respect to C and D, however, as QI reports their accounts under QI’s requirements as a participating FFI, QI may report the amount realized allocable to C and D in a chapter 4 withholding rate pool of U.S. payees.

Example 6. The facts are the same as Example 5, except the QI acts as a disclosing QI for the payment of the amount realized. Unlike Example 5, because the QI is a disclosing QI, it may not allocate any portion of the payment to a chapter 3 withholding rate pool on the withholding statement

$10 on behalf of foreign grantor trust H, an account holder of QI that has provided to QI the documentation from which QI can associate the amount realized with G, a nonresident alien that is the sole grantor of the trust;
$10, on behalf of N, an account holder of the QI that is a nonqualified intermediary.

As QI is not acting as a disclosing QI for this payment, QI may provide to its U.S. broker a withholding statement that allocates the amount realized to chapter 3 withholding rate pools, excluding amounts allocable to a U.S. partner or to a chapter 4 reporting pool of U.S. payees. QI must report on the withholding statement the payment allocated as follows:

To a chapter 3 withholding rate pool at a 10% rate - $70 (for the $40 allocable to A and B, $10 allocable to F’s nonresident alien partners; $10 allocable to G, and $10 allocable to N);
To a chapter 4 withholding rate pool of U.S. payees - $20 (for the total amount allocable to C and D); and
Nonparticipating FFI Pool — $20 (which is subject to chapter 4 withholding);
Recalcitrant Account Holder Pool — $20 (which is subject to chapter 4 withholding and which is aggregated in a single pool of recalcitrant account holders rather than each class described in Regulations section 1.1471-4(d)(6));
Chapter 4 Withholding Rate Pool of U.S. Payees — $10 (for the portion of the payment allocable to A and B);
Chapter 3 30% Rate Pool — $10;
Chapter 3 15% Rate Pool — $10; and
0% Rate Pool — $10 (for the portion of the payment allocable to C).

The QI will also be required to allocate $20 to a separate withholding rate pool for D because D is a U.S. non-exempt recipient who cannot be included in a chapter 4 withholding rate pool of U.S. payees (because D’s account is maintained by a certified deemed-compliant FFI). The QI will provide Form W-8IMY and check the boxes on lines 14, 15g, and 15h.

Example 5. A QI that is foreign corporation and a Participating FFI does not assume primary withholding and reporting responsibility for a payment of $100 from a U.S. broker that is an amount realized from the sale of a PTP interest. The QI also does not assume primary Form 1099 reporting and backup withholding responsibility for any of its accounts. The QI holds the PTP interest in an account with a U.S. broker and does not act as a disclosing QI for the payment of the amount realized. The QI determines that the amount realized from the sale is allocable to the following transferors of the interest in the PTP on whose behalf the QI held the interest:

$20 each on behalf of A and B, two nonresident alien individuals who are account holders of the QI;
$10 each on behalf of C and D, two U.S. individual account holders of the QI that the QI reports as U.S. accounts pursuant to its chapter 4 reporting obligations as a participating FFI;
$20 on behalf of F, a foreign partnership and account holder of the QI that has provided the certification and other

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provided to the U.S. broker. QI must instead allocate the payment of the amount realized to each account holder that is a transferor of the PTP interest, excluding any transferors that are includible in a chapter 4 withholding rate pool of U.S. payees. See Regulations section 1.1446(f)-4(a)(7)(iii). Thus, with respect to QI’s account holders that are foreign transferors, QI must allocate $20 of the amount realized each to A and B and must associate a valid Form W-8BEN for each of them with the withholding statement. With respect to foreign partnership F, QI must identify F as the transferor of the interest (with a valid Form W-8IMY from F completed in accordance with Part VIII, later), must indicate on its withholding statement that QI has determined a modified amount realized of $10 from the $20 of the amount realized allocable to F, and must allocate the amount realized between each of the partners of F based on the certification and withholding statement provided by F for this payment in accordance with Regulations section 1.1446(f)-4(c)(2)(ii)(C). QI must include on the withholding statement the amount allocable to USP for the reasons noted in Example 5, earlier, (with the documentation permitted to support USP’s non-foreign status) that F should have provided to QI with its withholding statement. With respect to foreign grantor trust H, QI must allocate the $10 received on behalf of H to G (as G is the transferor), and must associate with the withholding statement a valid Form W-8IMY from H (completed in accordance with Part VIII, later), a valid Form W-8BEN from G, and information provided by H regarding the amount realized allocable to G. With respect to nonqualified intermediary N, QI must allocate the $10 received on behalf of N to N and associate this amount with the withholding statement and a valid Form W-8IMY from N. See Withholding statement for amount realized or PTP distribution in Part IV , later, however, for when N would also be permitted to provide to QI allocation information and beneficial owner withholding certificates for the account holders of N receiving the amount realized from the sale. As indicated in Example 5, earlier, QI may include C and D in a chapter 4 withholding rate pool of U.S. payees with respect to the amount allocable to them (an allowance that applies even when a QI acts as a disclosing QI for an amount realized).

If you are acting as a QDD that meets the conditions described below, you must provide on line 9b, your foreign taxpayer identification number (FTIN) issued by the jurisdiction in which you are tax resident identified on line 6, unless you were not issued an FTIN (including if the jurisdiction does not issue FTINs). If you do not provide your FTIN, you must provide on your QDD withholding statement a reasonable explanation of why you have not been issued an FTIN. For this purpose, such an explanation includes a statement that you are not legally required to obtain an FTIN in your jurisdiction of tax residence. Do not write “not applicable.” If you are acting as a QDD, you are required to provide your FTIN or an explanation of why you have not been issued an FTIN if: