Part 2 of Application Part 2 — 1022 Publ 5262 (PDF)

	Part 2 Question	Instructions for QIs
	Type of account holders, partners, benefciaries, or owners (enter approximate number for each Do not include information related to the applicant’s QDD or QSL activities type)	Enter the approximate number of each type of account holder. “Foreign individual non-treaty claimant” means a non-U.S. natural person who is a resident of a country that does not have an income tax treaty with the United States and is the benefcial owner of income paid to the account or a non-U.S. natural person who is a resident of a country that has an income tax treaty with the United States but is not entitled to treaty benefts on the income paid by the QI. “Foreign individual treaty claimant” means a non-U.S. natural person who is a resident of a country with an income tax treaty with the United States, is the benefcial owner of income paid to the account, and is entitled to treaty benefts on that income. “Foreign non-individual benefciaries/owners non-treaty claimant” means a non-U.S. entity, other than a fow-through entity, that is a resident of a country that does not have an income tax treaty with the United States and is the benefcial owner of income paid to the account or a non-U.S. entity, other than a fow-through entity, that is a resident of a country that has an income tax treaty with the United States but is not entitled to treaty benefts on the income paid by the QI. “Foreign non-individual benefciaries/owners treaty claimant” means a non-U.S. entity that is a resident of a country with an income tax treaty with the United States, is the benefcial owner of the income paid to the account, and is entitled to treaty benefts on such income. “Foreign tax-exempt entity” means a non-U.S. entity that is a foreign organization described under section 501(c) of the Code, charitable organization, government, central bank, or international organization designated by Executive Order of the President of the United States as exempt from withholding under section 892 of the Code. “Foreign intermediary” means a non-U.S. entity acting on behalf of another person, such as a custodian, broker, nominee, or other agent. “Foreign fow-through entity” means a foreign partnership described in Treas. Reg. §301.7701-2 or 3 (other than a withholding foreign partnership), a foreign trust (other than a withholding foreign trust) that is described in section 651(a) of the Code, or a foreign trust if all or a portion of such trust is treated as owned by the granter or other person under sections 671 through 679 of the Code. “U.S. individual, partnership, and trust” means a U.S. natural person, partnership, or trust. “Other U.S. person” means any U.S. entity that is not a partnership or trust.

	Part 2 Question	Instructions for QIs
	Investments in U.S. Assets (enter approximate value for each in whole U.S. dollars)	Enter the approximate value of investments in U.S. assets held by each type of account holder. “Foreign individual non-treaty claimant” means a non-U.S. natural person who is a resident of a country that does not have an income tax treaty with the United States and is the benefcial owner of income paid to the account or a non-U.S. natural person who is a resident of a country that has an income tax treaty with the United States but who is not entitled to treaty benefts on the income paid by the QI. “Foreign individual treaty claimant” means a non-U.S. natural person who is a resident of a country with an income tax treaty with the United States, is the benefcial owner of income paid to the account, and is entitled to treaty benefts on that income. “Foreign non-individual benefciaries/owners non-treaty claimant” means a non-U.S. entity, other than a fow-through entity, that is a resident of a country that does not have an income tax treaty with the United States and is the benefcial owner of income paid to the account or a non-U.S. entity, other than a fow-through entity, that is a resident of a country that has an income tax treaty with the United States but is not entitled to treaty benefts on the income paid by the QI. “Foreign non-individual benefciaries/owners treaty claimant” means a non-U.S. entity that is a resident of a country with an income tax treaty with the United States, is the benefcial owner of the income paid to the account, and is entitled to treaty benefts on that income. “Foreign tax-exempt entity” means a non-U.S. entity that is a foreign organization described under section 501(c) of the Code, charitable organization, government, central bank, or international organization designated by Executive Order of the President of the United States as exempt from withholding under section 892 of the Code. “Foreign intermediary” means a non-U.S. entity acting on behalf of another person, such as a custodian, broker, nominee, or other agent. “Foreign fow-through entity” means a foreign partnership described in Treas. Reg. §301.7701-2 or 3 (other than a withholding foreign partnership), a foreign trust (other than a withholding foreign trust) that is described in section 651(a) of the Code, or a foreign trust if all or a portion of such trust is treated as owned by the granter or other person under sections 671 through 679 of the Code. “U.S. individual, partnership, and trust” means a U.S. natural person, partnership, or trust. “Other U.S. person” means any U.S. entity that is not a partnership or trust.

Part 2 Question		Instructions for QIs
Does the applicant presently intend to assume primary chapters 3 and 4 withholding responsibility?	Does the applicant presently intend to assume primary chapters 3 and 4 withholding responsibility?	Select “Yes” if the applicant presently intends to assume primary chapters 3 and 4 withholding responsibility with respect to payments of U.S. source FDAP income. A QI that assumes primary withholding responsibility assumes the primary responsibility for deducting, withholding, and depositing the appropriate amount from a payment. Generally, QI’s assumption of primary chapters 3 and 4 withholding responsibility relieves the person who makes a payment to QI from the responsibility to withhold under chapter 3 or 4. When QI acts as a QI for an account and assumes primary chapter 3 withholding responsibility for payments to the account, QI must also assume primary withholding responsibility for withholdable payments made to such account for chapter 4 purposes. Select “No” if the applicant does not presently intend to assume primary chapters 3 and 4 withholding responsibility.	Select “Yes” if the applicant presently intends to assume primary chapters 3 and 4 withholding responsibility with respect to payments of U.S. source FDAP income. A QI that assumes primary withholding responsibility assumes the primary responsibility for deducting, withholding, and depositing the appropriate amount from a payment. Generally, QI’s assumption of primary chapters 3 and 4 withholding responsibility relieves the person who makes a payment to QI from the responsibility to withhold under chapter 3 or 4. When QI acts as a QI for an account and assumes primary chapter 3 withholding responsibility for payments to the account, QI must also assume primary withholding responsibility for withholdable payments made to such account for chapter 4 purposes. Select “No” if the applicant does not presently intend to assume primary chapters 3 and 4 withholding responsibility.
If the applicant intend to enter into any joint account arrangements agency agreements, e the estimated number each below	s or nter of	For each o sections 9 QI agreem partnershi	ption that applies to the applicant, enter the estimated number of each. See .01 and 9.02 of the WP or WT agreement or sections 4.05 and 4.06 of the ent for information on joint account treatment and agency option for certain ps and trusts.
Does the applicant presently intend to assume primary Form 1099 reporting and backup withholding responsibility?	Does the applicant presently intend to assume primary Form 1099 reporting and backup withholding responsibility?	Select “Yes” if the applicant presently intends to assume primary Form 1099 reporting and backup withholding responsibility. A QI assumes primary Form 1099 reporting and backup withholding responsibility assumes the primary responsibility for deducting, withholding, and depositing the appropriate amount from a payment. Generally, QI’s assumption of primary backup withholding responsibility relieves the person who makes a payment to QI from the responsibility to withhold under section 3406 of the Code. Select “No” if the applicant does not presently intend to assume primary Form 1099 reporting and backup withholding responsibility.	Select “Yes” if the applicant presently intends to assume primary Form 1099 reporting and backup withholding responsibility. A QI assumes primary Form 1099 reporting and backup withholding responsibility assumes the primary responsibility for deducting, withholding, and depositing the appropriate amount from a payment. Generally, QI’s assumption of primary backup withholding responsibility relieves the person who makes a payment to QI from the responsibility to withhold under section 3406 of the Code. Select “No” if the applicant does not presently intend to assume primary Form 1099 reporting and backup withholding responsibility.

Part 2 Question	Instructions for QIs
Will the applicant have any Private Arrangement Intermediary (PAI) agreements in effect?	Select the appropriate response. A private arrangement intermediary (PAI) is an intermediary that is a certifed deemed- compliant FFI (other than a registered deemed-compliant Model 1 IGA FFI) that enters into an agreement with a QI that is an FFI (except when the QI is acting as a QDD) to perform the obligations of the QI under the QI agreement, as described in section 4 of the QI agreement. If yes, separately identify each PAI agreement and enter the PAI’s name and address. The PAI name is the name the PAI uses in offcial incorporation or organization documents, or the name otherwise recognized by the government as the PAI’s offcial name. The address of the PAI is the address where the PAI maintains its principal offce. For the country/jurisdiction option, if selecting “other”, enter the name of the country/jurisdiction. Enter the name and contact information of the PAI’s responsible offcer. For the country/ jurisdiction option, if selecting “other”, enter the name of the country/jurisdiction. A note on PAI agreements: You may delete a PAI agreement by using the icons in the PAI agreement information table’s last column.

Part 2 Question

Instructions for QIs

Will the applicant have
any Private Arrangement
Intermediary (PAI)
agreements in effect?

Select the appropriate response.
A private arrangement intermediary (PAI) is an intermediary that is a certifed deemed-
compliant FFI (other than a registered deemed-compliant Model 1 IGA FFI) that enters
into an agreement with a QI that is an FFI (except when the QI is acting as a QDD) to
perform the obligations of the QI under the QI agreement, as described in section 4 of the
QI agreement.
If yes, separately identify each PAI agreement and enter the PAI’s name and address. The
PAI name is the name the PAI uses in offcial incorporation or organization documents,
or the name otherwise recognized by the government as the PAI’s offcial name. The
address of the PAI is the address where the PAI maintains its principal offce. For the
country/jurisdiction option, if selecting “other”, enter the name of the country/jurisdiction.
Enter the name and contact information of the PAI’s responsible offcer. For the country/
jurisdiction option, if selecting “other”, enter the name of the country/jurisdiction.
A note on PAI agreements: You may delete a PAI agreement by using the icons in the
PAI agreement information table’s last column.