Systems and Procedures
A Division of The Corporate Controller's Office


Form Instructions

Part I - Identification of Beneficial Owner

  1. Name of individual who is the beneficial owner - Payee Name
  2. U.S. Tax Identification Number is one of the following:
    • U.S. Social Security Number (SSN) - OR -
    • Individual Tax Identification Number (ITIN) - OR -
    • Copy of form W-7 Application for ITIN
  3. Foreign tax identification number, if any - Leave Field BLANK
  4. Permanent residence address (street, apt, or suite no., or rural route) Do not use a P.O. box
    • Payee's address in Country of Permanent Residency under which they are claiming Tax Treaty Exemption
    • City or town, state or province. Include postal code where appropriate
    • Country (do not abbreviate)
  5. Enter the individual's address while in the United States (street, apt. or suite no., or rural route); if the individual will only be in the U.S. for a few days, enter the address of the payor. Do not use a P.O. box unless that is the individual's only U.S. mailing address
  6. Enter the U.S. VISA type. Enter N/A if a VISA is not required
  7. Citizens of Canada or Mexico are not required to completes lines 7a and 7b
    1. Country issuing passport
    2. Passport Number
  8. Date of entry into the United States - Date of entry shown on the US Customs and Border Patrol Admission Classification Stamp in the passport
  9. Status
    1. Current non-immigrant status - Entry Status from the Admission Classification Stamp in the passport
    2. Data your current non-immigrant status expires - The Status Expiration Date is on the Admission Classification Stamp and will be either a date or Duration of Status (D/S)
  10. If you are a foreign student, trainee, professor/teacher, or researcher, check this box - Leave Field BLANK

PART II - Claim for Tax Treaty Withholding Exemption

  1. Compensation for independent (and certain dependent) personal services:
    1. Description of personal services you are providing - Description of what the payee did (i.e., gave a lecture, collaborated on research, etc.)
    2. Total compensation you expect to be paid for these services in this calendar or tax year $ - Amount of the payment
  2. If compensation is exempt from withholding based on a tax treaty benefit, provide:
    1. Tax treaty on which you are basing exemption from withholding - The Treaty being used for tax exemption. This needs to read "Treaty between the United States and (Payee's Country of Tax Residence)"
    2. Treaty article on which you are basing exemption from withholding - Treaty Article Number (from the Tax Treaty Chart )
    3. Total compensation listed on line 11b above that is exempt from tax under this treaty $
    4. Country of Residence (must match Part I, question 4)
  3. Lines 13a - 13d - Leave Fields BLANK
  4. Leave Field BLANK

Part III - Certification

The payee needs to sign and date the form.

NOTE: The signature must be an original, not a copy or fax. This form is sent to the IRS

Part IV - Withholding Agent Acceptance and Certification

This will be signed in Accounting Operations.

For additional information, please see the IRS Exemption from Withholding 8233 Instructions