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Sample Wb8en 3
Sample Wb8en 3
Certi
Certificate of Foreign Status of Beneficial Owner for United SUBSTITUTE
Form W-8BEN States Tax Withholding and Reporting (Individuals) (Rev. October 2021)
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
Jalan Lintas Sumatera Gang 5 No 1 Kabupaten Lahat Provinsi S
Country
Indonesia
Country
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions)
XXXXXXXXXXXX0010
I certify that I have the capacity to sign for the person identified on line 1 of this form.
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Anisa Adinata
Print name of signer