**Form W-8IMY (Rev. 9-2016)**
Page 2

**Part II Disregarded Entity or Branch Receiving Payment. (Complete only if a disregarded entity with a GIIN or a branch of an FFI in a country other than the FFI's country of residence. See instructions.)**

11 Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment.
   - Limited branch (see instructions).
   - Reporting Model 1 FFI.
   - U.S. Branch.
   - Reporting Model 2 FFI.

12 Address of branch (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).

City or town, state or province. Include postal code where appropriate. | Country

13 GIIN (if any)

**Chapter 3 Status Certifications**

**Part III Qualified Intermediary**

14a (All qualified intermediaries check here.) I certify that the entity identified in Part I (or branch, if relevant):
   - Is a qualified intermediary with respect to the account(s) identified on line 10 or in a withholding statement associated with this form (as required) that is either:
     (i) not acting for its own account;
     (ii) a qualified derivatives dealer; and/or
     (iii) a qualified intermediary assuming primary withholding responsibility for payments of substitute interest, as permitted by the QI Agreement.
   - Has provided or will provide a withholding statement, as required, for purposes of chapters 3 and 4 that is subject to the certifications made on this form.

Check all that apply.

b I certify that the entity identified in Part I of this form is not providing a withholding statement associated with this form because it assumes primary withholding responsibility for purposes of chapters 3 and 4, and either:
   - Primary Form 1099 reporting and backup withholding responsibility; or
   - Reporting responsibility as a participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains and that are held by specified U.S. persons as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting.

c I certify that the entity identified in Part I of this form assumes primary withholding responsibility under chapters 3 and 4 with respect to payments made to each account identified on this line 14c (or on an attachment to this form).

d I certify that the entity identified in Part I of this form assumes primary Form 1099 reporting and backup withholding responsibility with respect to payments made to each account identified on this line 14d or on an attachment to this form or reporting responsibility as a participating FFI or registered deemed-compliant FFI with respect to accounts that it maintains and that are held by specified U.S. persons as permitted under Regulations sections 1.6049-4(c)(4)(i) or (c)(4)(ii) in lieu of Form 1099 reporting.

e I certify that the entity identified in Part I of this form does NOT assume primary Form 1099 reporting and backup withholding responsibility. Check all that apply.

(i) I certify that the entity identified in Part I of this form is using this form to transmit Forms W-9 with respect to each account(s) not covered by the certification in (ii) held by a U.S. nonexempt recipient identified on this line 14e or in a withholding statement associated with this form.

(ii) If the entity identified on Part I of this form has allocated or will allocate a portion of a payment to a chapter 4 withholding rate pool of U.S. payees on a withholding statement associated with this form, I certify that the entity meets the requirements of Regulations section 1.6049-4(c)(4)(iii) with respect to any account holder of an account that it maintains that is included in a withholding rate pool of U.S. payees provided on a withholding statement associated with this form.

(iii) If the entity identified on Part I of this form has allocated or will allocate a portion of a payment to a chapter 4 withholding rate pool of U.S. payees on a withholding statement associated with this form, to the extent the entity is providing a withholding statement that includes a chapter 4 withholding rate pool of U.S. payees that are account holders of an intermediary or flow-through entity receiving a payment from the entity identified on line 1, I certify that the entity on line 1 has obtained or will obtain documentation sufficient to establish each such intermediary or flow-through entity's status as a participating FFI, registered deemed-compliant FFI, or FFI that is a qualified intermediary.

f I certify that the entity identified in Part I of this form is acting as qualified securities lender with respect to payments associated with this form that are U.S. source substitute dividends received from the withholding agent.

g I certify that the entity identified in Part I of this form meets the requirements to act as a qualified derivatives dealer and assumes primary withholding responsibility for the payments associated with this form and/or identified on a withholding statement.

h I certify that the entity identified in Part I of this form is acting as a qualified intermediary and assumes primary withholding responsibility under chapters 3 and 4 and primary Form 1099 reporting and backup withholding responsibility for all payments of substitute interest associated with this form as permitted by the QI Agreement.

Form W-8IMY (Rev. 9-2016)