2/20/2015

TaxInformationInterview

YourIRSFormW8hasbeenreceived
Yourinformationhasbeenreceivedandisawaitingvalidation.Thereis
nothingelseyouneedtodo.Wewillcontactyouifwerequire
additionalinformation.

Form

W8BEN

CertificateofForeignStatusofBeneficial
OwnerforUnited
StatesTaxWithholdingandReporting
(Individuals)

DoNOTusethisformif:

SUBSTITUTE
(February2014)

Instead,useForm:

YouareNOTanindividual

W8BENE

YouareaU.S.citizenorotherU.S.person,includingaresidentalienindividual

W9

Youareabeneficialownerclaimingthatincomeiseffectivelyconnectedwiththeconductoftradeor

W8ECI

businesswithintheU.S.(otherthanpersonalservices)
YouareabeneficialownerwhoisreceivingcompensationforpersonalservicesperformedintheUnited

8233orW4

States
Apersonactingasanintermediary

W8IMY

PartI IdentificationofBeneficialOwner
1 Nameofindividualwhoisthebeneficialowner

FerdinandWullur
2 Countryofcitizenship

Indonesia
3 Permanentresidenceaddress(street,apt.orsuiteno.,orruralroute).DonotuseaP.O.boxorincareofaddress.

PerumahanKairagiPermaiBlokF2No.2Kairagi2LingkunganXKec.MapangetKotaMadyaManadoSulawesiUtara
Cityortown,stateorprovince.Includepostalcodewhereappropriate.

Manado95114
Country

Indonesia
4 Mailingaddress(ifdifferentfromabove)

Cityortown,stateorprovince.Includepostalcodewhereappropriate.

Country

5 U.S.taxpayeridentificationnumber(SSNorITIN),ifrequired(see
instructions)
6 Foreigntaxidentifyingnumber(seeinstructions)

PartII ClaimofTaxTreatyBenefits
9 IcertifythatthebeneficialownerisaresidentofwithinthemeaningoftheincometaxtreatybetweentheUnitedStatesandthatcountry.
10 Specialratesandconditions(ifapplicableseeinstructions):Thebeneficialownerisclaimingtheprovisionsofofthetreaty
identifiedonline9abovetoclaima%rateofwithholdingon(specifytypeofincome):.
Explainthereasonsthebeneficialownermeetsthetermsofthetreatyarticle

PartIII Certification

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2/20/2015

TaxInformationInterview

Underpenaltiesofperjury,IdeclarethatIhaveexaminedtheinformationonthisformandtothebestofmyknowledgeandbeliefitistrue,
correct,andcomplete.Ifurthercertifyunderpenaltiesofperjurythat:
1. Iamtheindividualthatisthebeneficialowner(oramauthorizedtosignfortheindividualthatisthebeneficialowner)ofalltheincometowhich
thisformrelatesoramusingthisformtodocumentmyselfasanindividualthatisanowneroraccountholderofaforeignfinancialinstitution,
2. Thepersonnamedonline1ofthisformisnotaU.S.person,
3. Theincometowhichthisformrelatesis(a)noteffectivelyconnectedwiththeconductofatradeorbusinessintheUnitedStates,(b)
effectivelyconnectedbutisnotsubjecttotaxunderanincometaxtreaty,or(c)thepartner'sshareofapartnership'seffectivelyconnected
income,
4. Thepersonnamedonline1ofthisformisaresidentofthetreatycountrylistedonline9oftheform(ifany)withinthemeaningoftheincome
taxtreatybetweentheUnitedStatesandthatcountry,and
5. Forbrokertransactionsorbarterexchanges,thebeneficialownerisanexemptforeignpersonasdefinedintheinstructions.
Furthermore,Iauthorizethisformtobeprovidedtoanywithholdingagentthathascontrol,receipt,orcustodyoftheincomeofwhichIamthe
beneficialowneroranywithholdingagentthatcandisburseormakepaymentsoftheincomeofwhichIamthebeneficialowner.IagreethatI
willsubmitanewformwithin30daysifanycertificationmadeonthisformbecomesincorrect.

SignHere

FerdinandWullur
Signatureofbeneficialowner(orindividualauthorizedtosignforbeneficialowner)

02202015
Date(MMDDYYYY)

Individual
Capacityinwhichacting

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