States Tax Withholding and Information about Form W-8BEN and its separate
Form W-8BEN (Rev. February 2014)
Reporting (Individuals)
instructions is at www.irs.gov/formw8ben. ▶ Give this
form to the withholding agent or payer. Do not send to
Department of the Treasury Internal Revenue Service the IRS.
Certificate of Foreign Status of
Beneficial Owner for United ▶
For use by individuals. Entities must use Form
W-8BEN-E. OMB No. 1545-1621
Do NOT use this form if:
Instead, use Form: • You are NOT an individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN-E • You are a U.S. citizen or
other U.S. person, including a resident alien individual ........................................ W-9
• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal
services) .................................................................... W-8ECI
• You are a beneficial owner who is receiving compensation for personal services performed in the United States . . . . . . . 8233 or W-4 • A person
acting as an intermediary ................................................................W-8IMY
Part I Identification of Beneficial Owner (see instructions)
1. Name of individual who is the beneficial owner – Manisha Pramod Gaikwad 2. Country of citizenship – INDIA
3. Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. City
or town, state or province. Include postal code where appropriate – Classic Arcade Second Floor C Wing Shop Number C
1 to 9 Upendra Nagar Muthoot Finance Opposite Symbiosis Collage Ambad Link Road CIDCO Nashik 422009 .
Country - INDIA
4. Mailing address (if different from above) City or town, state or province. Include postal code where appropriate.
5. U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) –
6. Foreign tax identifying number (see instructions) – Pan Number – AOQPG7025R .
7. Reference number(s) (see instructions) –
8. Date of birth (see instructions) – (06/01/1984)
Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 I certify that the beneficial owner is a resident of within the meaning of the income tax treaty between the United States and that country.
10 Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article of the treaty identified on
line 9 above to claim a % rate of withholding on (specify type of income): .
Explain the reasons the beneficial owner meets the terms of the treaty article:
Part III Certification
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further
certify under penalties of perjury that:
• I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or am
using this form to document myself as an individual that is an owner or account holder of a foreign financial institution,
• The person named on line 1 of this form is not a U.S. person,
• The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or
(c) the partner’s share of a partnership's effectively connected income,
• The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the
United States and that country, and
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or
any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days if
any certification made on this form becomes incorrect.
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (06/01/1984) –
Print name of signer
Capacity in which acting (if form is not signed by beneficial owner) For Paperwork Reduction Act Notice, see separate
instructions. Cat. No. 25047Z Form W-8BEN (Rev. 2-2014)
