Certificate of Foreign Status for Individuals (Form W-8BEN) - Cheryl Samuya
This document is a fully completed IRS Form W-8BEN, titled "Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)". The form is filled out on behalf of Cheryl Samuya (also printed as Cheryl Lou Jane Samys), a non‑U.S. individual claiming foreign status to reduce or eliminate U.S. tax withholding. The form records her personal identification details (name, permanent residence address in Davao City, Philippines, foreign tax identifying number, reference number, and date of birth), confirms that she is a resident of the Philippines for treaty purposes, and includes a certification under penalty of perjury that she is not a U.S. person, that the income is not effectively connected with a U.S. trade or business, and that she is eligible for treaty benefits. The form is signed and dated 03‑13‑2024. The surrounding IRS instructions clarify when the form should be used and which alternative forms apply to other entities or situations.
Topics
Purpose and Applicability of Form W-8BEN
Explanation of the form's role in certifying foreign status for individuals to claim reduced U.S. withholding tax, and the conditions under which it must be used versus other IRS forms.
Beneficial Owner Identification Details
All personal data supplied for Cheryl Samuya, including name, permanent residence address in the Philippines, foreign tax identifying number, reference ID, and date of birth.
Tax Treaty Claim and Residency Declaration
Line 9 certification that the beneficial owner is a resident of the Philippines for treaty purposes, and the related claim of treaty‑based reduced withholding rates (though no specific rate is entered).
Certification Statements Under Penalty of Perjury
The series of attestations in Part III confirming non‑U.S. person status, the nature of the income, eligibility for treaty benefits, and the authority to sign.
Signature, Date, and Authorization
The signed declaration by Cheryl Lou Jane Samys dated 03‑13‑2024, authorizing the form’s use by any withholding agent and obligating a new submission if circumstances change.