This is only an Example of How to Fill out a W-8BEN Form.
Please Put Your Correct Information

where you see the Red Writing in this Example!

Form  W-8BEN
(Rev. February 2006)
Department of the Treasury
Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner
for United States Tax Withholding
See separate instructions.
Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No. 1545-1621
Do not use this form for: Instead, use Form:
● A U.S. citizen or other U.S. person, including a resident alien individual W-9
● A person claiming that income is effectively connected with the conduct
of a trade or business in the United States W-8ECI
● A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions) W-8ECI or W-8IMY
● A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization,
foreign private foundation, or government of a U.S. possession that received effectively connected income or that is
claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions) W-8ECI or W-8EXP
Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to
claim they are a foreign person exempt from backup withholding.
● A person acting as an intermediary W-8IMY
Note: See instructions for additional exceptions.

Part I Name of individual or organization that is the beneficial owner
1. Name of Individual or Organization that is the beneficial owner:       2.    Country of incorporation or organization
     John Doe                                                                                                     Example:  United Kingdom

Type of beneficial owner:   Choose this:   Individual

4.   Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
Example: Geo Cottage  12902 Down The Road Street  Govnowapt

City or town, state or province. Include postal code where appropriate.                        County (Do Not Abbreviate)
       Example   Torquay, Devon SQ2 6RB                                                                           United Kingdom

Mailing address (if different from above) :   Leave this Blank please unless diferent from above

Part II  Claim of Tax Treaty Benefits (if applicable)
Check this one and write in your country as the example show you.  This is what most people check and send in.
They do not usually fill out
B,C,D, E and #10

9.  I certify that (check all that apply):
The beneficial owner is a resident of ________United Kingdom___ within the meaning of the income
tax treaty between the United States and that country.

Part III Notional Principal Contracts  - Leave Blank

Part IV  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:
1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates,
2 The beneficial owner is not a U.S. person,
3 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 income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income, and
4 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.

Sign Here _________Sign Your Name Here________________________Todays Date ______Put this word: Individual___
 Signature of beneficial owner (or individual authorized to sign for beneficial owner)       Date (MM-DD-YYYY)         
 Capacity in which acting

After you have printed out the W-8Ben and fill it out, please fax or mail to:
P.E.E.L. Inc., 146 N. Hamilton Road, Gahanna, Ohio, 43230 or faxed to 1(775)258-4714.

You Must To This with in 90 Days of your sign up to womvegas. When it is received you will get a
note at the top of the Sales Agent Page letting you know it was received. This can take some time.
So please be patient.

If you do not mail or fax this form in you will not be able to receive commissions after your 90 days
is up. So please get this form in. Does not take but a few minutes to fill it out and fax or mail.

Example Created by Georgetta MonroeGeorgetta

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