12/08/2021 Tax Information Interview
Reference Id: A01354373F692RKAMDME9
Certificate of Foreign Status of
Beneficial Owner for United
States Tax Withholding and SUBSTITUTE
Form W-8BEN Reporting (Individuals) (July 2017)
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 W-8ECI
conduct of trade or business within the U.S.
(other than personal services)
You are a beneficial owner who is receiving compensation for personal services 8233 or W-4
performed in the United States
A person acting as an intermediary W-8IMY
Part I Identification of Beneficial Owner
1 Name of individual who is the beneficial owner
YOUSSEF AIT ELMOUDEN
2 Country of citizenship
Morocco
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of
address.
DR IZIKI DB AABAD N 06
City or town, state or province. Include postal code where appropriate.
MARRAKECH 40000
Country
Morocco
4 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
5 U.S. taxpayer identification number (SSN or ITIN), if required (see
instructions)
6 Foreign tax identifying number (see instructions)
EE674313
Part II Claim of Tax Treaty Benefits
9 I certify that the beneficial owner is a resident of Morocco 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 and paragraph 12(2) of the treaty identified on line 9 above to claim a
10.0% rate of withholding on
(specify type of income):
Copyright Royalties
Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate
of withholding:
Part III Certification
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12/08/2021 Tax Information Interview
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 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
for chapter 4 purposes,
2. The person named on line 1 of this form 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,
4. 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
5. 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.
The Internal Revenue Service does not require your consent to any provisions of this document other than the
certifications required to establish your status as a non-U.S. individual and, if applicable, obtain a reduced rate of
withholding.
Sign Here
YOUSSEF AIT ELMOUDEN
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
08-12-2021
Date (MM-DD-YYYY)
YOUSSEF AIT ELMOUDEN
Print name of signer
Capacity in which acting (if form is not signed by beneficial owner)
Above is preview of your tax form based on the information you have provided. Please review and
submit the form, or make changes if needed.
Make Changes Submit Form
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