Part I - Identification of Beneficial Owner
Name of organization that is the beneficial owner
NAME OF SMSF (e.g. Smith Family Super Fund)
DO NOT INCLUDE COMPANY TRUSTEE DETAILS
Country of incorporation or organization
AUSTRALIA
Name of disregarded entity receiving the payment
Leave blank
Chapter 3 Status (entity type):
COMPLEX TRUST
FACTA Status
Nonreporting IGA FFI. Complete Part XII.
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address).
BUSINESS/RESIDENTIAL ADDRESS OF SMSF
Mailing address
Leave blank
U.S. taxpayer identification number (TIN), if required
Leave blank
b. Foreign TIN
SMSF ABN NUMBER
Part III - Claim of Tax Treat Benefits
14.a. The beneficial owner is a resident of AUSTRALIA
14.b. ☑︎ Tick Item b and tick the last option
☑︎ Other (specify Article and paragraph):
Article 16 (2)(g) – ownership/base erosion test
Part XII - Nonreporting IGA FFI
26. ☑︎ Tick I certify that the entity identified in Part I:
Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
AUSTRALIA
The applicable IGA is a Model ☑︎ 1 IGA; and is treated as a
investment entity wholly owned by exempt beneficial owner
Part XXX - Certification
Sign with a wet-ink signature (electronic signatures are not accepted);
Print name of 1 director who is signing;
Date in US date format MM/DD/YYYY