Appendix L
IRS Form W-8:
Certificate of Foreign Status
Reader's Notes:
Links to scanned pages of this form:
ASSEVERATION OF FOREIGN STATUS
[Substitute W-8 Form]
This document replaces/supersedes any/all previous
declarations of status by John Q. Doe and it is to be used as my NOTICE OF
RESCISSION OF ANY PREVIOUS SIGNATURE AND ANY POWER OF ATTORNEY, ab initio, as it relates to any previous
W-4, W-8, W-9, etc., as well as Federal and State information forms or
presentments.
California State/Republic )
) ASSEVERATION OF STATUS
County of Marin )
I, John Q. Doe, state, of Right, my Status as follows:
1. That I am of lawful age and that I am
competent to make this Asseveration of Status;
2. That I am a non-immigrant, non-naturalized,
nonresident alien, non-taxpayer, natural born free American, Sovereign man and
an inhabitant of a geographical area in a State of the American Union known as
the California Republic;
3. That I am an American and nonresident alien with respect to the "United
States" (i.e., the District of
Columbia, Guam, American Samoa, Virgin Islands, Commonwealth of Puerto Rico,
etc.) with no income effectively connected with a "trade or business"
(IRC 7701(a)(26)) within the "United States" (Government);
4. That I have never knowingly, willingly,
voluntarily and intentionally inhabited the state of the forum (Forum Contractus in Latin);
5. That I have never been involved in any
taxable "trade or business" activity under 27 Code of Federal
Regulations (CFR) pursuant to commerce in Alcohol, Tobacco Products and
Firearms, State or Federal;
6. That this Asseveration is to be used in lieu of Form W-8, as suggested by
that Form W-8, specifically: "Use
Form W-8 or a substitute form containing a substantially similar statement to
tell the payor ... that you are a nonresident alien individual, foreign entity,
or exempt foreign person not subject to certain U.S. information return,
reporting or backup withholding rules."
The following information is given in lieu of a Form W-8:
Name: John Q. Doe
Location: c/o general delivery
San
Rafael [ZIP code exempt]
CALIFORNIA
STATE, USA
Please note: I
do not voluntarily use unqualified ZIP codes or other forms of Federal
Identification, e.g., "CA",
"TX", "FL", etc., because I do not reside inside Government
(U.S.) Territory or any of its Federal Territories.
U.S.
taxpayer identification number: not
applicable
See Form W-8: "... foreign persons
[sic] are not generally required to have a U.S. taxpayer identification number,
nor are they subject to any backup withholding because they do not furnish such
a number to a payer or broker."
[Emphasis added for purposes of conspicuous
notice.]
You are hereby ordered to purge the
"Social Security or Taxpayer I.D. Number" as shown on Your
"Payer's Request for Taxpayer Identification Number" form, if any.
Check
the appropriate space(s) with an "X":
( ) For
Interest Payments, I am not a
"U.S. citizen" or "U.S. resident"; AND
( ) For
Broker Transactions or Barter Exchanges, I am an exempt
foreign Sovereign man.
THIS ASSEVERATION
OF STATUS IS TO NOTIFY PAYERS, MIDDLEMEN, BROKERS, AND BARTER EXCHANGES NOT TO
WITHHOLD OR REPORT PAYMENTS OF INTEREST, BROKER TRANSACTIONS, OR BARTER
EXCHANGES.
The W-8
accompanying this ASSEVERATION OF STATUS
should not and cannot be attached to this ASSEVERATION
OF STATUS but is enclosed for information purposes only.
NUNC PRO TUNC, this ________ day of ______________, 19____ Anno Domini, for ___ /___ /___ (date of
birth),
with explicit reservation all of my unalienable rights
and without
prejudice to any of my unalienable rights,
I, ______________________________________________________________
(signature)
______________________________________________________________
(printed name)
state that the foregoing is true in substance and in
fact, to the best of my knowledge and belief, and is made in good faith, and
that this asseveration could be used as evidence, and that I have personal
knowledge of the facts stated herein.
California All-Purpose Acknowledgement
CALIFORNIA
STATE/REPUBLIC )
)
COUNTY OF
MARIN )
On the ______
day of ____________, 199___ Anno Domini,
before me personally appeared John Q.
Doe, personally known to me (or proved to me on the basis of satisfactory
evidence) to be the Person whose name is subscribed to the within instrument and
acknowledged to me that he executed the same in His authorized capacity, and
that by His signature on this instrument the Person, or the entity upon behalf
of which the Person acted, executed the instrument. Purpose of Notary Public is for identification only, and not
for entrance into any foreign jurisdiction.
WITNESS my hand and official seal.
_____________________________________
Notary Public
Reader's Notes:
