Free F248-361-909 Provider Application for Spanish Speaking Providers Outside the United States APLICACIÓN PARA CUENTA DE PROVEEDOR - Washington

STATE OF WASHINGTON

DEPARTMENT OF LABOR AND INDUSTRIES
PO Box 44261 · Olympia, Washington 98504-4261

Dear Provider: Thank you for your interest in providing services to our injured workers. Attached you will find the Provider Application necessary for obtaining an account number with us. To receive payment, a provider must have an active provider account number. What do I need to submit? · Completed application. · Signed Provider Agreement. · License or Certification required by your country's Department of Health regulations. · W-8ECI form (Internal Revenue Service International form for tax exempt businesses). Complete an application for each individual provider. What's next? After we process your application, you will receive a welcome packet containing the following: · Billing forms. · Electronic and paper billing instructions. · Provider Tip Sheet. · Attending Doctor's Handbook. · Address Change Form: Changes to your account should be reported within 15 days. Want to speed up bill payment? Electronic billing will speed payment. For information call the Electronic Billing Unit at (360)902-6511. Need more information? Contact: · Provider Accounts 360-902-5140--for questions concerning your account. · Provider Hotline: 1-800-848-0811--for billing and payment questions. · Medical Aid Rules and Fee Schedules: http://www.lni.wa.gov/ClaimsIns/Providers/. Sincerely,

Sandra L. Chabot Provider Accounts Enclosures

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

PROVIDER AGREEMENT
THE PROVIDER UNDERSTANDS AND AGREES: · To meet and maintain all licensing or certification requirements. · That providing services or filing an accident report on behalf of an injured or ill department worker, accepts and complies with the requirements of Title 51 RCW, and the WACs, including but not limited to, Chapters 296-19A, 296 -20, 296-21, 296-23, and 296-23A, and policies adopted by the department, including fee schedules and medical coverage decisions. Payments will be made according to the department's "Medical Aid Rules and Fee Schedules" as updated annually. · To accept the department's payment as sole and complete remuneration for services provided to the worker as required by Washington State law. · That if the provider receives payment from the department in error or in excess of the amount properly due, the provider will promptly return to the department any excess monies received. The department may audit the provider's records to determine compliance with the rules and regulations of the department as provided in Washington State law. · A provider holds to all the terms of this agreement even though a third party may be involved in billing claims to the department. · The department reserves the right to deny, revoke, suspend, or condition a provider's authorization to treat injured workers in accordance with Washington Law. · Issuance of a provider number does not guarantee that the department will pay all services billed by a provider. · To maintain documentation and records for a minimum of five years billed. The provider agrees that these records and supportive materials are available to the department upon request as provided in Washington State law. · To submit a Provider's Request for Adjustment Form--instructions are contained on the Remittance Advice--if the provider believes additional funds are due. · To notify the department immediately, in writing, of any changes to information in this application--or provider status (e.g., licensing, certification, or registration, disciplinary action, impairment, limitations of privileges, or address, etc). · That they are currently in good standing with their physical & mental health status. · That they do not possess any of the following: o Lack of impairment due to chemical dependency/substance abuse. o History of loss of license, certification, or registration. o Felony convictions. o Loss or limitations of privileges. o Disciplinary actions. o Professional liability claims history. THE PROVIDER AGREES NOT TO BILL AN INJURED WORKER FOR: · Services covered by the industrial insurance program related to the industrial injury or occupational disease. · The difference between the billed charges and the amount paid. · The difference between the provider's customary fee and the Department's fee schedule. · Missed appointments. Provider's Statement of Agreement I (the provider), ____________________, (print or type) agree to abide by the terms of this agreement and by all applicable federal and Washington State statutes, rules and policies. I have enclosed with my application all required supporting information necessary to establish a provider account, including: a copy of my current license (if I am required to be licensed by my licensing authority); and a completed Form W-8ECI. Date Title Signature

F248-011-000 provider account application and notice 10-06

APPLICATION INSTRUCTIONS
A. Administrative Information 1. Enter the business name. 2. Enter the business location phone number. 3. Enter the business fax number. 4. Enter the business location address. 5. Enter the billing address--where we mail your payments--as it appears on your bills submitted to the Department of Labor & Industries. 6. Enter the contact person's name--the person who can answer questions regarding your bills or your account, and the billing phone number. 7. Enter the billing contact phone number. B. Individual or Organization Information 1. Enter the name of the individual or organization providing services to injured workers. 2. Enter the type of service(s) provided. 3. Enter the professional license number. 4. Enter the license issue date (month, day, and year). ATTACH COPY 5. Enter the date the license will expire (month, day, and year). 6. Enter the issuing country, province, and state. C. Agreement Page Read and sign the agreement page. D. Identify your Provider Specialty 1. Mark the box next to your provider specialty 2. Provide any additional specialized information. (Optional) NOTICE: The application is available at www.lni.wa.gov/hsa or call (360) 902-5140 to have one sent to you. We accept photo copies of this application.

F248-011-000 provider account application and notice 10-06

PROVIDER ACCOUNT APPLICATION
Return To:

Please type or print clearly on all sections
Department of Labor and Industries Attn: Provider Accounts PO Box 44261 Olympia WA 98504-4261 Internet address: http://www.lni.wa.gov/forms Phone (360) 902-5140 Toll Free 1-800-848-0811 FAX (360) 902-4484
Please check if you would like all mail to go to the billing address. Unless otherwise notified, your claims related correspondence will go to your business (physical) address.

A. Account and Billing Information 1. Business name 2. Business phone# 3. Business FAX#

4. Business location address

5. Billing address (where payments should be mailed)

6. Billing contact person's name

7. Billing contact person's phone# (where we may call regarding your account/bills)

B. Individual Provider or Organization Information ­ Attach a copy of your professional license 1. Provider's name (Last, First, MI) 2. Specialty / Services provided

3. Professional license number

4. License issue date

5. License expiration date

6. Country and state

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

C. Agreement Page Read agreement page and sign at the bottom. D. Provider Specialty Information Check the specialty or services that you provide

Please note:
* Physical medicine must include copy of physician certification/licensing

** Must include a copy of privilege letter with each facility

Adult Family Home Ambulance Ambulatory Surgery Center ** ARNP Audiologist Chiropractor Clinic CRNA Dentist DME Supplier Drug & Alcohol Treatment First Surgical Assist (RNFA) * Head Injury Program Hospital ** Hospital Psychiatric Interpreter (Must include submission of provider credentials and copy of certification)

Lab Facility ** LMP Nursing Home Occupational Therapist Optician Optometrist Osteopathic Physician * Physical Therapist Physician * Prosthetist/Orthotist Psychologist Radiologist Registered Nurse Rehab Training Supplier

2.

Other specialized information

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES PO Box 44261 · Olympia, Washington 98504-4261 Estimado proveedor: Gracias por su interés en proporcionarle servicios a nuestros trabajadores lesionados. Adjunto encontrará la Aplicación para proveedor necesaria para obtener un número de cuenta con nosotros. Para recibir pago, un proveedor debe tener un número de cuenta de proveedor activo. ¿Qúe necesita someter? · Una aplicación completa. · El Acuerdo del proveedor firmado. · La licencia o certificación requerida por las leyes del Departamento de Salud de su país. · El formulario W-8ECI (Formulario internacional del Departamento de Servicios de Impuestos Internos para los negocios exentos del pago de impuestos). Complete una aplicación para cada proveedor individual. ¿Qué sigue? · Después de procesar su aplicación, usted recibirá un paquete de bienvenida que contiene lo siguiente: · Formularios para facturación. · Instrucciones para facturar electrónicamente y en papel. · Hoja de consejos para proveedores. · Manual del doctor de cabecera. · Formulario para cambio de dirección: los cambios a su cuenta deben reportarse dentro de 15 días a partir de la fecha del cambio. ¿Desea acelerar el pago de su factura? La facturación electrónica acelerará el pago. Para información llame a la unidad de Facturación electrónica al 360-902-6511. ¿Necesita más información? Comuníquese con: · Cuentas del proveedor al 360-902-5140--para preguntas referentes a su cuenta. · Línea de asistencia al proveedor: 1-800-848-0811--para preguntas de facturación y pagos. · Reglamentos de asistencia médica y tarifas autorizadas: http://www.lni.wa.gov/ClaimsIns/Providers/.

Atentamente, Sandra L. Chabot Cuentas al proveedor Adjuntos

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

ACUERDO DEL PROVEEDOR EL PROVEEDOR ENTIENDE Y ESTÁ DE ACUERDO CON LO SIGUIENTE: · · Mantener todos los requisitos de licencia o certificación. El proporcionar servicios o presentar un reporte de accidente a nombre de un trabajador lesionado o enfermo que esté cubierto bajo la jurisdicción del departamento constituye la aceptación de los requisitos del Título 51 RCW y los Códigos Administrativos de Washington (WAC's) incluyendo pero no limitado a los capítulos 296-19A, 296-20, 296-21, 296-23, y 296-23A y a las políticas adoptadas por el Departamento incluyendo las tarifas autorizadas y las decisiones sobre cobertura médica. Los pagos se harán de acuerdo a los Reglamentos de asistencia médica y las tarifas autorizadas del Departamento según se actualicen anualmente. Aceptar el pago del Departamento como la remuneración única y completa de los servicios proporcionados al trabajador como lo requiere la ley estatal de Washington. Si el proveedor recibe un pago del Departamento por error o en exceso a la cantidad que se debe, el proveedor le devolverá al Departamento cualquier exceso de dinero recibido inmediatamente. El Departamento puede hacer una auditoría de los récords de los proveedores para determinar el cumplimiento con las reglas y leyes del Departamento como lo estipula la ley estatal de Washington. El proveedor será responsable de todos los términos de este acuerdo aunque un tercero esté involucrado en cobrarle reclamos al Departamento. El Departamento se reserva el derecho de negar, revocar, suspender o poner una condición en la autorización del proveedor para brindar tratamiento a los trabajadores lesionados de acuerdo a la ley de Washington. La entrega de un número de proveedor no garantiza que el Departamento pagará todos los servicios facturados por un proveedor. Mantener documentación y récords por un mínimo de cinco años. El proveedor acuerda que estos récords y materiales deben estar disponibles para el Departamento al solicitarlo como se estipula en la ley estatal de Washington. Someter el formulario, Solicitud para ajuste del proveedor (Provider's Request for Adjustment) ­ Las instrucciones están en el Aviso de pago (Remittance Advice) en caso de que el proveedor crea que se le deben pagos adicionales. Notificarle al Departamento inmediatamente por escrito si hay cambios en la información contenida en esta aplicación o el estado del proveedor (licencia, certificación o registro, acción disciplinaria, impedimento, limitaciones de privilegios o dirección, etc). Que actualmente tiene buena salud física y mental. Que no tiene ninguna de las siguientes restricciones: o Impedimentos debido a dependencia química/abuso de drogas o Historia de pérdida de la licencia, certificación o registro. o Convicciones por delitos graves. o Pérdida o limitaciones de privilegios. o Acciones disciplinarias. o Historia de reclamos por responsabilidad profesional.

· ·

· · · · · · · ·

EL PROVEEDOR ESTÁ DE ACUERDO EN NO COBRARLE AL TRABAJADOR LESIONADO POR: · Los servicios cubiertos por el programa de seguro industrial que estén relacionados con la lesión industrial o enfermedad ocupacional; · La diferencia entre los cargos cobrados y cantidades pagadas. · La diferencia entre los costos usuales del proveedor y las tarifas autorizadas del Departamento. · Las citas perdidas. Declaración de acuerdo del proveedor Yo (el proveedor), ____________________, (imprima o escriba) estoy de acuerdo en cumplir con los términos de este acuerdo y con todos los estatutos, leyes y políticas federales y del estado de Washington aplicables. He incluído con mi aplicación toda la información requerida para establecer una cuenta de proveedor incluyendo: una copia de mi licencia actualizada (si la autoridad de licencias requiere que tenga una licencia) y el formulario W-8ECI completo.

Fecha

Título

Firma

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

INSTRUCCIONES PARA LLENAR LA APLICACIÓN
A. Información administrativa 1. Escriba el nombre del negocio. 2. Escriba el número de teléfono del negocio. 3. Escriba el número de fax del negocio. 4. Escriba la dirección física del negocio. 5. Escriba la dirección postal (donde los pagos deben enviarse) como aparece en sus facturas sometidas al Departamento de Labor e Industrias. 6. Escriba el nombre del representante del proveedor ­ la persona que puede contestar preguntas relacionadas con sus facturas o su cuenta y el número de teléfono de la oficina de facturación. 7. Escriba el número de teléfono de la oficina de facturación. B. Información individual o de la organización 1. Escriba el nombre del individuo u organización que le está proporcionando servicios a los trabajadores lesionados. 2. Escriba la clase de servicio(s) proporcionados. 3. Escriba su número de licencia profesional. 4. Escriba la fecha en que la licencia fue emitida (mes, día y año). ADJUNTE UNA COPIA 5. Escriba la fecha en que la licencia expira (mes, día y año). 6. Escriba el país, provincia o estado donde fué emitida su licencia. C. Página con el acuerdo Lea y firme la página de acuerdo del proveedor. D. Identifique la especialidad de su proveedor Marque la página al lado de la especialidad del proveedor Proporcione cualquier información especializada adicional (Opcional) AVISO: La aplicación está disponible en www.lni.wa.gov/Spanish/FormPub o llame a (360) 902-5140 para que le envíen una. Aceptamos copias de esta aplicación.

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

APLICACIÓN PARA CUENTA DE PROVEEDOR
Devuelva a: Department of Labor and Industries Attn: Provider Accounts PO Box 44261 Olympia WA 98504-4261

(Por favor escriba o imprima claramente en todas las secciones)

Dirección de Internet: http://www.lni.wa.gov
Teléfono sin costo de larga distancia desde Mexico: 1-888814-4936 Línea gratuita dentro de Estados Unidos 1-800-848-0811 FAX: (código internacional) + 1 (código de EE.UU.) 902-4484

+ (360)

Por favor marque si le gustaría recibir toda su correspondencia en la dirección de facturación. A menos que se notifique de otra manera la correspondencia relacionada con reclamos se le enviará a la dirección (física) del negocio.
2. Número de teléfono del negocio 3. Número de FAX del negocio

INFORMACIÓN SOBRE LA CUENTA Y FACTURACIÓN

A. Información administrativa
1. Nombre del negocio

4. Dirección física del negocio

5. Dirección postal (donde los pagos deben enviarse)

6. Nombre del representante del proveedor

7. Número de teléfono del representante del proveedor (donde debemos
llamar con referencia a su cuenta/facturas)

a.
1.

Información del proveedor individual o de la organización­ Adjunte copia de su licencia profesional
2. Especialidad/ Servicios suministrados

Nombre del proveedor (Apellido, nombre)

3.

Número de licencia profesional

4.

Fecha de emisión de la licencia (mes/día/año)

5. Fecha de expiración de la licencia (mes/día/año)

6. País y estado

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

C. Hoja de acuerdo del proveedor Lea la hoja de acuerdo del proveedor y firme la parte de abajo. D. Información sobre la especialidad del proveedor Marque la especialidad o servicios que usted proporciona

Por favor tome nota:
* Para medicina física debe incluír una copia de la certificación/licencia del médico

** Debe incluír una copia de la carta de autorización para trabajar en cada centro médico

Hogar para adultos Ambulancia Centro quirúrgico ambulatorio ** Enfermera registrada avanzada (ARNP) Audiólogo Quiropráctico Clínica CRNA (enfermero/a anestesista certificado/a registrado/a) Dentista Proveedor de equipo médico durable (DME) Tratamiento para Drogas y Alcohol Enfermera registrada como asistente de cirugía (RNFA) * Programa para traumatismo del cráneo Hospital ** Intérprete de hospital psiquiátrico (Debe presentar las credenciales de proveedor y copia de la certificación)

Laboratorio ** Masajista con licencia Casa de reposo Terapeuta ocupacional Oculista Optometrista Osteópata * Terapeuta físico Médico ** Prostético/ortótico Psicólogo Radiólogo Enfermera/o registrada/o Proveedor para rehabilitación

2.

Información sobre otra especialidad

F248-361-909 Provider account application for Spanish-speaking providers outside the United States 09-2008

Form

W-8ECI

(Rev. February 2006) Department of the Treasury Internal Revenue Service

Certificate of Foreign Person's Claim That Income Is Effectively Connected With the Conduct of a Trade or Business in the United States
Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS.

OMB No. 1545-1621

Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively connected with a U.S. trade or business (see instructions).
Do not use this form for: A beneficial owner solely claiming foreign status or treaty benefits A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) Instead, use Form: W-8BEN W-8EXP

Note: These entities should use Form W-8ECI if they received effectively connected income (e.g., income from commercial activities). A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively W-8BEN or W-8IMY connected with the conduct of a trade or business in the United States) W-8IMY A person acting as an intermediary Note: See instructions for additional exceptions.

Part I
1 3

Identification of Beneficial Owner (See instructions.)
2 Country of incorporation or organization

Name of individual or organization that is the beneficial owner Type of entity (check the appropriate box): Partnership Government Private foundation Individual

Simple trust Grantor trust International organization

Corporation Complex trust Central bank of issue

Disregarded entity Estate Tax-exempt organization

4

Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box. City or town, state or province. Include postal code where appropriate. Country (do not abbreviate)

5

Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box. City or town, state, and ZIP code

6 8

U.S. taxpayer identification number (required--see instructions) SSN or ITIN Reference number(s) (see instructions)

7 EIN

Foreign tax identifying number, if any (optional)

9

Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade or business in the United States (attach statement if necessary)

Part II

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: I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the income to which this form relates, The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States and are includible in my gross income (or the beneficial owner's gross income) for the taxable year, and The beneficial owner is not a U.S. person. 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

Signature of beneficial owner (or individual authorized to sign for the beneficial owner)

Date (MM-DD-YYYY) Cat. No. 25045D

Capacity in which acting Form

For Paperwork Reduction Act Notice, see separate instructions.

W-8ECI

(Rev. 2-2006)

Instructions for Form W-8ECI
(Rev. February 2006)
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted. Note. For definitions of terms used throughout these instructions, see Definitions beginning on page 2. Purpose of form. Foreign persons are generally subject to U.S. tax at a 30% rate on income they receive from U.S. sources. However, no withholding under section 1441 or 1442 is required on income that is, or is deemed to be, effectively connected with the conduct of a trade or business in the United States and is includible in the beneficial owner's gross income for the tax year. The no withholding rule does not apply to personal services income and income subject to withholding under section 1445 (dispositions of U.S. real property interests) or section 1446 (foreign partner's share of effectively connected income). If you receive effectively connected income from sources in the United States, you must provide Form W-8ECI to: · Establish that you are not a U.S. person, · Claim that you are the beneficial owner of the income for which Form W-8ECI is being provided, and · Claim that the income is effectively connected with the conduct of a trade or business in the United States. If you expect to receive both income that is effectively connected and income that is not effectively connected from a withholding agent, you must provide Form W-8ECI for the effectively connected income and Form W-8BEN (or Form W-8EXP or Form W-8IMY) for income that is not effectively connected. If you submit this form to a partnership, the income claimed to be effectively connected with the conduct of a U.S. trade or business is subject to withholding under section 1446. If a nominee holds an interest in a partnership on your behalf, you, not the nominee, must submit the form to the partnership or nominee that is the withholding agent. If you are a foreign partnership, a foreign simple trust, or a foreign grantor trust with effectively connected income, you may submit Form W-8ECI without attaching Forms W-8BEN or other documentation for your foreign partners, beneficiaries, or owners. A withholding agent or payer of the income may rely on a properly completed Form W-8ECI to treat the payment associated with the Form W-8ECI as a payment to a foreign person who beneficially owns the amounts paid and is either entitled to an exemption from withholding under sections 1441 or 1442 because the income is effectively connected with the conduct of a trade or business in the United States or subject to withholding under section 1446.

Department of the Treasury Internal Revenue Service

Certificate of Foreign Person's Claim That Income Is Effectively Connected With the Conduct of a Trade or Business in the United States
Provide Form W-8ECI to the withholding agent or payer before income is paid, credited, or allocated to you. Failure by a beneficial owner to provide a Form W-8ECI when requested may lead to withholding at the 30% rate or the backup withholding rate. Additional information. For additional information and instructions for the withholding agent, see the Instructions for the Requester of Forms W-8BEN, W-8ECI, W-8EXP, and W-8IMY. Who must file. You must give Form W-8ECI to the withholding agent or payer if you are a foreign person and you are the beneficial owner of U.S. source income that is (or is deemed to be) effectively connected with the conduct of a trade or business within the United States.

· You are a nonresident alien individual who claims

Do not use Form W-8ECI if:

exemption from withholding on compensation for independent or certain dependent personal services performed in the United States. Instead, provide Form 8233, Exemption from Withholding on Compensation for Independent (and Certain Dependent) Personal Services of a Nonresident Alien Individual, or Form W-4, Employee's Withholding Allowance Certificate. · You are claiming an exemption from withholding under section 1441 or 1442 for a reason other than a claim that the income is effectively connected with the conduct of a trade or business in the United States. For example, if you are a foreign person and the beneficial owner of U.S. source income that is not effectively connected with a U.S. trade or business and are claiming a reduced rate of withholding as a resident of a foreign country with which the United States has an income tax treaty in effect, do not use this form. Instead, provide Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding. · You are a foreign person receiving proceeds from the disposition of a U.S. real property interest. Instead, see Form 8288-B, Application for Withholding Certificate for Dispositions by Foreign Persons of U.S. Real Property Interests. · You are filing for a foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession claiming the applicability of section 115(2), 501(c), 892, 895, or 1443(b). Instead, provide Form W-8EXP, Certificate of Foreign Government or Other Foreign Organization for United States Tax Withholding. However, these entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim exempt recipient status for backup withholding purposes. They should use Form W-8ECI if they received effectively connected income (for example, income from commercial activities).

Cat. No. 25902V

for your own account or for that of your partners, but for the account of others as an agent, nominee, or custodian). Instead, provide Form W-8IMY, Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding. · You are a withholding foreign partnership or a withholding foreign trust for purposes of sections 1441 and 1442. A withholding foreign partnership is, generally, a foreign partnership that has entered into a withholding agreement with the IRS under which it agrees to assume primary withholding responsibility for each partner's distributive share of income subject to withholding that is paid to the partnership. A withholding foreign trust is, generally, a foreign simple trust or a foreign grantor trust that has entered into a withholding agreement with the IRS under which it agrees to assume primary withholding responsibility for each beneficiary's or owner's distributive share of income subject to withholding that is paid to the trust. Instead, provide Form W-8IMY. · You are a foreign corporation that is a personal holding company receiving compensation described in section 543(a)(7). Such compensation is not exempt from withholding as effectively connected income, but may be exempt from withholding on another basis. · You are a foreign partner in a partnership and the income allocated to you from the partnership is effectively connected with the conduct of the partnership's trade or business in the United States. Instead, provide Form W-8BEN. However, if you made or will make an election under section 871(d) or 882(d), provide Form W-8ECI. In addition, if you are otherwise engaged in a trade or business in the United States and you want your allocable share of income from the partnership to be subject to withholding under section 1446, provide Form W-8ECI. Giving Form W-8ECI to the withholding agent. Do not send Form W-8ECI to the IRS. Instead, give it to the person who is requesting it from you. Generally, this will be the person from whom you receive the payment, who credits your account, or a partnership that allocates income to you. Give Form W-8ECI to the person requesting it before the payment is made, credited, or allocated. If you do not provide this form, the withholding agent may have to withhold at the 30% rate or the backup withholding rate. A separate Form W-8ECI must be given to each withholding agent. U.S. branch of foreign bank or insurance company. A payment to a U.S. branch of a foreign bank or a foreign insurance company that is subject to U.S. regulation by the Federal Reserve Board or state insurance authorities is presumed to be effectively connected with the conduct of a trade or business in the United States unless the branch provides a withholding agent with a Form W-8BEN or Form W-8IMY for the income. Change in circumstances. If a change in circumstances makes any information on the Form W-8ECI you have submitted incorrect, you must notify the withholding agent or payer within 30 days of the change in circumstances and you must file a new Form W-8ECI or other appropriate form. For example, if during the tax year any part or all of the income is no longer effectively connected with the conduct of a trade or business in the United States, your Form W-8ECI is no longer valid. You must notify the withholding agent and provide Form W-8BEN, W-8EXP, or W-8IMY. -2-

· You are acting as an intermediary (that is, acting not

Expiration of Form W-8ECI. Generally, a Form W-8ECI will remain in effect for a period starting on the date the form is signed and ending on the last day of the third succeeding calendar year, unless a change in circumstances makes any information on the form incorrect. For example, a Form W-8ECI signed on September 30, 2005, remains valid through December 31, 2008. Upon the expiration of the 3-year period, you must provide a new Form W-8ECI.

Definitions
Beneficial owner. For payments other than those for which a reduced rate of withholding is claimed under an income tax treaty, the beneficial owner of income is generally the person who is required under U.S. tax principles to include the income in gross income on a tax return. A person is not a beneficial owner of income, however, to the extent that person is receiving the income as a nominee, agent, or custodian, or to the extent the person is a conduit whose participation in a transaction is disregarded. In the case of amounts paid that do not constitute income, beneficial ownership is determined as if the payment were income. Foreign partnerships, foreign simple trusts, and foreign grantor trusts are not the beneficial owners of income paid to the partnership or trust. The beneficial owners of income paid to a foreign partnership are generally the partners in the partnership, provided that the partner is not itself a partnership, foreign simple or grantor trust, nominee or other agent. The beneficial owners of income paid to a foreign simple trust (that is, a foreign trust that is described in section 651(a)) are generally the beneficiaries of the trust, if the beneficiary is not a foreign partnership, foreign simple or grantor trust, nominee or other agent. The beneficial owners of a foreign grantor trust (that is, a foreign trust to the extent that all or a portion of the income of the trust is treated as owned by the grantor or another person under sections 671 through 679) are the persons treated as the owners of the trust. The beneficial owners of income paid to a foreign complex trust (that is, a foreign trust that is not a foreign simple trust or foreign grantor trust) is the trust itself. Generally, these beneficial owner rules apply for purposes of sections 1441, 1442, and 1446, except that section 1446 requires a foreign simple trust to provide a Form W-8 on its own behalf rather than on behalf of the beneficiary of such trust. The beneficial owner of income paid to a foreign estate is the estate itself. A payment to a U.S. partnership, U.S. trust, or U.S. estate is treated as a payment to a U.S. payee. A U.S. partnership, trust, or estate should provide the withholding agent with a Form W-9. However, for purposes of section 1446, a U.S. grantor trust shall not provide the withholding agent a Form W-9. Instead, the grantor or other owner must provide Form W-8 or Form W-9 as appropriate. Disregarded entity. A business entity that has a single owner and is not a corporation under Regulations section 301.7701-2(b) is disregarded as an entity separate from its owner. A disregarded entity shall not submit this form to a partnership for purposes of section 1446. Instead, the owner of such entity shall provide appropriate documentation. See Regulations section 1.1446-1.

Effectively connected income. Generally, when a foreign person engages in a trade or business in the United States, all income from sources in the United States other than fixed or determinable annual or periodical (FDAP) income (for example, interest, dividends, rents, and certain similar amounts) is considered income effectively connected with a U.S. trade or business. FDAP income may or may not be effectively connected with a U.S. trade or business. Factors to be considered to determine whether FDAP income and similar amounts from U.S. sources are effectively connected with a U.S. trade or business include whether: · The income is from assets used in, or held for use in, the conduct of that trade or business, or · The activities of that trade or business were a material factor in the realization of the income. There are special rules for determining whether income from securities is effectively connected with the active conduct of a U.S. banking, financing, or similar business. See section 864(c)(4)(B)(ii) and Regulations section 1.864-4(c)(5)(ii) for more information. Effectively connected income, after allowable deductions, is taxed at graduated rates applicable to U.S. citizens and resident aliens, rather than at the 30% rate. You must report this income on your annual U.S. income tax or information return. A partnership that has effectively connected income allocable to foreign partners is generally required to withhold tax under section 1446. The withholding tax rate on a partner's share of effectively connected income is 35%. In certain circumstances the partnership may withhold tax at the highest applicable rate to a particular type of income (for example long-term capital gain allocated to a noncorporate partner). Any amount withheld under section 1446 on your behalf, and reflected on Form 8805 issued by the partnership to you may be credited on your U.S. income tax return. Foreign person. A foreign person includes a nonresident alien individual, a foreign corporation, a foreign partnership, a foreign trust, a foreign estate, and any other person that is not a U.S. person. Nonresident alien individual. Any individual who is not a citizen or resident alien of the United States is a nonresident alien individual. An alien individual meeting either the "green card test" or the "substantial presence test" for the calendar year is a resident alien. Any person not meeting either test is a nonresident alien individual. Additionally, an alien individual who is a resident of a foreign country under the residence article of an income tax treaty, or an alien individual who is a bona fide resident of Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, or American Samoa is a nonresident alien individual. Even though a nonresident alien individual married to a U.S. citizen or resident alien may CAUTION choose to be treated as a resident alien for certain purposes (for example, filing a joint income tax return), such individual is still treated as a nonresident alien for withholding tax purposes on all income except wages. See Pub. 519, U.S. Tax Guide for Aliens, for more information on resident and nonresident alien status. Withholding agent. Any person, U.S. or foreign, that has control, receipt, or custody of an amount subject to

withholding or who can disburse or make payments of an amount subject to withholding is a withholding agent. The withholding agent may be an individual, corporation, partnership, trust, association, or any other entity including (but not limited to) any foreign intermediary, foreign partnership, and U.S. branches of certain foreign banks and insurance companies. Generally, the person who pays (or causes to be paid) an amount subject to withholding to the foreign person (or to its agent) must withhold.

Specific Instructions
Part I
Line 1. Enter your name. If you are filing for a disregarded entity with a single owner who is a foreign person, this form should be completed and signed by the foreign single owner. If the account to which a payment is made or credited is in the name of the disregarded entity, the foreign single owner should inform the withholding agent of this fact. This may be done by including the name and account number of the disregarded entity on line 8 (reference number) of Part I of the form. If you own the income or account jointly with one TIP or more other persons, the income or account will be treated by the withholding agent as owned by a foreign person if Forms W-8ECI are provided by all of the owners. If the withholding agent receives a Form W-9, Request for Taxpayer Identification Number and Certification, from any of the joint owners, the payment must be treated as made to a U.S. person. Line 2. If you are filing for a corporation, enter the country of incorporation. If you are filing for another type of entity, enter the country under whose laws the entity is created, organized, or governed. If you are an individual, write "N/A" (for "not applicable"). Line 3. Check the box that applies. By checking a box, you are representing that you qualify for this classification. You must check the one box that represents your classification (for example, corporation, partnership, etc.) under U.S. tax principles. If you are filing for a disregarded entity, you must check the "Disregarded entity" box (not the box that describes the status of your single owner). Line 4. Your permanent residence address is the address in the country where you claim to be a resident for that country's income tax. Do not show the address of a financial institution, a post office box, or an address used solely for mailing purposes. If you are an individual who does not have a tax residence in any country, your permanent residence is where you normally reside. If you are not an individual and you do not have a tax residence in any country, the permanent residence address is where you maintain your principal office. Line 5. Enter your business address in the United States. Do not show a post office box. Line 6. You must provide a U.S. taxpayer identification number (TIN) for this form to be valid. A U.S. TIN is a social security number (SSN), employer identification number (EIN), or IRS individual taxpayer identification number (ITIN). Check the appropriate box for the type of U.S. TIN you are providing. -3-

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If you are an individual, you are generally required to enter your SSN. To apply for an SSN, get Form SS-5 from a Social Security Administration (SSA) office. Fill in Form SS-5 and return it to the SSA. If you do not have an SSN and are not eligible to get one, you must get an ITIN. To apply for an ITIN, file Form W-7 with the IRS. It usually takes 4-6 weeks to get an ITIN. If you are not an individual (for example, a foreign estate or trust), or you are an individual who is an employer or who is engaged in a U.S. trade or business as a sole proprietor, use Form SS-4, Application for Employer Identification Number, to obtain an EIN. If you are a disregarded entity, enter the U.S. TIN of your foreign single owner. Line 7. If your country of residence for tax purposes has issued you a tax identifying number, enter it here. For example, if you are a resident of Canada, enter your Social Insurance Number. Line 8. This line may be used by the filer of Form W-8ECI or by the withholding agent to whom it is provided to include any referencing information that is useful to the withholding agent in carrying out its obligations. A beneficial owner may use line 8 to include the name and number of the account for which he or she is providing the form. A foreign single owner of a disregarded entity may use line 8 to inform the withholding agent that the account to which a payment is made or credited is in the name of the disregarded entity (see instructions for line 1 on page 3). Line 9. You must specify the items of income that are effectively connected with the conduct of a trade or business in the United States. You will generally have to provide Form W-8BEN, Form W-8EXP, or Form W-8IMY for those items from U.S. sources that are not effectively connected with the conduct of a trade or business in the United States. See Form W-8BEN, W-8EXP, or W-8IMY, and its instructions, for more details. If you are providing this form to a partnership because you are a partner and have made an election under section 871(d) or section 882(d), attach a copy of the election to the form. If you have not made the election, but intend to do so effective for the current tax year, attach a statement to the form indicating your intent. See Regulations section 1.871-10(d)(3).

owner is not an individual, by an authorized representative or officer of the beneficial owner. If Form W-8ECI is completed by an agent acting under a duly authorized power of attorney, the form must be accompanied by the power of attorney in proper form or a copy thereof specifically authorizing the agent to represent the principal in making, executing, and presenting the form. Form 2848, Power of Attorney and Declaration of Representative, may be used for this purpose. The agent, as well as the beneficial owner, may incur liability for the penalties provided for an erroneous, false, or fraudulent form. Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. If you want to receive exemption from withholding on income effectively connected with the conduct of a trade or business in the United States, you are required to provide the information. We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping, 3 hr., 35 min.; Learning about the law or the form, 3 hr., 22 min.; Preparing the form, 3 hr., 35 min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can email us at *[email protected]. Please put "Forms Comment" on the subject line. Or you can write to Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406, Washington, DC 20224. Do not send Form W-8ECI to this office. Instead, give it to your withholding agent.

Part II
Signature. Form W-8ECI must be signed and dated by the beneficial owner of the income, or, if the beneficial

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