Foreign Source Statement

for Payment(s) Made to a Non-U.S. Entity

for Services Performed Outside the United States

I, __________________________________, am an authorized employee/representative of

(Name)

______________________________________________ and hereby certify that:

(Entity name)

 The above-named Entity is not organized as a U.S. Company or U.S. Corporation;

 The above-named Entity does not maintain a U.S. presence and/or U.S. tax base; and

 _____% of the services for which Central Washington University will make payment to the
above-named Entity are performed, or will be performed, outside of the United States.

I understand that Central Washington University may be required by law to withhold taxes,
including U.S. Federal, State, and/or Local tax, if applicable, from any payments made to the
above-named Entity.

______________________________________________
(Signature)

______________________________________________
(Printed Name)

______________________________________________
(Title)

______________________________________________
(Date)

Revised 11-14-16