com W-BBEN | Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals) (Pe. Ostober 2021) > For use by individuals. Entities must use Form W-SBEN-E. (OME No, 1546-1621 bauetalaworl > Go to mwu.irs.govIFormWSBEN for instructions and the latest information. ‘lal Hovrue Sere > Give this form to the withholding agent or payer. Do not send to the IRS. Do NOT use this formif: Instead, use Form: + You are NOT an individual We8BENE + You are a USS. citizen or other U.S. person, including a resident alien incividual wa + You are a beneficial onner claiming thet income is effectively connected with the conduct of trade or business within the United States (other than personal services) w-8eo! + You are beneficial onner who is receiving compensation for personal services performed in the United States... : 233 oF Wa + You area person acting as an intermediary Se w-simy Note you are resident in a PATOA pariner jurisdiction (hat fs, a Model 1 IGA jurisdiction with reciprocity), cara tax account information may BS provided to your junsdction of resicence identification of Beneficial Owner (see instructions) "| Name ofindvidualwho isthe beneficial owner 2 Country ofciizenship h Riadi People’s of Indonesia Permanent rescence accross (Se, apt oY Sle i, oF Pal rote) not use 8 P.O, box oF in-care-of address. Bukit Baja Sejahtera 2 no.40, Cilegon cit ‘Gy of town, state or provines Include postal code where appropriate. County Cilegon 42418 Indonesia Ming acres (cere Fem above) ‘ity or fawn, state or provines, Include postal code where appropriate. Country ‘5 US. taxpayer Wenification number (SSN or ITN), i required 88 instructions) (6a Foreign tx identifying number (see instructions) (6. Check FTIN not logaly required a National ID: 3672020404920002 7 Patamce nur eoinsructons) 3 Da oft BAN; DD-YYY) ee nto) Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions) 9 {cory thatthe beneficial owners a resident of treaty between the Und States ard hat county 410 Special rates and conditions (i applicabie—see instructions}: The beneficial owner is claiming the provisions of Article and paragraph of the treaty identted on ine 8 above to claim a__96 rata of ithhalding an fpeciy type of income} ‘within the meaning f the income tax ‘Explain the addtional conditions inthe Aricle and paragraph the beneficial owner meets to be eligible fr the rate of withholding [MM Certification Uno ais opr, ore tha eine on ineaon ooh fa note estoy knw ae ats um comet a apt I era uc Fei rs + Lam the ndhiual hats the bene one ( am autbrizd o son fr helncvdua at's the beni‘ owner al the income o proceeds fo which this fom rates ram ing tis foro documant yea for chapter 4 pumps +The parson ramic on ina 1 of storm a nat U.S. eso; (@income ot efectvely connect wih the conduct ta rade busines nthe Unted States: (income etectvety connect win he conduct fa wade or busines in the Untad States but not subject fo ax under an sppcabe come aX Wel (e1me partner's snare ofa paersn's etecwey connected taxable income: or (@)tme parne’'samcuntrestzec tom the tater a partnership interest subject to witholcng under sacton 1486 + Teper nana nro 1 of fom a reser of tay cox Id entn 9m fa wintb narnghnc ax teat betwen he id Sates ana erty and + For trokertansactons or barter exchanges, the beneficial oaneris an exempt foreign parson as dfnein the rstretons, SEEemeTaakd pres ettcete each ooteoredl afore topes hath otciond ae tons ar dey yoann made oo Rk nel Pore the person identified on Sn 1 of this fom, ical authorized to apn fer banal ower) ‘ate NEDO) 05-03-2023 For Paperwork Reduction Act Notice, see separate nstructions. ‘cat No 250472 om W-BBEN (fev. 10-2021) Pret name of ser