W-8BEN-E- Amerika Birleşik Devletleri Vergi Stopajı ve Bildirimi (Kurumlar) İntifa Hakkı Sahibi Yabancılar için Mali Durum

Belgesi
W-8BEN-E formu, üzerinde herhangi bir değişiklik yapılmadan, doğru bir biçimde A. Doğru W formunu doldurduğunuzdan emin olmak için lütfen bu bölümü ve ilgili talimatları okuyunuz.
doldurulmalıdır.
B. BÖLÜM I (Faydalanıcının (İntifa Hakkı Sahibinin) Kimlik Bilgileri) (Formun 1. sayfası)
Hata yapmanız halinde,yeni bir form alıp baştan doldurunuz.
1. Satır İntifa Hakkı sahibi olan kuruluşun tam adı

Daksil veya başka bir düzeltme aracı kullanmayınız.
2. Satır Şirketin veya kuruluşun bulunduğu ülke

Tüm W Formları İngilizce doldurulmalıdır.
3. Satır Ödemeyi Alacak Olan, Dikkate Alınmayan Tüzel Kişi adı (var ise)

4. Satır Alan 3 - Durum (tüzel kişilik türü) (Yalnızca bir kutu işaretlenmelidir):

Form W-8BEN-E Certificate of Status of Beneficial Owner for
(February 2014) United States Tax Withholding and Reporting (Entities)
▶ For use by entities. Individuals must use Form W-8BEN. ▶ Section references are to the Internal Revenue Code.
OMB No. 1545-1621 5. Satır Alan 4 Durum (FATCA durumu)

Department of the Treasury ▶ Information about Form W-8BEN-E and its separate instructions is at www.irs.gov/formw8bene.
Internal Revenue Service
Do NOT use this form for:
▶ Give this form to the withholding agent or payer. Do not send to the IRS.

Instead use Form:

6. Satır 
 Daimi ikamet adresi.
İlk satıra tam adresi yazınız, İli, ilçeyi, köyü veya mahalleyi ve ülke kutusunda yer alan “Ülkeyi” posta kodu ile
• A foreign individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
• U.S. entity or U.S. citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . .

• A foreign individual or entity claiming that income is effectively connected with the conduct of trade or business within the U.S.
. . . . . W-9
W-8BEN (Individual)
birlikte 2. satıra yazınız.
(unless claiming treaty benefits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . . W-8IMY AŞAĞIDAKİLERİ KULLANMAYINIZ:
• 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 that income is effectively connected U.S. income or that is claiming
Posta ofisinde olan veya adresinizde olmayan posta kutusu numarası veya başka bir alıcının adresi
the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions) . . . .
• Any person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . .
W-8ECI or W-8EXP
. . . W-8IMY
Üçüncü tarafın adı
Part I Identification of Beneficial Owner Bir Finans Kuruluşunda kayıtlı adresi
B
1 Name of organization that is the beneficial owner 2 Country of incorporation or organization
ABD adresi
3 Name of disregarded entity receiving the payment (if applicable)

4 Chapter 3 Status (entity type) (Must check one box only):
Simple trust Grantor trust
Central Bank of Issue Tax-exempt organization
If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
claim? If "Yes" complete Part III.
5 Chapter 4 Status (FATCA status) (Must check one box only unless otherwise indicated). (See instructions for details and complete the
certification below for the entity's applicable status).
Nonparticipating FFI (including a limited FFI or an FFI related to a
Reporting IGA FFI other than a registered deemed-compliant FFI
or participating FFI).
Participating FFI.
Reporting Model 1 FFI.
Reporting Model 2 FFI.
Registered deemed-compliant FFI (other than a reporting Model 1
FFI or sponsored FFI that has not obtained a GIIN).
Sponsored FFI that has not obtained a GIIN. Complete Part IV.
Certified deemed-compliant nonregistering local bank. Complete
Part V.
Certified deemed-compliant FFI with only low-value accounts.
Complete Part VI.
Certified deemed-compliant sponsored, closely held investment
vehicle. Complete Part VII.
Certified deemed-compliant limited life debt investment entity.
Complete Part VIII.
Certified deemed-compliant investment advisors and investment
managers. Complete Part IX.
Owner-documented FFI. Complete Part X.
Restricted distributor. Complete Part XI.
Sponsored direct reporting NFFE. Complete Part XXVIII.
6 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).
City or town, state or province. Include postal code where appropriate.
7 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Corporation
7. Satır Ülke kutusundaki "Ülkeyi" kapsayan posta adresi. Yalnızca daimi ikamet adresinizden farklı olması

Disregarded entity Partnership
Complex trust Estate Government durumunda posta adresini yazınız.
Private foundation
Not: ABD sınırları içerisindeki bir posta adresinin verilmesi durumunda, bu adrese ilişkin yazılı açıklama yapılması veya gerekçe gösterilmesi
Yes No gerekmektedir. Ülke daimi ikamet adresindeki ülkeden farklıysa yazılı açıklama yapılması gerekmektedir.
Nonreporting IGA FFI (including an FFI treated as a registered
8. Satır ABD vergi kimlik numarası (VKN), gerekiyorsa
deemed-compliant FFI under an applicable Model 2 IGA).
Complete Part XII.
Mevcut olması durumunda, İşveren Kimlik Numarasını (İKN) yazınız.
Foreign government, government of a U.S. possession, or foreign Geçerli İKN, her zaman 9 rakamdan oluşur.
central bank of issue. Complete Part XIII.
International organization. Complete Part XIV. İKN :
Exempt retirement plans. Complete Part XV.
Entity wholly owned by exempt beneficial owners. Complete Part XVI. (1) yalnızca rakamlardan oluşmalı,
Territory financial institution. Complete Part XVII.
Nonfinancial group entity. Complete Part XVIII.
(2) dokuz adetten az veya fazla rakam içermemeli,
Excepted nonfinancial start-up company. Complete Part XIX.
Excepted nonfinancial entity in liquidation or bankruptcy.
(3) aynı dokuz rakamdan oluşmamalıdır veya
Complete Part XX.
(4) dokuz ardışık rakamdan (küçükten büyüğe veya büyükten küçüğe) oluşmamalıdır.
501(c) organization. Complete Part XXI.
Nonprofit organization. Complete Part XXII.
Publicly traded NFFE or NFFE affiliate of a publicly traded
9. Satır 9a "GIIN" kutusunu işaretleyiniz ve Küresel Aracı Kurum Kimlik Numaranızı (GIIN) yazınız veya 9b "Yabancı

corporation. Complete Part XXIII. Vergi Kimlik Numarası (VKN)" kutusunu işaretleyiniz ve mevcut olması durumunda Yabancı Vergi Kimlik
Excepted territory NFFE. Complete Part XXIV.
Active NFFE. Complete Part XXV. Numaranızı (Yabancı VKN) yazınız.
Passive NFFE. Complete Part XXVI.
Excepted inter-affiliate FFI. Complete Part XXVII.  Küresel Aracı Kurum Kimlik Numarasına sahip olmamanız ve yakın bir tarihte Küresel Aracı Kurum Kimlik Numarası
Direct reporting NFFE.
almak için başvuruda bulunmayı planlıyor olmanız veya halihazırda Küresel Aracı Kurum Kimlik Numarası başvurusu
yapmış olmanız durumunda, GIIN alanına "Başvuru Yapıldı" yazınız. Size Küresel Aracı Kurum Kimlik Numaranızı bize
Country bildirmeniz için 60 gün verilecektir.
10. Satır Boş bırakınız.
Country

8 U.S. taxpayer identification number (TIN), if required 9a GIIN b Foreign TIN 10 Reference number(s) (see instructions) Not: Lütfen intifa hakkı sahibinin kim olduğuna dair daha
Note. Please complete remainder of the form including signing the form in Part XXIX.
fazla bilgi edinmek için W-8BEN-E talimatlarına başvurunuz.
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 59689N Form W-8BEN-E (2-2014)

© HSBC Bank A.Ş. 2014. Tüm Hakları Saklıdır.

W-8BEN-E- Amerika Birleşik Devletleri Vergi Stopajı ve Bildirimi (Kurumlar) İntifa Hakkı Sahibi Yabancılar için Mali Durum Belgesi
Form W-8BEN-E (2-2014) Page 2 C. 
BÖLÜM II (Formun 2. Sayfası)
Part II Disregarded Entity or Branch Receiving Payment. (Complete only if disregarded entity or branch of an
FFI in a country other than the FFI's country of residence.) Ödemeyi Alacak Olan Dikkate Alınmayan Tüzel Kişi veya Şube. (Yalnızca Yabancı Finansal Kuruluşa ait dikkate
Form
11 W-8BEN-E (2-2014)
Chapter 4 Status (FATCA status) of disregarded entity or branch receiving payment Page 2
Part II Disregarded
Limited Branch. Entity or Branch Receiving ReportingPayment.
Model 1 FFI. (Complete only if disregarded entity or branch of an
U.S. Branch. alınmayan kurumun veya şubenin Yabancı Finansal Kuruluşun kayıtlı bulunduğu ülkeden başka bir ülkede bulunması
12
FFI in a FFI.
Participating
Address4ofStatus
country other than the FFI's country
disregarded
Reportingof residence.)
Model 2 FFI.
route). Do not use a P.O. box or in-care-of address (other than a
durumunda doldurunuz.)
11 Chapter (FATCAentity or of
status) branch (street, entity
disregarded apt. ororsuite no.,receiving
branch or rural payment

C 
registered
Limited address).
Branch. Reporting Model 1 FFI. U.S. Branch.
Form W-8BEN-E
Participating FFI.
Certificate of Status of Beneficial Owner for
Reporting Model 2 FFI.
12
(February City
2014)or town,
Address state or province.
of disregarded United States Tax Withholding and Reporting (Entities)
Include
entity or branch postal code
(street, where
apt. appropriate.
or suite no., or rural route). Do not use a P.O. box or in-care-of OMBaddress (other than a
No. 1545-1621
▶ For use by entities. Individuals must use Form W-8BEN. ▶ Section references are to the Internal Revenue Code.
Department registered address). ▶ Information about Form W-8BEN-E and its separate instructions is at www.irs.gov/formw8bene.
of the Treasury
Internal Revenue Service ▶ Give this form to the withholding agent or payer. Do not send to the IRS.
Country
Do NOT use this form for: Instead use Form:
City or town, state or province. Include postal code where appropriate.
• U.S.
13 entity
GIINor (if U.S.
any) citizen or resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-9
• APart
foreign
III individual
Country Claim. of. Tax . .Treaty . . Benefits
. . . . (if .applicable). . . . . (For . . chapter
. . . 3 purposes. . . . only) . . . . . . . . W-8BEN (Individual)
• A14foreign individual
I certify or entity
that (check allclaiming
that apply): that income is effectively connected with the conduct of trade or business within the U.S.
(unless claiming treaty benefits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI D. BÖLÜM III (Vergi Anlaşması Avantajları Hak Talebi) (varsa). (Yalnızca alan 3'te belirtilen amaçlara yönelik
13 a GIINThe (if any)beneficial owner is a resident of within the meaning of the income tax
• A foreign partnership,
Part III treaty Claim
between a foreign
of the TaxUnitedsimple
Treaty trust,and
States or athat
Benefits foreign grantor trust (unless claiming treaty benefits) (see instructions for exceptions) . . W-8IMY
(if applicable).
country. (For chapter 3 purposes only) olarak)
D
• 14 b I certify
A foreign government,
Thethat beneficial
(check international
owner
all organization,
derives
that apply): the itemforeign central
(or items) of bank
income of issue, foreign
for which the tax-exempt organization,
treaty benefits foreignand,
are claimed, private
if applicable, meets the
foundation,
a The or beneficial
government
requirements of of atreaty
the
owner U.S.
is possession
provision
a resident claiming
of dealing withthat incomeonisbenefits
limitation effectively
the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (unless claiming treaty benefits) (see instructions) . . . .
(see connected
instructions). U.S. income or that is claiming
within the meaning of the income tax
W-8ECI or W-8EXP
Yalnızca anlaşmaya taraf olan ülkelerden birinde ikamet ediyorsanız ve vergi anlaşması avantajı elde etmeye hak
c The(2-2014)
beneficial
between owner is claiming
States treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business
Form W-8BEN-E
b
Part II
treaty
• Any personofacting a foreign
The Disregarded
as an
the United
intermediary
corporation
beneficial ownerEntity
and .meets
derivesor the
and that
. .qualified
country.
. . resident
. . . status
item (orReceiving
Branch items) of income
. . (see . instructions).
Payment.
. . . . . . . . . . . . . . . . . . . . W-8IMY
for which the treatyonly
(Complete benefits
if are claimed,entity
disregarded and, iforapplicable,
branch
Page 2
meets
of an the
kazanmışsanız (örneğin temettü ödemeleri gibi sabit veya belirlenebilir yıllık veya dönemsel (FDAP) geliriniz varsa
Part Special
I requirements Identification of Beneficial Owner
15
1 Name
of the of
rates andofconditions
FFI in
organization
treaty
a
identifiedthat
the treaty
country other
is the
on line
(if applicable—see
provision
14a
than
beneficial
dealing
above toowner
the with
FFI's
claim a
instructions):
limitation
country The
on
of beneficial
benefits
residence.) (seeowner
% rate
is claiming the provisions of Article
instructions).
of withholding 2 Country
on (specify of incorporation or organization .
ve söz konusu ödeme ABD içerisindeki kaynaklardan yapılıyorsa) bu bölümü doldurunuz. Vergi anlaşması avantajı
11c Chapter The beneficial owner is claiming treaty benefits forordividends received from a foreign corporation ortype of income):
interest from a U.S. trade or business
Explainof a the
Limited
4 Status (FATCA
reasons
foreign corporation
status)
the beneficialand meets
of disregarded
ownerqualified
Branch. entity receiving the payment (if applicable)
meets the
entity branch receiving
termsstatus
resident of the (see
payment
treatyinstructions).
Reporting Model 1 FFI.
article:
U.S. Branch.
talebinde bulunma hakkını haiz olup olmadığınıza ilişkin sorularınız varsa bağımsız vergi danışmanına başvurmanızı
3 Name of disregarded
15
Part of
Special rates andFFI.
Participating
IVthe treaty Sponsored
identified on
conditions (if applicable—see instructions):
FFIlineThat 14a Has to
above Not claimObtained
a or suite
ReportingThe Model beneficial
2 FFI. owner is claiming the provisions of Article
a GIIN % rate of withholding on (specify type of income): tavsiye ederiz.
12 Address of disregarded entity or branch (street, apt. no., or rural route). Do not use a P.O. box or in-care-of address (other than a.
4 Chapter 3sponsoring
Status (entity type) (Must checkmeets one box Corporation
16 Name
Explain ofthe reasons
address).the entity:
beneficial owner the only):
terms of the treaty article: Disregarded entity Partnership
17
registered
Check Simple trust box applies. Grantor trust
whichever Complex trust Estate Government 14a Satırı kutuyu işaretleyiniz ve ikamet edilen "Ülkeyi" yazınız
Central Bank of Issue Tax-exempt organization
Part IV I certify
City or town,
that the
Sponsored entity
state or province. FFIidentified
That Has
Include
in Part Not
postal
I: Obtained
code where appropriate. a GIIN Private foundation
16
If• you
Name Is anentered
ofFFI solely
sponsoring
disregarded
because entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty
entity:it is an investment entity; 14b VEYA 14c Satırı uygun olan kutulardan birini işaretleyiniz.
claim?
• Is notIfwhichever
a"Yes"
QI, WP, complete
or WT; Part
and III. Yes No
17 Check
Country box applies.
5 Chapter
• Has 4 Status
agreed with (FATCA
the
I certify that the entity identified
certification below for
entity
the
status)
identified
entity's
I certify that the entity identified in Part I:
(Must
in above
check one box only unless otherwise indicated). (See instructions for details and complete the
Part I: (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.
applicable status).
15. Satır Özel oranlar ve koşullar (geçerliyse - talimatlara bakınız).
13 •GIIN
Is an(ifFFI any)solely because it is an investment entity;
• IsNonparticipating
a controlled foreign FFIcorporation
(including aas limited
defined FFIinorsection
an FFI 957(a);
related to a Nonreporting IGA FFI (including an FFI treated as a registered
Part •III Is not aClaim QI, WP,of or Tax
WT; and Treaty
than a Benefits (if applicable). (For
FFI chapter 3 purposes only)
• IsReporting
not a QI, WP, IGA or FFIWT; other registered deemed-compliant deemed-compliant FFI under an applicable Model 2 IGA).
14 •I certify
Has or agreed with the
that (check
participating all entity
FFI). identified above (that is not a nonparticipating FFI)
that apply): to act asPart
Complete theXII.
sponsoring entity for this entity.
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this
a IThe
certify beneficial
that theowner entityisidentified
a resident in of
Part I: within the meaning of the income tax
E. BÖLÜM IV - XXVIII
E
entity; and
Participating FFI. Foreign government, government of a U.S. possession, or foreign
• Is atreaty controlled
between foreign corporation
the United Statesasand defined in section 957(a);
that country.
Reporting
• Shares a commonModel 1electronicFFI. account system with the sponsoring entity (identified central bank of issue.
above) Complete
that enables thePart XIII.
sponsoring entity to identify all
b • Is not Thea beneficial
QI, WP, orowner WT; derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the
account
•limited
Reporting
Is requirements
wholly
holders
to, customer
Model and2payees
owned,ofdirectly
FFI.
the treaty
identification
of the entity and to access all account and customer
or provision
indirectly, dealing
by thewith
information, U.S.limitation
customer financial on benefits (see
institution
documentation,
International information
instructions).
identified
account above
organization.
balance, thatand
maintained
agrees
Complete by Part
to act as made
all payments
the entity
XIV. including, but not
the sponsoring
to accountentity for this
holders or
Formun geri kalan Bölümleri (Bölüm IV ve XXVIII arası), Bölüm I, 5. Satırda işaretlediğiniz alan 4’te belirttiğiniz duruma
Registered deemed-compliant FFI (other than a reporting Model 1 Exempt retirement plans. Complete Part XV.
c entity;
payees. The and beneficial owner is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business
FFI or sponsored FFI that has not obtained a GIIN).
of a foreign corporation andaccount
meets qualified Entity wholly owned by exempt beneficial owners. Complete Part XVI. ilişkin olarak belirli belgelendirme ve tasdiğini içermektedir.
• Shares a common electronic system resident
with thestatus (see instructions).
sponsoring entity (identified above) that enables the sponsoring entity to identify all
Partaccount
V Sponsored Certified
holders FFI and
Deemed-Compliant
that has notofobtained
payees a GIIN. Nonregistering
Complete
access Part IV. Local Bank
Territory financial institution. Complete Part XVII.including, but not
Special rates and conditions (if the entity and to all account and customer information maintained ofby the entity
15
18 limited
of the Certified
I certify deemed-compliant
that
to, customer
treaty the FFI
identified onidentified
identification
applicable—see
line 14anonregistering I: claimlocal
ininformation,
abovePart to
instructions):
a bank. Complete
customer
The beneficial
documentation, % rate
owner is claiming
Nonfinancial
account groupand
balance,
of withholding
the provisions
entity.
on (specify
Complete Part
all payments
Article
made
type of income):
XVIII.
to account holders .or Formun bu kısmı için yalnızca alan 4’te belirttiğiniz durumunuza uygulanabilir olan belgeyi doldurmanız
Part V. and is licensed solely as a bank or credit union (or similar cooperative
payees.
• Operates
Explain the reasons the beneficial owner meets the terms of the treaty article:
incorporationdeemed-compliant
or organization; FFI with only low-value accounts.
Excepted creditnonfinancial
organization start-up
operated company.
without Complete
profit) Part
in its XIX. of
country
gerekmektedir.
Part V Certified Certified Deemed-Compliant Nonregistering Local Bank Excepted nonfinancial entity in liquidation or bankruptcy.
Part IV
18
bank
Complete
• Engages
I certifySponsored
and, with
Certified
Part VI.
primarily in the
that the FFIFFI
deemed-compliant
business
ThatinHas
identified
respect to a credit
of receiving
Part Not
sponsored,
I:
union or similar
deposits from
Obtained
closelycooperative
held investment credit organization,
Complete
501(c) members,
Part
organization.
XX.
and making loans to, with respect to a bank, retail customers unrelated to such
a GIIN
provided
Complete that Part
no member
XXI. has a greater than five

16 •NameOperates of sponsoring
and is entity: solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of
percentvehicle. interest
Complete in licensed
such credit
Part VII. union or cooperative credit organization; Nonprofit organization. Complete Part XXII.
17 Check whichever
incorporation box applies.
or organization;
• Does not
Certified solicit account
deemed-compliant holders outside
limited its
life debt country of organization;
I certifyprimarily
•• Engages that the in entity identified
thebusiness
businessoutside in
of Part I: investment
receiving
entity. Publicly traded NFFE or NFFE affiliate of a publicly traded
Complete
Has no fixed Part placeVIII. of such deposits
country (for fromthisandpurpose,
making loans to,place
acorporation.
fixed with Complete
respect
of businesstoPart
a bank,
XXIII.
does retail
not customers
include unrelated
a location that to
is such
not
• Is an
bank and,FFI with
solely because
respect it is an investment entity;cooperative credit organization, members, provided that no member has a greater than five
advertised
Certified publicto
todeemed-compliant
the and a credit
from unionthe
which
investment
or similar
FFI performs
advisors and solely administrativeExcepted
investment support functions);
territory NFFE. Complete Part XXIV.
percent
• Is not interesta QI, WP, in orsuch WT;credit
and union or cooperative credit organization;
managers. Complete Part IX.
• Has no more than $175 million in assets on its balance sheet and, if it is aActive member NFFE.of an expanded
Complete affiliated
Part XXV. group, the group has no more
••than
Has agreed
Does $500not million withaccount
solicit the entity
in totalFFI.
identified
holders
assets onoutside
above its (that
its consolidated countryis not
orof
aorganization;
nonparticipating FFI) to act as the sponsoring entity for this entity.
combined balance sheets; andNFFE. Complete Part XXVI.
Owner-documented
I certify thatplacethe entity Complete
identified PartI:X.
in Part Passive
•• HasDoes nonotfixed
have any memberof business of itsoutside
expanded such countrygroup
affiliated (for this
that purpose,
is a foreign a fixed
financialplace of business
institution, other does
than not include
a foreign a location that is not
•is Is Restricted
a controlled
advertised to theordistributor.
foreign
public Complete
corporation
and from Part XI.
as defined FFIinperforms
section 957(a); Excepted inter-affiliate FFI. Complete Part financial
XXVII. institution that
incorporated organized in thewhich
same the
country as the FFI solely administrative
identified in Part I and support functions);
that meets the requirements set forth in this Part V.
• Is not a QI, WP, or WT; Direct reporting NFFE.
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more
Sponsored direct Form W-8BEN-E (2-2014)
than $500 million
• Is wholly owned, in total assets
directly on its consolidated
or indirectly, by the U.S. or financial
combined balance sheets;
institution identified andabove that reporting
agrees toNFFE. act asComplete Part XXVIII.
the sponsoring entity for this
6 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).
Does and
•entity; not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that
is
• incorporated
Shares a common or organizedelectronic in the same system
account country with as the theFFI identified in
sponsoring Part(identified
entity I and that above)
meets thethatrequirements set forth in this
enables the sponsoring entityPart
to V.
identify all Örnek:

7
City
account or town, stateand
holders or province.
payees ofInclude the entitypostal andcode
Örnek where appropriate.
to access all account and customer information maintained
limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or
payees.address (if different from above)
Mailing
Country
by the entity including, but not
Form W-8BEN-E (2-2014)
Tüzel Kişinin Bölüm I, 5. Satırda, “Onaylı uygun bulunan kaydedilmemiş yerel banka” ifadesini seçmesi
Part V Certified Deemed-Compliant Nonregistering Local Bank
durumunda,
18 City or town, state or province. Include postal code where appropriate.
I certify that the FFI identified in Part I:
Country
W-8BEN-E Formunun V. Bölümünü doldurması gerekmektedir.
• Operates and is licensed solely as a bank or credit union (or similar cooperative credit organization operated without profit) in its country of
8 U.S. taxpayer identification
incorporation number (TIN), if required
or organization; 9a GIIN b Foreign TIN 10 Reference number(s) (see instructions)

• Engages primarily in the business of receiving deposits from and making loans to, with respect to a bank, retail customers unrelated to such
Note. Please
bank and,complete remainder
with respect to a credit of theorform
union similarincluding
cooperativesigning the form in
credit organization, Part XXIX.
members, provided that no member has a greater than five Doldurulacak bölümün başlığının Bölüm I, 5. satırda seçilen, alan 4’te belirttiğiniz durumunuzla (FATCA
For Paperwork
percent Reduction Act Notice,
interest in such see or
credit union separate instructions.
cooperative credit organization; Form W-8BEN-E (2-2014)
• Does not solicit account holders outside its country of organization;
Cat. No. 59689N
durumu) eşleşip eşleşmediğine dikkat etmeniz gerekmektedir; Bölüm I, 5. satır aynı zamanda doldurulacak
• Has no fixed place of business outside such country (for this purpose, a fixed place of business does not include a location that is not bölüme referans vermektedir; bu örnekte Bölüm V’ten bahsedilmektedir.
advertised to the public and from which the FFI performs solely administrative support functions);
• Has no more than $175 million in assets on its balance sheet and, if it is a member of an expanded affiliated group, the group has no more
than $500 million in total assets on its consolidated or combined balance sheets; and
• Does not have any member of its expanded affiliated group that is a foreign financial institution, other than a foreign financial institution that
is incorporated or organized in the same country as the FFI identified in Part I and that meets the requirements set forth in this Part V.

© HSBC Bank A.Ş. 2014. Tüm Hakları Saklıdır. Form W-8BEN-E (2-2014)
W-8BEN-E- Amerika Birleşik Devletleri Vergi Stopajı ve Bildirimi (Kurumlar) İntifa Hakkı Sahibi Yabancılar için Mali Durum Belgesi
Form W-8BEN-E (2-2014) Page 8 F. BÖLÜM XXIX (Belgelendirme ve Tasdik) (Formun 8. sayfası)
Part XXVIII Sponsored Direct Reporting NFFE
42 Name of sponsoring entity: Satırda belirtilen Tüzel Kişi adına imza atmak için yetkili olmanız gerekmektedir.
43 I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified in line 42.
Part XXIX Certification 1. Lütfen formu imzalayınız
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: 2. Lütfen imzanızın yanında bulunan satıra isminizi yazınız.
• The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4
3. Lütfen GG/AA/YYYY biçimini kullanarak forma tarih atınız.
F
purposes, or is a merchant submitting this form for purposes of section 6050W,
Page 8
4. Lütfen “Formun 1. Satırında belirtilen kurum adına imza atmaya
Form W-8BEN-E (2-2014)
• The entity identified on line 1 of this form is not a U.S. person,
Part XXVIII Sponsored
• The income to which thisDirect Reporting
form relates NFFEconnected with the conduct of a trade or business in the United States, (b) effectively connected but is
is: (a) not effectively

42 Name of sponsoring entity:
not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, and yetkili olduğumu teyit ederim” bölümünü işaretleyiniz. 
43 • ForI certify that the entity
broker transactions identified
or barter in Part
exchanges, theI beneficial
is a directowner
reporting NFFE foreign
is an exempt that is person
sponsored by the
as defined entity
in the identified in line 42.
instructions.
Furthermore, Certification
Part XXIX I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which the entity on line 1 is the beneficial
ownerpenalties
or any withholding
of perjury,agent that that
can Idisburse or makethe
payments of the
onincome of which
and tothe
theentity onmy
lineknowledge
1 is the beneficial owner.
Not: İlgili Vekaletnamede (POA) temsilcinin/avukatın vergi ile ilgili konularda veya vergi formlarına imza atabileceğine
Under I declare have examined information this form best of and belief it is true, correct, and complete. I further
certify
I agreeunder
that penalties of perjury
I will submit a newthat:
form within 30 days if any certification on this form becomes incorrect.

1 2 3
• The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4 ilişkin özel bir hüküm mevcut değilse (ve bir nüshası ibraz edilmemiş veya mevcut değilse) ya da alternatif olarak 2848
▲

Sign Here
purposes, or is a merchant submitting this form for purposes of section 6050W,
• The entity identifiedSignature of this
on line 1 of individual
form isauthorized
not a U.S.toperson,
sign for beneficial owner Print Name Date (MM-DD-YYYY) numaralı IRS Formu ibraz edilmemişse işbu form vekaletname ile imzalanamaz. 
4
• The income to which this form relates is: (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is
not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership's effectively connected income, and
I certify that I have the capacity to sign for the entity identified on line 1 of this form. 
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Part XXXI authorize
Furthermore, Substantial U.S.
this form to be Owners
provided of Passive
to any withholding NFFE
agent that has control, receipt, or custody of the income of which the entity on line 1 is the beneficial
owner or any withholding
As required agent
by Part XXVI, that canthe
provide disburse
name,oraddress,
make payments
and TIN ofof
theeach
income of which the
substantial entity
U.S. on line
owner 1 is NFFE.
of the the beneficial
Pleaseowner.
see instructions for definition of
I substantial
agree that I U.S. owner.a new form within 30 days if any certification on this form becomes incorrect.
will submit
▲

Sign Here
Name Address TIN
Signature of individual authorized to sign for beneficial owner Print Name Date (MM-DD-YYYY)

I certify that I have the capacity to sign for the entity identified on line 1 of this form.

Part XXX Substantial U.S. Owners of Passive NFFE

As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see instructions for definition of
G. Bölüm XXX Pasif Finansal Olmayan Yabancı Kuruluşun (Pasif NFFE) Fiziksel Olarak ABD’li Sahipleri
substantial U.S. owner. (yalnızca Bölüm XXVI’nın doldurulmuş olması ve uygun olması halinde doldurunuz.)
Name Address TIN Lütfen fiziksel olarak ABD’li olan NFFE sahiplerinin her birinin adını, adresini ve Vergi Kimlik Numarası bilgilerini
sağlayınız.
Fiziksel olarak ABD’li olan sahipler tanımı için W-8BEN-E Formu talimatlarına bakınız.

G
Form W-8BEN-E (2-2014)

Form W-8BEN-E (2-2014)

* HSBC, Vergi danışmanlığı sağlamaz. Danışmanlığa gereksinim duyuyorsanız bağımsız bir

vergi danışmanına başvurunuz.
© HSBC Bank A.Ş. 2014. Tüm Hakları Saklıdır.