Guide to Global Payroll Management - 2020 - D-167

Appendix D-Federal Forms and Instructions

Form 8233 (Rev. 9-2018)

Part II
11
a

Page

2

Claim for Tax Treaty Withholding Exemption

Compensation for independent (and certain dependent) personal services:
Description of personal services you are providing

b
12
a
b
c
d

Total compensation you expect to be paid for these services in this calendar or tax year $
If compensation is exempt from withholding based on a tax treaty benefit, provide:
Tax treaty on which you are basing exemption from withholding
Treaty article on which you are basing exemption from withholding
Total compensation listed on line 11b above that is exempt from tax under this treaty $
Country of residence
Note: Do not complete lines 13a through 13d unless you also received compensation for personal services from the same
withholding agent.

13
a
b
c
d
14

Noncompensatory scholarship or fellowship income:
Amount $
Tax treaty on which you are basing exemption from withholding
Treaty article on which you are basing exemption from withholding
Total income listed on line 13a above that is exempt from tax under this treaty $
Sufficient facts to justify the exemption from withholding claimed on line 12 and/or line 13 (see instructions)

Part III

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 am authorized to sign for the beneficial owner) of all the income to which this form relates.
* The beneficial owner is not a U.S. person.
* The beneficial owner is a resident of the treaty country listed on line 12a and/or 13b above within the meaning of the income tax treaty
between the United States and that country, or was a resident of the treaty country listed on line 12a and/or 13b above at the time of, or immediately
prior to, entry into the United States, as required by the treaty.
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
Part IV

▶

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

Date

Withholding Agent Acceptance and Certification
Employer identification number

Name
Address (number and street) (Include apt. or suite no. or P.O. box, if applicable.)
City, state, and ZIP code

Telephone number

Under penalties of perjury, I certify that I have examined this form and any accompanying statements, that I am satisfied that an exemption from
withholding is warranted, and that I do not know or have reason to know that the nonresident alien individual is not entitled to the exemption or
that the nonresident alien's eligibility for the exemption cannot be readily determined.

Signature of withholding agent

▶

Date

▶
Form

8233 (Rev. 9-2018)

D-167
Guide to Global Payroll Management - 2020

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