Attachment 5: Form W 14

Form

W-14

(August 2016)
Department of the Treasury
Internal Revenue Service

Part I

Certificate of Foreign Contracting Party
Receiving Federal Procurement Payments

OMB No. 1545-2263

▶ Information about Form W-14 and its separate instructions is at www.irs.gov/w14. ▶ Give this form to the acquiring agency. Do not send to the IRS.

Identification of Foreign Contracting Party and Acquiring Agency

Name of foreign contracting party

2 Country of incorporation or organization, if applicable (do not abbreviate the name of the country)

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

Country (do not abbreviate)

Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.

U.S. taxpayer identification number (TIN), if any

Name and address of the acquiring agency

Country (do not abbreviate)

Contract/reference number (if known)

City or town, state or province. Include postal code where appropriate.

Part II

Exemption Based on an International Agreement (if applicable) Check this box if claiming relief from the tax under section 5000C pursuant to an international agreement with the United States (such as a qualified income tax treaty). Also complete Part IV.

Part III

Exemption Based on an International Procurement Agreement or Because Goods/Services Produced/Performed in the United States Check this box if identifying specific exempt and nonexempt 10 Total contract price or estimated total contract price amounts (for example, by contract line item number). Skip lines 10 through 14 and complete Part IV, line 15.

Country (do not abbreviate)

Nonexempt amount or estimated nonexempt amount

Part IV

Contract ratio (line 11 divided by line 10)

Explanation (Complete if Part II or Part III is applicable)

13 If you checked the box in Part II, state the name of the agreement and specific provision relied upon (for example, the nondiscrimination article of a qualified income tax treaty); and the basis on which you are entitled to the benefits of that provision (for example, because you are a corporation organized in a foreign country with which the United States has a qualified income tax treaty that covers all nationals). (Use additional sheets as necessary.)

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 67553M

Form W-14 (8-2016)

Form W-14 (8-2016)

Part IV

Explanation (Complete if Part II or Part III is applicable) (continued)