Appendix L: IRS Form W-8: Certificate of Foreign Status

 
 
                         ASSEVERATION OF FOREIGN STATUS 
 
                              [Substitute W-8 Form] 
 
        This document  replaces/supersedes any/all  previous declarations 
        of status  by John  Q. Doe  and it  is to be used as my NOTICE OF 
        RESCISSION OF  ANY PREVIOUS  SIGNATURE AND ANY POWER OF ATTORNEY, 
        ab initio,  as it relates to any previous W-4, W-8, W-9, etc., as 
        well as Federal and State information forms or presentments. 
 
        California State/Republic ) 
                                  )                ASSEVERATION OF STATUS 
        County of Marin           ) 
 
        I, John Q. Doe, state, of Right, my Status as follows: 
 
        1.   That I am of lawful age and that I am competent to make this 
             Asseveration of Status; 
 
        2.   That I  am  a  non-immigrant,  non-naturalized,  nonresident 
             alien, non-taxpayer,  natural born  free American, Sovereign 
             man and  an inhabitant  of a geographical area in a State of 
             the American Union known as the California Republic; 
 
        3.   That I  am an American and nonresident alien with respect to 
             the "United  States" (i.e.,  the District of Columbia, Guam, 
             American Samoa, Virgin Islands, Commonwealth of Puerto Rico, 
             etc.) with  no income effectively connected with a "trade or 
             business"  (IRC  7701(a)(26))  within  the  "United  States" 
             (Government); 
 
        4.   That I  have never  knowingly,  willingly,  voluntarily  and 
             intentionally  inhabited  the  state  of  the  forum  (Forum 
             Contractus in Latin); 
 
        5.   That I  have never  been involved  in any  taxable "trade or 
             business" activity  under 27  Code  of  Federal  Regulations 
             (CFR) pursuant  to commerce in Alcohol, Tobacco Products and 
             Firearms, State or Federal; 
 
        6.   That this Asseveration is to be used in lieu of Form W-8, as 
             suggested by  that Form W-8, specifically:  "Use Form W-8 or 
             a  substitute   form  containing   a  substantially  similar 
             statement to  tell the  payor ... that you are a nonresident 
             alien individual,  foreign entity,  or exempt foreign person 
             not subject to certain U.S. information return, reporting or 
             backup withholding rules." 
 
        The following information is given in lieu of a Form W-8: 
 
             Name:          John Q. Doe 
             Location:      c/o USPS P. O. Box [##] 
                            San Rafael, California Republic 
                            zip code exempt (DMM 122.32) 
 
 
             Please note:  I do not voluntarily use unqualified ZIP codes 
             or other  forms of Federal Identification, e.g., "CA", "TX", 
             "FL", etc., because I do not reside inside Government (U.S.) 
             Territory or any of its Federal Territories. 
 
             U.S. taxpayer identification number:  not applicable 
 
             See Form  W-8:  "... foreign persons [sic] are not generally 
             required to  have a U.S. taxpayer identification number, nor 
             are they  subject to  any backup withholding because they do 
             not furnish  such a number to a payer or broker."  [Emphasis 
             added for purposes of conspicuous notice.] 
 
             You are  hereby ordered  to purge  the "Social  Security  or 
             Taxpayer I.D.  Number" as shown on Your "Payer's Request for 
             Taxpayer Identification Number" form, if any. 
 
             Check the appropriate space(s) with an "X": 
 
             (   )     For Interest  Payments, I  am not a "U.S. citizen" 
                       or "U.S. resident";  AND 
 
             (   )     For Broker  Transactions or Barter Exchanges, I am 
                       an exempt foreign Sovereign man. 
 
 
        THIS ASSEVERATION  OF STATUS  IS  TO  NOTIFY  PAYERS,  MIDDLEMEN, 
        BROKERS, AND  BARTER EXCHANGES NOT TO WITHHOLD OR REPORT PAYMENTS 
        OF INTEREST, BROKER TRANSACTIONS, OR BARTER EXCHANGES. 
 
        The W-8  accompanying this  ASSEVERATION OF STATUS should not and 
        cannot be attached to this ASSEVERATION OF STATUS but is enclosed 
        for information purposes only. 
 
 
        NUNC PRO  TUNC, this _____ day of __________, 19____ Anno Domini, 
        for June 21, 1948 (date of birth), 
 
        with explicit reservation all of my unalienable rights 
        and  without prejudice to any of my unalienable rights, 
 
 
 
        I, ______________________________________________________________ 
           (signature) 
 
           ______________________________________________________________ 
           (printed name) 
 
 
        state that the foregoing is true in substance and in fact, to the 
        best of  my knowledge  and belief, and is made in good faith, and 
        that this asseveration could be used as evidence, and that I have 
        personal knowledge of the facts stated herein. 
 
 
                     California All-Purpose Acknowledgement 
 
        CALIFORNIA STATE/REPUBLIC       ) 
                                        ) 
        COUNTY OF MARIN                 ) 
 
             On the  ________ day  of  ____________,  199_  Anno  Domini, 
        before me personally appeared John Q. Doe, personally known to me 
        (or proved to me on the basis of satisfactory evidence) to be the 
        Person whose  name is  subscribed to  the within  instrument  and 
        acknowledged to  me that  he executed  the same in His authorized 
        capacity, and  that by  His  signature  on  this  instrument  the 
        Person, or  the entity  upon behalf  of which  the Person  acted, 
        executed the  instrument.    Purpose  of  Notary  Public  is  for 
        identification only,  and  not  for  entrance  into  any  foreign 
        jurisdiction. 
 
        WITNESS my hand and official seal. 
 
 
 
        _____________________________________ 
        Notary Public