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