IRS Form W-8:
Certificate of Foreign Status
Links to scanned pages of this form:
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 general delivery
San Rafael [ZIP code exempt]
CALIFORNIA STATE, USA
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 ___ /___ /___ (date of birth),
with explicit reservation all of my unalienable rights
and without prejudice to any of my unalienable rights,
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.