Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United

States Tax Withholding and Reporting (Individuals)

Substitute Form ▶ For use by individuals. Entities must use Form W-8BEN-E. OMB No. 1545-1621

Department of the Treasury Go to www.irs.gov/FormW8BEN for instructions and the latest information.
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Internal Revenue Service ▶ Give this form to the withholding agent or payer. Do not send to the IRS.

Note: a) If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), a certain tax account information may be provided
to your jurisdiction of residence.
b) This form can be used by a non-U.S. individual to certify tax status for payments made under section 1441.
c) The number of the questions in this substitute form matches the official IRS form so that the signer can cross reference the official IRS instructions.
Do NOT use this form if: Instead, use Form:
• You are NOT an individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN-E
• You are a U.S. citizen or other U.S. person, including a resident alien individual . . . . . . . . . . . . . . . . . . . W-9
• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
• You are a beneficial owner who is receiving compensation for personal services performed in the United States . . . . . . . 8233 or W-4
• You are a person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8IMY

Part I Identification of Beneficial Owner (see instructions)

1 Name of individual who is the beneficial owner 2 Country of citizenship
Encep Suryana Indonesia
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
Perum Griya Permata 2 Kopkarin Blok A8 Gunungmanik, Tanjungsari
City or town, state or province. Include postal code where appropriate. Country
Sumedang Jawa Barat 45362 Indonesia
4 Mailing address (if different from above)
Perum Griya Permata 2 Kopkarin Blok A8 Gunungmanik, Tanjungsari
City or town, state or province. Include postal code where appropriate. Country
Sumedang Jawa Barat 45362 Indonesia
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions)
•••••••••••7000
7 Reference number(s) (see instructions) 8 Date of birth (MM-DD-YYYY) (see instructions)

Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 I certify that the beneficial owner is a resident of ID within the meaning of the income tax
treaty between the United States and that country.
10 Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article and paragraph
article 13 paragraph 2 of the treaty identified on line 9 above to claim a 10 % rate of withholding on (specify type of income):
Motion picture royalties .
Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:
As a tax resident of Indonesia, Encep Suryana meets required terms of the treaty, doesn't have a permanent establishment in the US, and doesn't perform independent personal services in the
US from a fixed base in the US; or the right or property in respect of which royalties are paid isn't effectively connected with a permanent establishment or fixed base

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 individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or
am using this form to document myself for chapter 4 purposes,
• The person named on line 1 of this form is not a U.S. person,
• The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or
(c) the partner’s share of a partnership's effectively connected income,

• The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between
the United States and that country, and
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
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. I agree that I will submit a new form within 30 days
if any certification made on this form becomes incorrect.
The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a non-
U.S. person, establish your Chapter 4 status (if required), and, if applicable, obtain a reduced rate of withholding.
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Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY)

Print name of signer Capacity in which acting (if form is not signed by beneficial owner)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 7-2017)