AFFIDAVIT RELATING TO FORM W-8BEN (for individuals) by zfh25590

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									                               Member FDIC




AFFIDAVIT RELATING TO FORM W-8BEN                                      AFFIDAVIT RELATING TO FORM W-8BEN
           (for individuals)                                                    (for organizations)

This Affidavit is furnished to Pacific National Bank in                This Affidavit is furnished to Pacific National Bank in
connection with the Form W-8BEN (Certificate of                        connection with the Form W-8BEN (Certificate of
Foreign Status of Beneficial Owner for United States                   Foreign Status of Beneficial Owner for United States
Tax Withholding) to which it is attached (the “Form W-                 Tax Withholding) to which it is attached (the “Form W-
8BEN”).                                                                8BEN”).

By signing below, I certify under penalties of perjury                 By signing below, I certify under penalties of perjury
that, at all times during the years:                                   that, at all times during the years:

(Check appropriate years)                                              (Check appropriate years)

       2004       2005          2006          2007                            2004       2005           2006          2007


•   My permanent residence address has been the                        •   The country of incorporation or organization of the
    address specified on line 4 of Part I of the Form W-                   organization identified on line 1 of Part I of the
    8BEN (the “Line 4 Address”) or another address                         Form W-8BEN (the “Organization”) has been the
    located in the same country as the Line 4 Address.                     country specified on line 2 of Part I of the Form
                                                                           W-8BEN.
•   I have not been a U.S. person.
                                                                       •   The Organization’s permanent residence address
•   The income to which the Form W-8BEN relates has                        has been the address specified on line 4 of Part I
    not been effectively connected with the conduct of a                   of the Form W-8BEN or another address located
    trade or business in the United States.                                in the same country as the Line 4 Address.

                                                                       •   The Organization has not been a U.S. person.

                                                                       •   The income to which the Form W-8BEN relates
Sign here          ________________________                                has not been effectively connected with the
                   Signature of Beneficial Owner                           conduct of a trade or business in the United
                                                                           States.
Date               ________________
                   (MM-DD-YYYY)
                                                                       Sign here        ____________________________
                                                                                        Signature of individual authorized to
                                                                                        sign for beneficial owner

                                                                                        _____________________________
                                                                                        Capacity in Which Acting

                                                                       Date                ________________
                                                                                           (MM-DD-YYYY)




                                                PACIFIC NATIONAL BANK – MEMBER FDIC
          1390 Brickell Avenue, Miami, FL 33131-3324 • P.O. Box 012620, Miami, FL 33101-2620 • Telex 6736848 • ABA: 066011350
              Tel.: (305) 539-7500 • Fax: (305) 539-7600 • Direct Call® (305) 539-7574 • From (Desde) Ecuador 1-800-722-4342

								
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