Page 33 of 37 Fileid: ... ons/I1042S/2020/A/XML/Cycle05/source 10:31 - 9-Mar-2020 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing. Appendix D--Federal Forms and Instructions Appendix B (continued) Recipient Status Codes (continued) and Box 13j LOB Codes Chapter 4 Status Codes 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 50 U.S. Withholding Agent - FI U.S. Withholding Agent - Other Territory FI - not treated as U.S. Person Territory FI - treated as U.S. Person Participating FFI - Other Participating FFI - Reporting Model 2 FFI Registered Deemed-Compliant FFI - Reporting Model 1 FFI Registered Deemed-Compliant FFI - Sponsored Entity Registered Deemed-Compliant FFI - Other Certified Deemed-Compliant FFI - Other Certified Deemed-Compliant FFI - FFI with Low Value Accounts Certified Deemed-Compliant FFI - Nonregistering Local Bank Certified Deemed-Compliant FFI - Sponsored Entity Certified Deemed-Compliant FFI - Investment entity that does not maintain financial accounts Nonparticipating FFI Owner-Documented FFI U.S. Branch - treated as U.S. person U.S. Branch - not treated as U.S. person (reporting under section 1471) Passive NFFE identifying Substantial U.S. Owners Passive NFFE with no Substantial U.S. Owners Publicly Traded NFFE or Affiliate of Publicly Traded NFFE Active NFFE Individual Section 501(c) Entities Excepted Territory NFFE Excepted NFFE - Other Exempt Beneficial Owner Entity Wholly Owned By Exempt Beneficial Owners Unknown Recipient Recalcitrant Account Holder Nonreporting IGA FFI Direct reporting NFFE U.S. reportable account Nonconsenting U.S. account Sponsored direct reporting NFFE Excepted Inter-affiliate FFI Undocumented Preexisting Obligation U.S. branch - ECI presumption applied Account Holder of Excluded Financial Account10 Passive NFFE reported by FFI11 NFFE subject to 1472 withholding U.S. Withholding Agent-Foreign branch of FI Pooled Reporting Codes 42 43 44 45 46 47 48 Recalcitrant Pool - No U.S. Indicia Recalcitrant Pool - U.S. Indicia Recalcitrant Pool - Dormant Account Recalcitrant Pool - U.S. Persons Recalcitrant Pool - Passive NFFEs Nonparticipating FFI Pool U.S. Payees Pool 49 QI-Recalcitrant Pool-General12 Box 13j. LOB Code (enter the code that best describes the applicable limitation on benefits (LOB) category that qualifies the taxpayer for the requested treaty benefits). Code LOB Treaty Category 02 Government - contracting state/political subdivision/local authority Tax exempt pension trust/Pension fund Tax exempt/Charitable organization Publicly traded corporation Subsidiary of publicly traded corporation 03 04 05 06 07 08 09 10 11 Company that meets the ownership and base erosion test Company that meets the derivative benefits test Company with an item of income that meets the active trade or business test Discretionary determination Other 10 This code should only be used if income is paid to an account that is excluded from the definition of financial account under Regulations section 1.1471-5(b)(2) or under Annex II of the applicable Model 1 IGA or Model 2 IGA. 11 This code should only be used when the withholding agent has received a certification on the FFI withholding statement of a participating FFI or registered deemed-compliant FFI that maintains the account that the FFI has reported the account held by the passive NFFE as a U.S. account (or U.S. reportable account) under its FATCA requirements. The withholding agent must report the name and GIIN of such FFI in Boxes 15d and 15e. 12 This code should only be used by a withholding agent that is reporting a payment (or portion of a payment) made to a QI with respect to the QI's recalcitrant account holders. -33- D-111