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DocuSign Envelope ID: 042CD293-A0F7-4D2B-94EF-93FAFEBE184C

Certificate of Foreign Status for Withholding and Reporting


This Form W-8 is used by non-US users to establish their non-US status.
Questions? See page 2 for instructions or email us at support@stripe.com.

1 Organization or individual Individual


Name

2 Disregarded entity or doing business Disregarded entity or doing business as name


Name
as name

3 Country Indonesia
Country
Of incorporation, organization, or citizenship

4 Classification Corporation Government Private foundation


Choose only one that applies X
Individual Tax-exempt organization International organization
Partnership

5 Permanent residence address Street


DUSUN SIDOMAKMUR RT003.RW001 GUCIALIT
Unit
Unit

Do not use a P.O. box or in-care-of address,


other than a registered address
LUMAJANG
City

JAWA TIMU
State or province if applicable

67353 INDONESIA
Postal code if applicable Country

6 Mailing address Street


Unit 2, Action Court, Ashford Road
Unit
Unit (mailing)

If different than your permanent residence


address above
Ashford
City

State or province if applicable


Ashford

Postal code if applicable


TW15 1XB UNITED KINGDOM
Country

7 Certification States persons have the authority to control all substantial decisions of the
Under penalties of perjury, I declare that the payee providing this certification trust), that the income to which this certification relates is not effectively
is not a United States person (i.e., a citizen or resident of the United States as connected with the conduct of a trade or business in the United States, and
determined for U.S. federal tax purposes, a corporation or partnership created that the undersigned has examined the information on this form and to the
or organized in the United States or under the law of the United States or of best of my knowledge and belief it is true, correct, and complete.
any State, any estate that would be subject to U.S. federal income tax on Furthermore, I authorize this form to be provided to any person that has
income from sources without the United States which is not effectively control, receipt, or custody of the payment to which I am entitled or any
connected with the conduct of a trade or business within the United States, person that can disburse or make the payments to which I am entitled. I agree
or any trust if a court within the United States is able to exercise primary that I will submit a new form within 30 days if any certification on this form
supervision over the administration of the trust and one or more United becomes incorrect.

X I certify that I have the capacity to sign for the organization or individual identified on the first line of this form.

Signature Print name Date


Sigit Irawan 1/7/2020 | 19:13:21 PST
DocuSign Envelope ID: 042CD293-A0F7-4D2B-94EF-93FAFEBE184C

Certificate of Foreign Status for Withholding and Reporting


Instructions — Appendix

1 Organization or individual Enter your name. If you are a disregarded entity or branch, do not enter the business name of the
disregarded entity or branch here. Instead, enter the legal name of the entity that owns the disregarded
entity (looking through multiple disregarded entities if applicable) or maintains the branch. If you are a
foreign individual who is the single owner of a disregarded entity you should complete this form with your
name and information.

2 Disregarded entity or doing business Complete only if a disregarded entity is receiving the payment. In such case, enter the name of the
as name disregarded entity or branch.

3 Country If you are a corporation, enter your country of incorporation. If you are another type of entity, enter the
country under whose laws you are created, organized, or governed. If you are a foreign individual, enter
your country of citizenship. If you are a dual citizen, enter the country where you are both a citizen and a
resident at the time you complete this form. If you are not a resident in any country in which you have
citizenship, enter the country where you were most recently a resident. However, if you are a United
States citizen, you should not complete this form even if you hold citizenship in another jurisdiction.
Instead, let us know and we will provide you with the appropriate form.

4 Classification Check the one box that applies. By checking a box, you are representing that you qualify for the
classification indicated. You must check the box that represents your classification (for example,
corporation, individual, partnership, trust, estate, etc.) under U.S. tax principles (not under the law of the
country you are established or resident in).

5 Permanent residence address Enter the permanent residence address of the organization or individual identified in line 1. Your
permanent residence address is the address in the country where the organization claims to be a resident
for purposes of that country’s income tax. Do not show the address of a financial institution (unless you
are a financial institution providing your own address), a post office box, or an address used solely for
mailing purposes unless it is the only address used by the entity and such address appears in the entity’s
organizational documents. If you do not have a tax residence in any country, the permanent residence
address is where you maintain your principal office or where you normally reside. If you reside in a country
that does not use street addresses, you may enter a descriptive address here. The address must accurately
indicate your permanent residence in the manner used in your jurisdiction.

6 Mailing address Enter your mailing address only if it is different from the address you show on line 5.

7 Certification This form must be signed and dated by you, your authorized representative or officer. An authorized
representative or officer must also check the box to certify that they have the legal capacity to sign for
the entity identified on line 1. You may incur liability for the penalties provided for an erroneous, false,
or fraudulent form. By signing this form, you, your authorized representative or officer of the entity also
agrees to provide a new form within 30 days following a change in circumstances affecting the
correctness of the form.

What is this form? This form is used by non-U.S. persons to document their status for purposes of U.S. information and
withholding matters as described here. Stripe may rely on a properly completed Certificate of Foreign
Status for Withholding and Reporting to treat a payment associated with the certificate as a payment
to a non-U.S. person. Provide a Certificate of Foreign Status for Withholding and Reporting to Stripe
before income is paid or credited to you. You should provide a Certificate of Foreign Status for
Withholding and Reporting to Stripe if you are a non-US person receiving payments subject to
reporting (payment card transactions and third-party network transactions) as a participating payee.
Failure to provide a Certificate of Foreign Status for Withholding and Reporting when requested may
lead to Stripe reporting your payments to the U.S Internal Revenue Service (IRS) and imposing backup
withholding tax at 28 percent.

However, if the payments are income which is effectively connected to the conduct of a U.S. trade or
business, you should instead provide Stripe with a Form W-8ECI Certificate of Foreign Person's Claim
That Income Is Effectively Connected With the Conduct of a Trade or Business in the United States
(the Form W-8ECI can be found at https://www.irs.gov/pub/irs-pdf/fw8eci.pdf).

Still have questions? We’re here to help. Email us at support@stripe.com.


DocuSign Envelope ID: 042CD293-A0F7-4D2B-94EF-93FAFEBE184C

Affidavit of Unchanged Status

I confirm, under penalties of perjury, that I have examined and signed the Form W-8 and that
the information and certifications have not changed from the time the account listed below
opened with Stripe on 2019/01/30
________________________________ to the present time.
(YY-MM-DD)

Account Legal Name:


Sigit Irawan
_____________________________________________

acct_1DyH0eAJyLuxL2of
Account #: _______________________________

1/7/2020 | 19:13:21 PST


Today’s Date: _______________________________
(YY-MM-DD)

Signature: _______________________________

Sigit Irawan
Print Name: _______________________________
Certificate Of Completion
Envelope Id: 042CD293A0F74D2B94EF93FAFEBE184C Status: Completed
Subject: Please DocuSign: Tax Certificate of Foreign Status & Affidavit (Nov 2018).pdf
Source Envelope:
Document Pages: 3 Signatures: 2 Envelope Originator:
Certificate Pages: 4 Initials: 0 Stripe
AutoNav: Enabled 185 Berry St
EnvelopeId Stamping: Enabled 550
Time Zone: (UTC-08:00) Pacific Time (US & Canada) San Francisco, CA 94107
docusign-hk-launch@stripe.com
IP Address: 36.74.163.43

Record Tracking
Status: Original Holder: Stripe Location: DocuSign
1/7/2020 6:54:55 PM docusign-hk-launch@stripe.com

Signer Events Signature Timestamp


Sigit Irawan Sent: 1/7/2020 6:54:56 PM
ecommglobaltrade@gmail.com Viewed: 1/7/2020 6:55:55 PM
Security Level: Signed: 1/7/2020 7:13:21 PM
DocuSign.email
ID: 1 Signature Adoption: Drawn on Device
1/7/2020 6:54:56 PM Using IP Address: 36.74.159.251

Electronic Record and Signature Disclosure:


Accepted: 1/7/2020 6:55:55 PM
ID: da862ca0-f5e5-42dd-8cb5-f1cc25c70485

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps


Envelope Sent Hashed/Encrypted 1/7/2020 6:54:56 PM
Certified Delivered Security Checked 1/7/2020 6:55:55 PM
Signing Complete Security Checked 1/7/2020 7:13:21 PM
Completed Security Checked 1/7/2020 7:13:21 PM

Payment Events Status Timestamps


Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 5/24/2018 12:35:23 PM
Parties agreed to: Sigit Irawan

CONSUMER DISCLOSURE
From time to time, Stripe (we, us or Company) may be required by law to provide to you certain
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such notices and disclosures electronically through the DocuSign, Inc. (DocuSign) electronic
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Unless you tell us otherwise in accordance with the procedures described herein, we will provide
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How to contact Stripe:

You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: support@stripe.com

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To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at support@stripe.com and in the
body of such request you must state: your previous e-mail address, your new e-mail address. We
do not require any other information from you to change your email address..

In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in the DocuSign system.

To request paper copies from Stripe


To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to support@stripe.com and in the body of
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To withdraw your consent with Stripe

To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:

i. decline to sign a document from within your DocuSign session, and on the subsequent
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state your e-mail, full name, US Postal Address, and telephone number. We do not need
any other information from you to withdraw consent.. The consequences of your
withdrawing consent for online documents will be that transactions may take a longer
time to process..

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(Mac only)
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Screen
800 x 600 minimum
Resolution:
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Allow per session cookies
Settings:
** These minimum requirements are subject to change. If these requirements change, you will be
asked to re-accept the disclosure. Pre-release (e.g. beta) versions of operating systems and
browsers are not supported.
Acknowledging your access and consent to receive materials electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please verify that you were
able to read this electronic disclosure and that you also were able to print on paper or
electronically save this page for your future reference and access or that you were able to e-mail
this disclosure and consent to an address where you will be able to print on paper or save it for
your future reference and access. Further, if you consent to receiving notices and disclosures
exclusively in electronic format on the terms and conditions described above, please let us know
by clicking the ‘I agree’ button below.
By checking the ‘I agree’ box, I confirm that:

 I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF


ELECTRONIC CONSUMER DISCLOSURES document; and
 I can print on paper the disclosure or save or send the disclosure to a place where I can
print it, for future reference and access; and
 Until or unless I notify Stripe as described above, I consent to receive from exclusively
through electronic means all notices, disclosures, authorizations, acknowledgements, and
other documents that are required to be provided or made available to me by Stripe
during the course of my relationship with you.