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

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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
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To confirm to us that you can access this information electronically, which will be similar to
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able to read this electronic disclosure and that you also were able to print on paper or
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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
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