Fatca (Us Foreign Account Tax Compliance Act) Declaration Page 2

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Section 3: Companies
Please select one of the categories below that identifies the company that you are investing through.
3.1 US Company
- Provide the Entity’s TIN
- Is this entity an Exempt Payee for US tax purposes
Yes
No
3.2 Australian company that is a Financial Institution
(A company may be a Financial Institution if it is an investment entity that trades in financial assets or invests, administers, manages
funds, money or certain financial assets on behalf of other persons.) (also complete Section 5)
3.3 Australian company that is not a Financial Institution
3.3.1 Does the company derive more than 50% of its gross income from passive investment investment activities (for example
rent, capital gains, interest & dividends) or does more than 50% of the entities assets produce or are held for the production
of passive investment income?
Yes (go to Section 3.3.2)
No (go to Signatories)
3.3.2 Are any of the Beneficial Owners, through one or more shareholdings of more than 25% of the company’s issued capital, US
Persons for tax purposes?
Yes (go to Section 4)
No (go to Signatories)
Section 4: Information on US owners / beneficiaries
You must complete this section if you have answered Yes to questions 2.4.2 or 3.3.2 please provide below the name, address and TIN of
each US Person.* If you need more space please continue the table on another page and attach it to this form.
Name
Address
Tax ID (TIN)
*This is required as we have deemed you a Passive Non-Financial Foreign Entity (refer to Centuria’s FATCA Guide). If you believe you fit any other definition for an Active NFFE,
please contact the investor services team.
Section 5: Financial Institutions
(A custodial or depository institution, an investment manager or a specified insurance company for FATCA purposes)
If you are a Financial Institution and have a Global Intermediary Identification Number (GIIN) please provide that here:
If you do not have a GIIN, please provide your FATCA Status as one of the following:
Deemed Compliant Foreign Financial Institution (FFI)
Excepted FFI
Exempt beneficial owner
Non-participating FFI
Other FATCA status
- Insert FATCA status
2
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