Entity Status Certification Form Page 2
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4ENTITY STATUS CERTIFICATION FORM
3 Information about
Individual 1 - Identify individual’s role with the entity:
owners and other
[ ]Owner or Controlling person
[ ]Trustee/Estate Executor [ ]Trust Beneficiary/Estate Beneficiary [ ]Trust settlor
individuals who
have control over a
First Name
Middle Name
Last Name
Passive NFFE
Address
City
Instructions:
For Corporation, Partnership, or other
type of Passive NFFE please select
Province/State
Country
Postal/Zip Code
Owner or Controlling person category.
Is the individual a U.S. citizen or resident?
For Formal Trust and Estate please
No Yes – If yes, provide the U.S. Taxpayer Identification Number (TIN) card. If no TIN card provided, complete Form W-9
select Trustee/Estate Executor, Trust
…………………..
Beneficiary/Estate Beneficiary or
Trust settlor.
U.S. TIN (e.g. SSN)
Is the individual a tax resident of any other country (ies)
No Yes – If yes, list ____________________________________________________________________________________________
Individual 2 - Identify individual’s role with the entity:
[ ]Owner or Controlling person
[ ]Trustee/Estate Executor [ ]Trust Beneficiary/Estate Beneficiary [ ]Trust settlor
First Name
Middle Name
Last Name
Address
City
Province/State
Country
Postal/Zip Code
Is the individual a U.S. resident for tax purposes (which includes a U.S. citizen)?
No Yes – If yes, provide the U.S. Taxpayer Identification Number (TIN) card. If no TIN card provided, complete Form W-9.
…………………
U.S. TIN (e.g. SSN)
Is the individual a tax resident of any other country (ies)
No Yes – If yes, list ____________________________________________________________________________________________
Individual 3 - Identify individual’s role with the entity:
[ ]Owner or Controlling person
[ ]Trustee/Estate Executor [ ]Trust Beneficiary/Estate Beneficiary [ ]Trust settlor
First Name
Middle Name
Last Name
Address
City
Province/State
Country
Postal/Zip Code
Is the individual a U.S. resident for tax purposes (which includes a U.S. citizen)?
No Yes – If yes, provide the U.S. Taxpayer Identification Number (TIN) card. If no TIN card provided, complete Form W-9.
………………..
U.S. TIN (e.g. SSN)
Is the individual a tax resident of any other country (ies)
No Yes – If yes, list ____________________________________________________________________________________________
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