Entity Status Certification Form (Page 3 of 4) in pdf

Entity Status Certification Form Page 3

ENTITY STATUS CERTIFICATION FORM

Individual 4 - 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 ____________________________________________________________________________________________

4 Entity Customer

DECLARATION

Representative(s)

I/We declare that the information supplied on this form is true, correct and complete. The owner(s) agrees/agree to

declaration and

immediately notify NCB of any errors, omissions or changes in the information provided in this form, including any

signatures

change in U.S. residency or citizenship status of a controlling person, owner, and individuals involved in a trust, or

any change in the entity’s FATCA classification.

First Name

Middle Name

Last Name

Signature of signing officer or trustee

Title

Date

First Name

Middle Name

Last Name

Signature of signing officer or trustee

Title

Date

First Name

Middle Name

Last Name

Signature of signing officer or trustee

Title

Date

5 Staff member

Following my assessment of the AML/KYC information and documentation provided by the abovementioned customer, I

confirm that the certification provided seems reasonable.

Certification

_______________________

_________________

_____________________

_______________

NCB Staff Member’s Name

Page #

Signature

Date

Entity Status Certification Form Page 3

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