Form Crs-I - Crs Individual Self-Certification Page 2
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4CRS Individual Self-Certification Form
Please complete parts 1-3 in BLOCK CAPITALS.
Important Notes
______________
This is a self-certification form provided by an account holder to Hang Seng Bank Limited for the purpose of automatic exchange of
•
financial account information. The data collected may be transmitted by Hang Seng Bank Limited to the Inland Revenue Department for
transfer to the tax authority of another jurisdiction.
An account holder should report all changes in his/her tax residency status to Hang Seng Bank Limited.
•
All parts of the form must be completed (unless not applicable or otherwise specified). If space provided is insufficient, continue on
•
additional sheet(s). Information in fields/parts marked with an asterisk (*) are required to be reported by Hang Seng Bank Limited to the
Inland Revenue Department.
Part 1 – Identification of Individual Account Holder
A. Name of Account Holder
Mr
Mrs
Ms
Miss
Other
__________________________________________________________________________
Family Name or Surname(s)*
First or Given Name*
Middle Name(s)
ID Document Type
HKID
Passport
Other
______________________________________________________________
ID Document No.
_______________________________________________________________________________________________________
B. Current Residence Address
Line 1
(e.g. Suite, Floor, Building,
Street, District)
Line 2
(e.g. City)*
Line 3
(e.g. Province/State)
Country*
Postal Code/ZIP Code
C. Mailing Address (Please only complete if different to the address shown in Section B)
Line 1
(e.g. Suite, Floor, Building,
Street, District)
Line 2
(e.g. City)
Line 3
(e.g. Province/State)
Country
Postal Code/ZIP Code
D. Date of Birth*
(DD/MM/YYYY)
For Bank Use
For Part 1, refer to AO Form of A/C No.:
dated
:
(DD/MM/YYYY)
_____________________________________
__________________________
For Part 1, refer to Insurance Application Form of No.:
dated
:
(DD/MM/YYYY)
_______________________________
____________________
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