Fillable Form Crs-I - Crs Individual Self-Certification (Page 4 of 4) in pdf

Part 3 – Declarations and Signature

I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder’s

relationship with Hang Seng Bank Limited (“Hang Seng Bank”) setting out how Hang Seng Bank may use and share the information supplied

by me.

I acknowledge and agree that (a) the information contained in this form is collected and may be kept by Hang Seng Bank for the purpose of

automatic exchange of financial account information, and (b) such information and information regarding the Account Holder and any

Reportable Account(s) may be provided by Hang Seng Bank to the Inland Revenue Department of the Government of the Hong Kong Special

Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the Account Holder may be

resident for tax purpose pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue

Ordinance (Cap.112).

I also agree that the information contained in this form may be shared to and used by any member of the Hang Seng Bank Group (including

any affiliates, subsidiaries and associated entities of Hang Seng Bank and their branches and offices) for the purposes of automatic

exchange of financial account information provided under the Inland Revenue Ordinance as set out above.

I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form relates.

I certify that where I have provided information regarding any other person (such as a Controlling Person or other Reportable Person to which

this form relates) that I will, within 30 days of signing this form, notify those persons that I have provided such information to Hang Seng Bank

and that such information may be provided to the Inland Revenue Department of the Government of the Hong Kong Special Administrative

Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the person may be resident for tax purposes

pursuant to the legal provisions for exchange of financial account information provided under the Hong Kong Inland Revenue Ordinance

(Cap.112).

I declare that the information given and all statements made in this form and declarations are, to the best of my knowledge and

belief, true, correct and complete.

I undertake to advise Hang Seng Bank within 30 days of any change in circumstances which affects the tax residency status of the individual

identified in Part 1 of this form or causes the information contained herein to become incorrect, and to provide Hang Seng Bank with a

suitably updated self-certification and Declaration within 90 days of such change in circumstances.

Print Name

Signature

Date

(DD/MM/YY)

____________________________________________________________

Please use signature(s)/chop(s) field with the Bank

Note: If you are not the Account Holder please indicate the capacity in which you are signing the form. If signing under a power of attorney please also

attach a certified copy of the power of attorney.

Capacity:

WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification,

makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the

statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a

fine at level 3 (i.e. HK$10,000).

In the event of any discrepancy or inconsistency between the English version and the Chinese version of this form, the English version shall

prevail.

Page 4/4

Form Crs-I - Crs Individual Self-Certification Page 4

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