Self Certification Form - Individual Page 3
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5Self Certification Form - Individual
Part 3
Declaration and Signature
I understand that the information supplied by me is subject to the terms and conditions governing the Account Holder’s
relationship with Standard Chartered PLC and its subsidiaries and affiliates where the Account Holder’s financial
relationship is maintained.
I acknowledge that the information contained in this Form and information regarding the Account Holder and any Reportable
Account(s) may be provided, directly or indirectly, to any relevant tax authority, including the tax authorities of the country
in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the
Account Holder may be resident for tax purposes pursuant to bilateral or multilateral agreements between governments to
exchange financial account information.
Certification
I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all of the account(s) to which this
Form relates.
I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.
I undertake to submit a suitably updated Form within 30 days of any change in circumstances which affects the tax
residency status of the Account Holder or where any information contained herein to become incorrect.
Sign Here
Signature of Account Holder (or individual authorised to sign for the Account Holder)
Print Name
Date (DD-MM-YYYY)
Note: If you are not the Account Holder please indicate the capacity in which you are signing the Form.
Capacity:
Please note that in providing the certification, a statement that is false, misleading or incorrect may be
regarded as an offence and, therefore may be subject to penalties under relevant law or regulation.
Page 2
Self Certification Form - Individual (10-2016)
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