Self Certification Form - Individual Page 4
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5Self Certification Form - Individual
Instructions
Part 1
Identification of Individual Account Holder
A) Name of the Individual who is
Enter the name of the person listed or identified as the holder of a Financial
the Account Holder
Account.
Enter the Account Holder’s date of birth. Use the following format to input
B) Date of Birth
the Account Holder’s information DD-MM-YYYY.
C) Place of Birth
Enter the Account Holder’s place of birth.
D) Current Residence Address
Enter the Account Holder’s current residence address.
Enter the Account Holder’s mailing address only if it is different from the Current
E) Mailing Address
Residence Address.
F) Gender*
Check the relevant box indicating the Account Holder’s gender.
G) Country of Citizenship*
Enter the Account Holder’s country of citizenship.
H) Identification Number*
Enter the Account Holders identification number.
*Only complete these fields if you maintain a Financial Account in India where collection is required
Part 2
Tax Residence Information
Please complete the table indicating (i) where the Account Holder is resident for tax
purposes and (ii) the Account Holder’s Taxpayer Identification Numbe
r or functional
equivalent (hereafter referred to as ‘TIN’) for each country indicated.
The requirement to pay tax in a particular country does not necessarily signify tax
residence in that country; it is possible to have to pay tax in a country in which one is not
tax resident, and not to have to pay tax in a country in which one is tax resident. Whether
a person is tax resident in a particular country depends on whether that person meets the
definition of a tax resident under the tax laws of that country. For more information on tax
residence, please consult your tax advisor or refer to the information at OECD automatic
exchange of information portal at
implementation-and-assistance/tax-residency/#d.en.347760.
If the Account Holder is a dual citizen, enter the country where the Account Holder is both
a citizen and a resident at the time this form is completed. If the Account Holder is not a
Tax Residence/Citizenship
resident in any country in which the Account Holder has citizenship, enter the country
Information
where the Account Holder was most recently a resident. If the Account Holder is a US
citizen, a Form W-9 must be provided.
If a TIN is unavailable, please provide the appropriate Reason A, B or C.
• Reason A should be selected by an Account Holder where the country concerned does
not, under any circumstances, issue TINs to individual tax residents. Where the country
concerned does issue TINs to individual tax residents, but the Account Holder has
not been issued with a TIN because of particular circumstances, Reason B should be
selected instead.
• If you have selected Reason B, please explain why the Account Holder is unable to
obtain a TIN, even though the country concerned does issue TINs to individual tax
residents.
•
Reason C should be selected if the country that issues the TINs does not require TINs of
individual tax residents to be collected or reported.
Page 3
Self Certification Form - Individual (10-2016)
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