Self Certification Form - Individual Page 5
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5Self Certification Form - Individual
Instructions
Part 3
Declaration and Signature
The Form must be signed and dated by the Account Holder. If this Form is completed by
Declaration and Signature
an Individual authorised to sign for the Account Holder, please indicate the capacity in
which you are signing the Form.
An authorised representative or officer must state the capacity in which he/she is signing
on behalf of the Account Holder. If this Form is completed by an agent acting under a duly
Capacity
authorised power of attorney, the Form must be accompanied by the power of attorney in
proper Form specifically authorising the agent to represent the Account Holder in making,
executing and presenting the Form.
Definitions
The following is a non-exhaustive list of selected terms to assist you with the completion of this Form. Should you have any
questions, please contact your tax, legal and/or other professional advisor.
• Account Holder: The term ‘Account Holder’ means the person listed or identified as the holder of a Financial Account.
A person, other than a Financial Institution, holding a Financial Account for the benefit of another person as an agent, a
custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated as the
Account Holder. In these circumstances that other person is the Account Holder. For example in the case of a parent/
child relationship where the parent is acting as a legal guardian, the child is regarded as the Account Holder. With respect
to a jointly held account, each joint holder is treated as an Account Holder.
• Financial Account: A Financial Account is an account maintained by a Financial Institution and includes: Depository
Accounts; Custodial Accounts; Equity and debt interest in certain Investment Entities; Cash Value Insurance Contracts;
and Annuity Contracts.
• Participating Jurisdiction: A Participating Jurisdiction means a jurisdiction with which an intergovernmental agreement
is in place pursuant to which it will provide the information required on the automatic exchange of financial account
information set out in the CRS.
• Reportable Account: A Reportable Account is a Financial Account that is maintained by a Reporting Financial Institution
and that, pursuant to due diligence procedures consistent with CRS, FATCA and any applicable IGAs, has been identified
as an account that is held by one or more persons that are US Persons or Reportable Persons with respect to another
Jurisdiction or by a Passive NFE with one or more Controlling Persons that are US Persons or Reportable Persons with
respect to another Jurisdiction.
• Reportable Jurisdiction: A Reportable Jurisdiction is a Participating Jurisdiction with which an obligation to provide
financial account information is in place.
• Reportable Person: The CRS defines the Account Holder as a ‘Reportable Person’. A Reportable Person is further
defined as an individual who is tax resident in a Reportable Jurisdiction under the laws of that jurisdiction.
• Taxpayer Identification Number (TIN): Taxpayer Identification Number or a functional equivalent in the absence of a
TIN. A TIN is a unique combination of letters or numbers assigned by a jurisdiction to an Individual or an Entity and used
to identify the Individual or Entity for the purposes of administering the tax laws of such jurisdiction. Further details of
acceptable TINs can be found at:
tax-identification-numbers/#d.en.347759.
Some jurisdictions do not issue a TIN. However, these jurisdictions often
utilise some other high integrity number with an equivalent level of identification (a ‘functional equivalent’). Examples
of that type of number include, for individuals, a social security/insurance number, citizen/personal identification/
service code/number, and resident registration number.
• US Person: A US Person is defined in section 7701(a) (30) of the Internal Revenue Code and includes an individual who
is a citizen or resident of the US.
Page 4
Self Certification Form - Individual (10-2016)
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