Certification, Consent, And Waiver (Page 2 of 4) in pdf

Act and Republic Act Number 8791 or the General Banking Law of 2000, as amended in

each case, for the purpose of the RBSC’s compliance with the reportorial requirements

of the FATCA/US IRS Regulations;

b) my/the Entity’s agreement and consent to the processing and updating of all

information relative to my/its Account under Republic Act Number 10173 or the Data

Privacy Act of 2012;

c) my/the Entity’s consent and waiver of such rights and privileges under any other law of

the Philippines which will require the issuance of a consent and/or waiver for the

disclosure and/or processing of any and all information relating to my/its Account with

RBSC for purposes of compliance with FATCA; and

d) my/the Entity’s acknowledgement and consent for RBSC to report and disclose to the

BIR and for the BIR, in turn, to disclose to the US IRS, the following information (and/or

such other information as may be required), relative to the Account pursuant to the

FATCA/US IRS Regulations and IGA Model 1:

i. The name, address, and U.S. tax identification number (TIN)

;

ii. In the case of any account holder that is a U.S. entity with one or more U.S. owners

of such entity;

iii. The account number;

iv. The year-end account balance or value; and

v. Gross receipts and gross withdrawals or payments from the account.

This Certification, Consent, and Waiver is given by me/the Entity only for purposes of

compliance by RBSC with the FATCA.

FOR NON-U.S. PERSONS: Where I have answered that I am NOT a U.S. Person and have

committed to submit the required documents in support thereof, I hereby affirm and confirm

the truth of such declaration and the authenticity of the supporting documents to be

submitted. I undertake to inform RBSC in writing of any change in circumstance that will affect

the accuracy of such declaration or supporting documents within thirty (30) calendar days from

the occurrence of such change. Further, I hereby acknowledge that RBSC shall operate the

Account on the basis of such declaration. In the event that RBSC discovers that I am a U.S.

Person, then RBSC is hereby absolutely and unconditionally authorized to report and disclose to

the U.S. IRS the Required Information. I further undertake to provide RBSC with such Required

Information as may be requested.

By signing this Certification, Consent, and Waiver, I/the authorized officers of the Entity hereby

undertake/s to indemnify and hold

, its officers, employees, representatives, agents, or

RBSC

relevant units, free and harmless from and against all liabilities, claims, demands, actions,

proceedings, losses, expenses, and all other liabilities of whatsoever nature or description

which may be suffered or incurred by

, its officers, employees, representatives, agents, or

RBSC

relevant units, arising from or in connection with the execution of this Supplemental

Certification, Consent, and Waiver.

By signing hereunder, I/the authorized officers of the Entity represent, warrant and confirm

that (1) I/we have read and understood this Supplemental Certification, Consent, and Waiver

and (2) the undersigned is/are the account holder/its duly authorized representative/s allowed

to execute and deliver this Certification, Consent, and Waiver for and on behalf of the Entity,

as evidenced by Annex "A".

US TIN may pertain to any of the following:

For individuals: (1) social security number (SSN), (2) individual taxpayer identification number (ITIN), or (3)

adoption taxpayer identification number (ATIN).

For juridical entities: Employer identification number (EIN).

Certification, Consent, And Waiver Page 2

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