Fatca Declaration Form

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TA Futures
A Member of the TA Group
FATCA DECLARATION FORM
Introduction
As a Malaysian Foreign Financial Institution (MYFI), TA Futures Sdn Bhd (hereinafter referred to as “TAF”) is obliged under an agreement reached in
substance between the Government of Malaysia and the Government of the United States of America to collect certain information about each
account holder’s tax residency status and to verify the status of the account holder for Foreign Account Tax Compliance Act (hereinafter referred to
as ‘FATCA’) purposes.
Instruction
Please complete this FATCA Declaration Form and provide any additional information or document as may be required by the relevant section.
Please consult your tax, legal and/or other professional advisers if you have any question on or in relation to FATCA, any of the U.S. IRS Form or this
Declaration Form. Account holders are required to complete Section A and B only.
Tick [ √ ] in the “Yes” or “No” column respectively for each of the following questions. Should you respond “Yes” to any of the following U.S. Indicia
Status, you are required to produce the required documents. If you do not submit the required documents, TAF will have to report your name, address
and other information to the Inland Revenue Board of Malaysia (hereinafter referred to as “IRBM”).
Please return this Declaration Form to TAF before 15th of June 2016 as failure to do so may result in TAF reporting your account detail to IRBM. A
duly completed Declaration Form shall be returned to TAF’s address, which can be found on the last page of this Declaration Form. If the client is
unable to return the Declaration Form before the stipulated date, a scanned copy e-mailed to .my would be deem sufficient to
meet the deadline. Notwithstanding the aforementioned, the client will still be required to send the original copy of the Declaration Form to TAF for
record-keeping purposes.
Section A
U.S. Indicia Status (Individual)
Yes
No
Document Required If Yes
1. Are you a U.S. citizen?
W-9 and U.S. Passport
2. Are you a U.S. Resident and a green card holder?
W-8BEN and MyKad / Malaysian
Passport / Loss Nationality
3. Is U.S. your country of birth?
Certificate
W-8BEN and MyKad / Malaysian
4. Is your residence address or mailing address (including a
Passport / Certificate of Residence
U.S. post office box) in the U.S.?
5. Do you have a current U.S. telephone number?
W-8 BEN and Mykad / Malaysian
6. Do you currently maintain any standing instructions to the U.S?
Passport
7. Do you currently grant power of attorney or signatory authority to any
person(s) within the U.S.?
8. Do you currently have a ‘hold mail’ or ‘in care of’ address located in
the U.S. as your sole address?
TA Futures Sdn Bhd
(340271-W)
1
(Trading Participant of Bursa Malaysia Derivatives Berhad)

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