Fatca Declaration Form Page 3
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3Declaration and Representation
1. I / We represent and declare that the information provided is true, accurate and complete, and agree to provide TAF with any further
documentation or information required in accordance with the requirements of the FATCA.
2. I / We hereby provide my / our consent to TAF to report any relevant information to regulatory authorities in accordance with the requirements of
FATCA as may be stipulated by applicable laws, regulations, agreement or regulatory guidelines or directives.
3. I / We hereby provide my / our consent to TAF withholding from my / our account(s) such amounts in accordance with the requirements of FATCA
as may be stipulated by applicable laws, regulations, agreement or regulatory guidelines or directives.
4. I / We agree that if there is any change in the information provided to TAF that classify me / us as a U.S. person or deemed by TAF as a recalcitrant
(a person who fails to comply with reasonable requests for information to determine if this account belongs to a U.S. person), TAF has the right to
terminate my / our account(s) and the facilities granted to me / us.
5. I / We undertake to notify TAF in writing within 30 calendar days if there is any change in the information provided herein.
6. I / We agree to indemnify TAF in respect of any false or misleading information regarding my / our U.S. person status for FATCA purposes.
Signature
Signature
Name of Account Owner (1) / Authorised Signatory (1)
Name of Account Owner (2) / Authorised Signatory (2)
Date
Date
Kindly photocopy this page if there are more than 2 account holders or more than 2 authorised signatories are required to attest this document.
SECTION C (FOR TAF’S USE ONLY)
Form’s Processing
Yes
No
1. Are all the relevant questions answered?
2. Have the client provided all the relevant supporting documents?
3. Is the Declaration Form completed?
Checked By (Signature)
Verified By (Signature)
Name
Name
Date
Date
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