CRS INDIVIDUAL TAX RESIDENCY SELF-CERTIFICATION FORM

Form CRS-I

B. ACCOUNT HOLDER’S INFORMATION   *Denotes required information
Title :
* First Name :
Middle Name :
* Last Name/Surname :
* Date of Birth: :
* City/Town/Village of Birth: :
*Country of Birth: :
Contact Numbers:
Home: :
Work #: :
Fax: :
Mobile: :
Residential Address:
Address Line 1: :
Address Line 2: :
Country: :
Zip Code: :
Mailing Address: SAME AS RESIDENTIAL ADDRESS (Select if applicable)
Address Line 1: :
Address Line 2: :
Country: :
Zip Code: :
C. JURISDICTION(S) OF RESIDENCE FOR TAX PURPOSES AND RELATED TAXPAYER IDENTIFICATION NUMBER (TIN) OR FUNCTIONAL EQUIVALENT
Please complete section C.1 below if you are a tax resident of a jurisdiction, indicating:
(1) where the Account Holder is tax resident;

(2) the Account Holder’s TIN for each country/jurisdiction indicated.

If the Account Holder is tax resident in more than three (3) jurisdictions please use a separate sheet for each jurisdiction. Where you do not provide a TIN for any of the countries/jurisdictions you list, provide the applicable reason as outlined in Reasons A, B, or C below.


(i) Reason A – The country where the Account Holder is liable to pay tax does not issue TINs to its residents.

(ii)Reason B – No TIN is required. The jurisdiction identified issues TINs for tax purposes but does not require the collection of that TIN.

(iii)Reason C – The Account Holder is otherwise unable to obtain a TIN. For each country/jurisdiction where this reason is applied, please provide a corresponding explanation in section C.2.
C.1 DECLARATION OF JURISDICTION & TIN
Sl.No COUNTRY/JURISDICTION(S) OF TAX RESIDENCE TIN REASON IF NO TIN (A, B, C)
1.
2.
3.