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CMB Self-Certification Form For Personal Account Holders September 27 2018

This document is a self-certification form for individuals and sole proprietors to complete for tax reporting purposes. It requests identification information about the account holder, their country of tax residence and taxpayer identification number. The form explains that the financial institution cannot provide tax advice and informs the individual to consult a tax advisor if needed. It also notes that information on the form will be reported as required to tax authorities in the country where the account is held and in other jurisdictions according to automatic exchange of information agreements.

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52 views3 pages

CMB Self-Certification Form For Personal Account Holders September 27 2018

This document is a self-certification form for individuals and sole proprietors to complete for tax reporting purposes. It requests identification information about the account holder, their country of tax residence and taxpayer identification number. The form explains that the financial institution cannot provide tax advice and informs the individual to consult a tax advisor if needed. It also notes that information on the form will be reported as required to tax authorities in the country where the account is held and in other jurisdictions according to automatic exchange of information agreements.

Uploaded by

Elly Pérez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

SELF CERTIFICATION FORM – Individuals/Sole Proprietors

Please complete this form if you are an individual account holder, sole trader or sole proprietor
For joint or multiple account holders please complete a separate form for each individual person.

If you are filling in this form on behalf of someone else.


You may be the custodian or nominee of an account on behalf of the account holder, or you may be
completing the form under a power of attorney.
Please tell us in what capacity you are signing in Part 3, and attach a supporting document to this
form, for example, a Power of Attorney or a Representation Agreement.
A legal guardian should complete the form on behalf of an account holder who is a minor.

As a financial institution, we are not allowed to give tax advice.


Your tax adviser may be able to assist you in answering specific questions on this form. Your
domestic tax authority can provide guidance regarding how to determine your tax status.

You can also find out more, including a list of jurisdictions that have signed agreements to
automatically exchange information, along with details about the information being requested, on
the OECD automatic exchange of information www.oecd.org.

Please complete parts 1-3 in BLOCK CAPITALS

Page 1 of 3
Part 1
Identification of Individual Account Holder

A. Name of Account Holder:


Family Name or Surname(s): _________________________________________________________
Title: ____________________________________________________________________________
First or Given Name:________________________________________________________________
Middle Name(s):___________________________________________________________________
Account number (s): ________________________________________________________________

B. Date of Birth: (dd/mm/yyyy) ________________________________________________________

C. Place of Birth: ___________________________________________________________________

D. Residence:
Residence address: _________________________________________________________________
Country of residence:________________________________________________________________

Part 2
Country/Jurisdiction of Residence for Tax Purposes and related
Taxpayer Identification Number or equivalent number (“TIN”)

Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the
Account Holder’s TIN for each country/jurisdiction indicated.
If the Account Holder is tax resident in more than three countries/jurisdictions, please use a separate sheet

If a TIN is unavailable please provide the appropriate reason A, B or C where indicated below:
 Reason A - The country/jurisdiction where the Account Holder is resident does not issue TINs to its
residents
 Reason B - The Account Holder is otherwise unable to obtain a TIN or equivalent number(Please
explain why you are unable to obtain a TIN in the below table if you have selected this reason)
 Reason C - No TIN is required

Country/Jurisdiction of Tax Residence TIN If no TIN available enter Reason A,B or C


1
2
3

Page 2 of 3
If applicable, please explain in the following boxes why you are unable to obtain a TIN if you selected
Reason B above

Part 3
Declarations and Signature
I agree that the information contained in this form and information regarding the Account Holder and any
Reportable Account(s) may be provided by CMB to the tax authorities of the country/jurisdiction in which
this account(s) is/are maintained and exchanged with tax authorities of another country/jurisdiction or
countries/jurisdictions in which the Account Holder may be tax resident pursuant to intergovernmental
agreements to exchange financial account information.

I certify that I am the Account Holder (or am authorized to sign for the Account Holder) of all the account(s)
to which this form relates.

I declare that all statements made in this declaration are, to the best of my knowledge and belief,
correct and complete.

I undertake to advise CMB within 30 days of any change in circumstances which affects the tax
residency status of the individual identified in Part 1 of this form or causes the information
contained herein to become incorrect or incomplete, and to provide CMB with a suitably updated
Self-certification and Declaration within 30 days of the occurrence of such change in circumstances.
Signature: ________________________________________________
Print name: ________________________________________________
Date: ________________________________________________

Note: If you are not the Account Holder please indicate the capacity in which you are signing the
form. If signing under a power of attorney please also attach a certified copy of the power of
attorney.
Capacity: _________________________________________________

Page 3 of 3

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