1 of 5 TAX RESIDENCY SELF-CERTIFICATION FORM (ENTITY)

Transcription

1 pplication No. / Nombor Permohonan TX RESIDENY SELF-ERTIFITION FORM (ENTITY) IMPORTNT NOTIE: You are to disclose in this form, fully and faithfully, all the facts which you know or ought to know, otherwise the policy if issued hereunder may be invalidated. If you are in any doubt about whether certain facts are material, these facts should be disclosed. NOTES: - Terms used in this form are defined in the separate RS ppendix. The RS ppendix can be obtained from the company website under the X FFIN Life Documents Download: Underwriting Questionnaire Form: See in the List of None Medical Questionnaires. - For the purposes of the RS in this form, "ccount Holder" are defined as Proposed Insured and Proposed Owner. - This form will remain valid unless there is a change in circumstances that affects the tax residency status of the account holder or causes the information contained herein to become incorrect or incomplete. In that case, you must notify by providing the ompany with an updated Self-ertification Form within thirty (0) days of such change in ommon Reporting Standard (RS) for the utomatic Exchange of Financial ccount Information The RS was developed by the Organisation for Economic ooperation and Development (OED) to put a global model of automatic exchange of information into practice for the purpose of tax compliance. It sets out the financial account information to be exchanged, the financial institutions required to report, the different types of accounts and taxpayers covered, as well as common due diligence procedures to be followed by financial institutions. Under the RS, Malaysian Financial Institutions (MYFIs) are required to collect and report to Inland Revenue oard of Malaysia (IRM), financial account information on non-residents. IRM will exchange this information with the participating foreign tax authorities of those non-residents. RS obligations are imposed on MYFIs through the operation of the Income Tax (utomatic Exchange of Financial ccount Information) Rules 06 (RS Rules) P.U. () /06. Tax residency - self-certification is a certification by the ccount Holder that provides the ccount Holder s status and any other information that may be reasonably requested by the MYFIs to fulfil its reporting and due diligence obligations, such as whether the ccount Holder is resident for tax purposes in a reportable jurisdiction. Each jurisdiction has its own rules for defining tax residence. If you have any questions on how to determine your tax residency status, you should consultyour tax adviser or information could be obtained at the OED automatic exchange of information portal [ information.htm]. The ompany will not be in a position to provide assistance beyond the information set out herein. Note: In the case of a ash Value Insurance ontract or an nnuity ontract, the ccount Holder is any person entitled to access the ash Value or change the beneficiary of the contract. If no person can access the ash Value or change the beneficiary, the ccount Holder is any person named as the owner in the contract and any person with a vested entitlement to payment under the terms of the contract. Upon the maturity of a ash Value Insurance ontract or an nnuity ontract, each person entitled to receive a payment under the contract is treated as an ccount Holder. ommon Reporting Standard (RS) Declaration: I certify that I am the ccount Holder of all the accounts to which this form relates. I acknowledge that the information contained in this form, including information regarding the ccount Holder and any reportable account(s) may be reported to IRM and exchanged with the tax authorities of another country or countries in which the ccount Holder may be tax resident, pursuant to intergovernmental agreements to exchange financial account information. I declare that all statements made in this form are, to the best of my knowledge and belief, correct and complete. I undertake to inform the ompany if there is any change in circumstances that affects the tax residency status of the ccount Holder or causes the information contained herein to become incorrect or incomplete. I shall provide the ompany with an updated self-certification form within thirty (0) days of such change in I understand that any person who provides any incorrect information required to be provided under the Malaysian laws of International Tax ompliance shall (unless he can show that he provided such incorrect information in good faith) be guilty of an offence is punishable with a fine not less than RM0,000 and not exceeding RM00,000 or imprisonment for up to six (6) months or both. I agree to complete and sign such documents and do such things for purposes reasonably required by the ompany to evaluate my proposal and to provide the products or services which I am applying for. X FFIN Life Insurance erhad (779W) 8th Floor, hulan Tower, No. Jalan onlay, 00 Kuala Lumpur Telephone: Fax: N/RS ENTITY/V./07 of

2 PRT : Identification of Entity ccount Holder. Legal name of Entity ccount Holder (as per ompany registration):. Entity Unique/ompany Registration No:. ountry of Incorporation or organisation (ountry of ompany being registered): D. usiness registered address: ountry E. usiness mailing address (please only complete if different from business registered address.) ountry PRT : Entity Type (Tick P Only One box to provide the ccount Holders s status.). P Financial Institution ( FI ) (a) n Investment Entity located in a Non-Participating Jurisdiction and managed by another FI. (If you have ticked this box, please complete the ontrolling Person of Entity below) (b) Other Investment Entity (c) Depository Institution, ustodial Institution or Specified Insurance ompany P Non-Financial Entity ( NFE ) (d) ctive NFE - orporation the stock of which is Regularly Traded on an established securities market or a corporation which is a Related Entity of such a corporation. i) Please provide the name of the established securities market on which the corporation is regularly traded: ii) If you are a Related Entity of a Publicly Traded orporation - please provide the name of the Regularly Traded orporation that you are a Related Entity of: (e) ctive NFE - Government Entity or entral ank (f) ctive NFE - n International Organisation (g) Other than (d)-(f) (for example a start-up NFE or a non-profit NFE) (h) Passive NFE : NFE that is not an ctive NFE (IF you have ticked this box, please complete the ontrolling Person of Entity below). ontrolling Person(s) of Entity (If you have tick (a) or (h) in Table above): i) Please indicate name of any ontrolling Person(s) of the ccount Holder below: ii) omplete a separate Tax Residency Self ertification Form (ontrolling Person) for each ontrolling Person.. No. Name of ontrolling Person(s) of the ccount Holder of

3 PRT : ountry/jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent ( TIN ) * Notes - If a TIN is unavailable please provide the appropriate reason, or where indicated below: Reason - The country/jurisdiction where the ccount Holder is resident does not issue TINs to its residents Reason - The ccount 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 - No TIN is required. (Note. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction) If the ccount Holder is tax resident in more than five countries/jurisdictions, please use a separate sheet Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason above. ountry of Tax Residence TIN * Reason IF TIN unavailable PRT : Please complete this section if the declaration in this form 'including the application form' differ from the supporting documents provided to us. Reason: Please also provide supporting document of the country(s) you are tax resident of. DELRTION OF UTHORISED PERSON I certify that I am the ccount Holder of all the accounts to which this form relates. I acknowledge that the information contained in this form, including information regarding the ccount Holder and any reportable account(s) may be reported to IRM and exchanged with the tax authorities of another country or countries in which the ccount Holder may be tax resident, pursuant to intergovernmental agreements to exchange financial account information. I declare that all statements made in this form are, to the best of my knowledge and belief, correct and complete. I undertake to inform the ompany if there is any change in circumstances that affects the tax residency status of the ccount Holder or causes the information contained herein to become incorrect or incomplete. I shall provide the ompany with an updated self-certification form within thirty (0) days of such I understand that any person who provides any incorrect information required to be provided under the Malaysian laws of International Tax ompliance shall (unless he can show that he provided such incorrect information in good faith) be guilty of an offence is punishable with a fine not less than RM0,000 and not exceeding RM00,000, or imprisonment for up to six(6) months or both. Date: Day Month Year Signature of ccount Holder Name: of

4 TX RESIDENY SELF-ERTIFITION FORM (ONTROLLING PERSON) IMPORTNT NOTIE : You are to disclose in this form, fully and faithfully, all the facts which you know or ought to know, otherwise the policy if issued hereunder may be invalidated. If you are in any doubt about whether certain facts are material, these facts should be disclosed. NOTES: - Terms used in this form are defined in the RS ppendix. The RS ppendix can be obtained from the company website under the X FFIN Life Documents Download: Underwriting Questionnaire Form: See in the List of None Medical Questionnaires. - This form will remain valid unless there is a change in circumstances relating to information that makes this form incorrect or incomplete. In that case, you must notify by providing the ompany with an updated Self-ertification Form within thirty (0) days of such change in PRT : Identification of a ontrolling Person. (a) Full Name (including aliases, as per Identification): (b) NRI / Passport No.: (d) ontact No.: (e) Date of irth (dd/mm/yyyy): (g) ountry of birth: (i) urrent Residence ddress: (State Name of ountry) (c) Passport Expiry Date (dd/mm/yyyy): - (f) Place of birth (/ity of irth): (h) Sex: Male Female ountry (j) Mailing ddress (please only complete if different from your residence address): ountry PRT - ountry/jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent ( TIN ) Note : Please complete the following table indicating: (i) where the ontrolling Person is tax resident; (ii) the ontrolling Person s TIN for each country/jurisdiction indicated; and (iii) if the ontrolling Person is a tax resident in a country/jurisdiction that is a Reportable Jurisdictions then please also complete Part Type of ontrolling Person. If the ontrolling Person is tax resident in more than five() countries/jurisdictions, please use a separate sheet. *If a TIN is unavailable please provide the appropriate reason, or where indicated below: Reason - The country/jurisdiction where the ontrolling Person is resident (liable to pay tax but) does not issue TINs to its residents. Reason - The ontrolling Person is otherwise unable to obtain a TIN or equivalent number. (Please explain why you are unable to obtain a TIN if you have selected this reason) Reason - No TIN is required. (Note. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction) ountry of Tax Residence Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason above. TIN If no TIN available enter Reason, or of

5 PRT : Please complete this section if the declaration in this form 'including the application form' differ from the supporting documents provided to us Reason (note: please tick only one box) P. Student at an educational institution in the country of residential/mailing address/telephone numbers. Working in the country of residential/mailing address/telephone number for less than 6 months. On an educational or cultural exchange visitor program in the country of residential/ mailing address/ telephone number for less than 6 months. Regular travel between countries/ jurisdictions for work and home. Others - Please state: ii) Please provide a copy of your national identity card or passport other government issued identity document of the country(s) you are tax resident of. PRT - Name of Legal Entity & Type of ontrolling Person (Please only complete this section if the ontrolling Person in Tax Residence in one or more Reportable Jurisdiction ) Please provide the ontrolling Person s status by ticking one of the appropriate box. ontrolling Person of a Legal Person ontrol by ownership ontrol by other means Senior managing official ontrolling Person of a Trust Settlor Trustee Protector eneficiary Others ontrolling Person of a Legal rrangement (non-trust) Settlor - Equivalent Trustee - Equivalent Protector - Equivalent eneficiary - Equivalent Others - Equivalent DELRTION ND SIGNTURE I certify that I am the ontrolling Person of all the accounts to which this form relates. I acknowledge that the information contained in this form, including information regarding the ontrolling Person and any reportable account(s) may be reported to IRM and exchanged with the tax authorities of another country or countries in which the ontrolling Person may be tax resident, pursuant to intergovernmental agreements to exchange financial account information. I declare that all statements made in this form are, to the best of my knowledge and belief, correct and complete. I undertake to inform the ompany if there is any change in circumstances that affects the tax residency status of the ontrolling Person or causes the information. contained herein to become incorrect or incomplete. I shall provide the ompany with an updated self-certification form within thirty (0) days of such I understand that any person who provides any incorrect information required to be provided under the Malaysian laws of international Tax ompliance shall (unless he can show that he provided such incorrect information in good faith) be guilty of an offence is punishable with a fine not less than RM0,000 and not exceeding RM00,000, or imprisonment for up to six (6) months or both. Date: Day Month Year Signature of ontrolling Person Name: of