B2 (English) Self-certification form for entities

Transcription

1 Załącznik nr 4-a do Zasad- Self-certification form for entities B2 (English) Self-certification form for entities In accordance with the provisions of the Act of 9 October 2015 on execution of the Agreement between the Government of the United States of America and the Government of Poland to Improve International Tax Compliance and to Implement FATCA (Journal of Laws of 2015, item 1712) (hereinafter, "the FATCA Act"), Polish financial institutions are required to identify US reportable accounts and to collect and transmit information about these accounts to the minister for public finances or another authorized body, which requires verification of whether a customer is a tax resident of the United States of America, i.e. whether it is a US Person (as defined below). Considering the above, Bank BGŻ BNP Paribas SA with its registered office in Warsaw at ul. Kasprzaka 10/16, Warsaw (hereinafter, the "Bank"), as the Polish reporting financial institution asks you to answer questions contained in this self-certification form. This form must be completed by the customer as part of the process of signing an agreement with the Bank. 1. General information Several terms in this form are underlined. Please find their explanation in the glossary attached to this form. 1a Entity name [ ] 1b Modulo No./Agreement No. (customer no.) [ ] [ ] [ ] [ ] 1c Entity registration number (KRS) [ ] The entity does not have KRS 1d Business address Street [ ] Number Postal code [ ] City [ ] Country [ ] Telephone number [ [ 1e Is Entity an Active NFFE (essentially an entity conducting commercial or business activity other than financial activity, or listed on a stock exchange or related to a listed company. Please refer to the Glossary below for full definition) Yes Please go to section 2 No Please go to section 2 (NB: answer to question 1e to be provided only by entities other than Financial Institutions)

2 2. Additional information 2a Is the entity a U.S. Person? Please go to section 3 (As a U.S. Person you may be liable to tax in the USA) 2b Was the entity incorporated in Please go to section 3 the United States or under the US law or the law of any State? Such information is to be found in the articles of association, instruments of incorporation, instrument of constitution of the entity. 2c Is the entity a financial institution? Please go to section 4 2d Does the entity have any Controlling Please go to section 5 Persons that are U.S. Persons? Please go to section 7 3. Employer Identification Number (EIN) 3a Please provide the EIN (Employer Identification Number) of the entity [ ] Please go to section 3b O The entity does not have an EIN Please request an EIN for the entity. Please fill out this form starting from question 3a once you have obtained the EIN. 3b Is the entity a non-specified, the exempt code of the entity is [ ] U.S. person? Please go to section 7 Please go to section 7 4. Information about the financial institution (The entity could be subject to tax in the United States). 4a Does the financial institution have a, the GIIN is [ ] GIIN (Global Intermediary Identification Please go to section 7 Number)? 4b Is the entity an Please go to section 7 Exempt Beneficial Owner? 4c Is the entity a certified deemed- Please go to section 7 compliant foreign financial institution? 4d Is the entity a non-participating Please go to section 7 financial institution? Please go to section 7 5. Information about the non-financial institution

3 5a Is the entity listed on a stock exchange? Please go to section 7 5b Is the entity part of a group? Please go to section 5d 5c Are one or more entities of this group Please go to section 7 listed on a stock exchange? 5d What percentage of the income of the O 50% or more Please go to section 5f entity consisted of passive income O Less than 50% during the last calendar year? 5e What percentage of the entity s assets were used to acquire passive income? O 50% or more of the entity s assets O less than 50% of the entity s assets Please go to section 7 5f Is the entity a holding company? Please go to section 5n 5g Are all subsidiaries of the holding company active operating companies? Please go to section 5n 5h Does the holding company perform Please go to section 7 activities that substantially consist of holding active operating companies? 5i Does the holding company perform activities Please go to section 7 that substantially consist of providing financing and services to active operating companies? 5j Does the holding company perform activities Please go to section 7 that substantially consist of a combination of the functions mentioned in 5h and 5i? 5k Does the holding company have any other income apart from the income of the Please go to section 7 active operating companies? 5l What percentage of this other income O 50% or more Please go to section 5n consisted of passive income during O Less than 50% the last year? 5m How did the entity acquire the passive income? O With less than 50% or more of the assets of the holding Please go to section 7 O With 50% of the assets of the holding 5n Does the entity have a GIIN, the GIIN is [ ] Please go to section 7 5o Is the entity a non-profit organization? Please go to section 7

4 5p Is the entity currently in liquidation or bankruptcy or is the entity reorganizing Please go to section 5s to resume activities? 5q Could the entity have been considered a financial institution in the past 5 years? Please go to section 5s 5r Is the entity planning to become please go to section 5s a financial institution? Please go to section 7 5s Is the entity an exempt beneficial owner? Please go to section 7 ` 5t Is the entity a U.S. territory NFFE? Please go to section 7 5u Does the entity act as a Qualified Intermediary Please go to section 7 withholding partnership or a withholding trust? 5v Is the entity a treasury center in a group? Please go to section 5z 5w Is the group primarily engaged in a business other than that of a financial Please go to section 5z institution? 5x Does the entity provide treasury services to third parties? Please go to section 5z 5y Does the entity provide treasury services to financial institutions? Please go to section 7 5z Is the entity currently operating a Please go to section 6 business? 5aa Has the entity operated a business Please go to section 6 in the past? 5ab Was the entity established less than 24 months ago? Please go to section 6 5ac Is the entity planning on performing activities? Please go to section 6 5ad Is the entity planning on performing Please go to section 6 activities similar to the activities of a financial institution? Please go to section 7

5 6. Information on Controlling Persons Please provide below the required information on controlling persons that are U.S. persons. We are legally bound to collect and report the data of U.S. persons to the minister for public finances or another authorized body. Controlling person 1 First and Middle Name(s) Date of birth U.S. TIN [ ] [ ] [ ] dd-mm-yyyy [ ] Residence Address Street Number Postal code City Province/state Country Controlling person 2 First and Middle Name(s) Date of birth U.S. TIN [ ] [ ] [ ] dd-mm-yyyy [ ] Residence Address Street Number Postal code City Province/state Country Controlling person 3 First and Middle Name(s) Date of birth U.S. TIN [ ] [ ] [ ] dd-mm-yyyy [ ] Residence Address Street Number Postal code

6 City Province/state Country Controlling person 4 First and Middle Name(s) Date of birth U.S. TIN [ ] [ ] [ ] dd-mm-yyyy [ ] Residence Address Street Number Postal code City Province/state Country If the entity has more than four Controlling Persons, please make a copy of this form and complete the information for the additional Controlling Persons. 7. Customer s statement and clause referred to in Article 4 para. 4 of the FATCA Act The customer hereby confirms that the information provided in this form has been checked and that it is true, correct and complete. The customer undertakes to inform the Bank of any changes concerning the information provided above within 30 days of such changes. The clause referred to in Article 4 para. 4 of the FATCA Act: "I am aware of criminal liability for making a false statement." This form should be signed in accordance with representation principles and by persons authorized to sign for and on behalf of the customer. Date [ ] [ ] [ ] dd-mm-yyyy Place [ ] Authorized representative First and Middle name(s) [ ] Signature Authorized representative

7 First and Middle name(s) [ ] Signature Authorized representative First and Middle name(s) [ ] Signature Doradca zweryfikował pod kątem zgodności ww. danych z przedstawionymi przez Klienta dokumentami Imię i nazwisko Doradcy Podpis Klasyfikacja FATCA (podaj kod 4-literowy):

8 Glossary USA/United States The United States of America, including the States thereof, but excluding the U.S. Territories. Any reference to a State of the United States includes the District of Columbia. The term U.S. Territory means American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Commonwealth of Puerto Rico, or the U.S. Virgin Islands. An Active NFFE It is any non-financial foreign entity (NFFE) that meets any of the following criteria: a) Less than 50 percent of the NFFE s gross income for the preceding calendar year or other appropriate reporting period is passive income (see Active/Passive Income) and less than 50 percent of the assets held by the NFFE during the preceding calendar year or other appropriate reporting period are assets that produce or are held for the production of passive income; b) The stock of the NFFE is regularly traded on an established securities market or the NFFE is a related entity (for a definition of related entity, see glossary) of an entity the stock of which is traded on an established securities market; c) The NFFE is organized in a U.S. Territory and all of the owners of the payee are bona fide residents of that U.S. Territory; d) The NFFE is a non-u.s. government, a government of a U.S. Territory, an international organization, a non-u.s. central bank of issue, or an entity wholly owned by one or more of the foregoing; e) Substantially all of the activities of the NFFE consist of holding (in whole or in part) the outstanding stock of, and providing financing and services to, one or more subsidiaries that engage in trades or businesses other than the business of a financial institution, except that an NFFE will not qualify for this status if the NFFE functions (or holds itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund or any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes; f) The NFFE is not yet operating a business and has no prior operating history, but is investing capital into assets with the intent to operate a business other than that of a Financial Institution, provided that the NFFE shall not qualify for this exception after the date that is 24 months after the date of the initial organization of the NFFE; g) The NFFE was not a financial institution in the past five years and is in the process of liquidating its assets or is reorganizing with the intent to continue or recommence operations in a business other than that of a financial institution; h) The NFFE primarily engages in financing and hedging transactions with or for related entities that are not financial institutions, and does not provide financing or hedging services to any entity that is not a related entity, provided that the group of any such related entities is primarily engaged in a business other than that of a financial institution; i) The NFFE is an excepted NFFE as described in relevant U.S. Treasury Regulations; or j) The NFFE meets all of the following requirements: i. It is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural, athletic or educational purposes, or it is established and operated in its jurisdiction of residence and it is a professional organization, business league, chamber of commerce, labor organization, agricultural or horticultural organization, civic league or an organization operated exclusively for the promotion of social welfare; ii. It is exempt from income tax in its jurisdiction of residence; iii. It has no shareholders or members who have a proprietary or beneficial interest in its income or assets; iv. The applicable laws of the entity s jurisdiction of residence or the entity s formation documents do not permit any income or assets of the entity to be distributed to, or applied for the benefit of, a private person or non-charitable entity other than pursuant to the conduct of the entity s charitable activities, or as payment of reasonable compensation for services rendered, or as payment representing the fair market value of property which the entity has purchased; and v. The applicable laws of the entity s country of residence or the entity s formation documents require that, upon the entity s liquidation or dissolution, all of its assets be distributed to a governmental entity or other non-profit organization, or escheat to the government of the entity s country of residence or any political subdivision thereof.

9 Certified Deemed-Compliant financial institution A certified deemed-compliant financial institution is a financial institution which must comply with the FATCA regulations. However, this institution does not have to register with the United States tax authorities (IRS) to receive a GIIN. Instead it certifies to other financial institutions that it is compliant with the requirements of a certified deemed-compliant financial institution according to FATCA. This also applies to institutions that have been included as deemed-compliant financial institutions in Annex II of any IGA. FATCA contains four categories of certified deemed-compliant financial institutions: 1. Certified deemed-compliant non-registering local bank 2. Certified deemed-compliant financial institution with only low value accounts 3. Certified deemed-compliant sponsored, closely held investment vehicle 4. Certified deemed-compliant limited life debt investment company. If you are uncertain whether the entity could qualify for a certified deemed-compliant FFI status, please consult a tax advisor specializing in American tax law. Controlling person Individual or individuals who exercise control over entity. In the case of a trust it means the founder, custodians, supervisors (if present), beneficiaries or group of beneficiaries and any other individual effectively exercising control over trust and in other than trust cases, this means individuals who perform similar roles. EIN (Employer Identification Number) An EIN is used by the United States tax authorities (IRS) as a tax identification number for employers. This number is also known as U.S. federal taxpayer identification number (U.S. TIN). Entity An entity is a legal person or a partnership. Examples of legal persons: limited liability company, jointstock company. Examples of partnerships: registered partnership, limited joint stock partnership, limited partnership, professional partnership. Exempt beneficial owner An exempt beneficial owner is a financial institution which is exempt from having to report to US IRS pursuant to FATCA/IGA. The following organizations could qualify for the status of exempt beneficial owner: Pension funds: Treaty-Qualified Retirement Fund, Broad Participation Retirement Fund, Narrow Participation Retirement Fund, Pension Fund of an Exempt Beneficial Owner; Polish government bodies and institutions and their agencies; International organizations or organizations wholly owned by an international organization that have signed an agreement to be domiciled or headquartered in Poland; The National Bank of Poland. This is not an exhaustive list. If you are uncertain whether the entity could qualify for the exempt beneficial owner status, please consult a tax advisor specializing in American tax law. Exempt code An exempt code can be used by the United States tax authorities (IRS) for identification purposes. This code or character indicates that the entity is a non-specified U.S. Person. If you are uncertain whether an entity has the correct exempt code, please consult a tax advisor specializing in American tax law. FATCA FATCA is an abbreviation of Foreign Account Tax Compliance Act. This United States tax legislation is aimed at identifying U.S. Persons that have an account or financial assets outside of the United States. The government of Poland has concluded an agreement with the government of the United States with respect to the exchange of information regarding: U.S. Persons in Poland, and

10 Polish taxpayers in the United States. IGA Agreement dated 7 October 2014 to improve international tax compliance and to implement FATCA, signed by the governments of Poland and the United States. Financial institution Entities that match one of the below mentioned definitions: The term Custodial Institution means any Entity that holds, as a substantial portion of its business, financial assets for the account of others (mostly customers). An entity holds financial assets for the account of others as a substantial portion of its business if the entity s gross income attributable to the holding of financial assets and related financial services equals or exceeds 20 percent of the entity s gross income during the shorter of: (i) the three-year period that ends on December 31 (or the final day of a non-calendar year accounting period) prior to the year in which the determination is being made; or (ii) the period during which the entity has been in existence. The term Depository Institution means any Entity that accepts deposits in the ordinary course of a banking or similar business, e.g. a bank. The term Investment Entity means any Entity that conducts as a business one or more of the following activities or operations for or on behalf of a customer: (1) trading in money market instruments (cheques, bills, certificates of deposit, derivatives, etc.); foreign currencies, exchange rates; interest rate and index instruments; transferable securities; or commodity futures trading; (2) individual and collective portfolio management; or(3) otherwise investing, administering, or managing funds or money on behalf of other persons. If the entity is managed by another entity exercising one or more of the above mentioned activities or operations, than the managed entity is also an investment entity. The term Specified Insurance Company means any Entity that is an insurance company (or the holding company of an insurance company) that issues, or is obligated to make payments with respect to, a Cash Value Insurance Contract or an Annuity Contract. If you are uncertain whether the entity is a financial institution, please consult a tax advisor specializing in American tax law or visit GIIN (Global Intermediary Identification Number) The GIIN is a global reference number of the United States tax authorities (IRS). The IRS will assign this number to financial institutions and certain other entities for identification purposes. You may request this number via Group A group is comprised of all the individual companies that are affiliated with other companies in the same group. Entities are affiliated if: 1. one of the entities controls the other entity; or 2. the entities are all controlled by the same entity. In this respect control is defined as: an individual or legal entity in the group that has a direct or indirect majority interest in the entity; an individual or legal entity in the group that has a direct or indirect majority vote in the entity. Holding Company A holding company is an entity whose primary activity consists of holding (directly or indirectly) all or part of the outstanding stock of one or more subsidiaries. If a holding company operates as an investment fund (or holds itself out as an investment fund), it will be classified as financial institution. Such entities are described in the definition of a financial institution.

11 IBAN IBAN is an abbreviation of International Bank Account Number. This account number has the same structure in every country. The number consists of the account number and the following codes in front of the account number: the country code (PL for Poland)); a control number (two digits); the code of the bank (eight digits in Poland); account number (16 digits in Poland). The IBAN consists of 28 characters in Poland. Listing on a stock exchange Admission and introduction of securities into trading on a regulated market, within the meaning of provisions of the Act of 29 July 2005 on Public Offering and Conditions Governing the Introduction of Financial Instruments to an Organized Trading System, and on Public Companies (consolidated text: Journal of Laws of 2013, item 1382, as amended), in connection with provisions of the Act of 29 July 2005 on Trading in Financial Instruments (consolidated text: Journal of Laws of 2014, item 94, as amended). FATCA/IGA regulations cover financial instruments that are traded on recognized stock exchanges. Recognized stock exchange A recognized stock exchange is a stock exchange which is officially recognized or ratified by a government institution of the country in which the stock exchange has been incorporated. The stock exchange should be under the supervision of a governmental authority. A stock exchange is considered established if a meaningful quantity of stocks is being traded annually. In Poland the Warsaw Stock Exchange has got the status of such exchange. Non-participating financial institution The term non-participating financial institution means a financial institution (except Polish financial institutions) other than: a financial institution that is participating according to FATCA regulations; a certified deemed-compliant financial institution, or an exempt beneficial owner (exempted organization). If you are uncertain whether an entity is a non-participating financial institution, please consult a tax advisor specializing in American tax law. Non-profit organization A non-profit organization within the meaning of the Public Benefit and Volunteer Work Act dated 24 April 2003 (consolidated text: Journal of Laws of 2010 No. 234, item 1536, as amended) is a non-governmental organization: 1) which is not an entity of the public finance sector within the meaning of the Public Finances Act dated 27 August 2009 (consolidated text: Journal of Laws of 2013, item 885, as amended), 2) which does not operate for profit, corporate or non-corporate entities which according to separate legal provisions have capacity to perform acts in law, including foundations and associations, subject to: 1) political parties; 2) trade unions and organizations of employers; 3) professional self-governing authorities; 4) foundations formed by political parties; Public benefit work may also be effected by: 1) corporate entities and entities acting pursuant to provisions on relations between the State and the Catholic Church in the Republic of Poland, on relations between the State and other churches and religious unions, and on the guaranteed freedom of conscience and religion, should their statutory objectives encompass public benefit work; 2) unions of local self-government units; 3) social co-operatives;

12 4) joint stock companies, limited liability companies, and sport clubs operating as companies under the provisions of the Sports Act dated 25 June 2010 (consolidated text: Journal of Laws of 2014, item 715, as amended) which do not operate for profit or allocate all of their profit to perform their statutory objectives, and they do not divide their profit between their shareholders, stockholders or employees; If the entity is a public benefit organization under the Polish Law and fulfills the above requirements, such entity is treated as a non-profit organization. If you are uncertain whether the entity is a non-profit organization, please consult a tax advisor. Non-specified US Person The United States tax authorities (IRS) have excluded certain U.S. Persons from the requirement to be reported by financial institutions pursuant to FATCA/IGA. If you are uncertain whether the entity has this specific status, please visit for more information or consult a tax advisor specializing in American tax law. Operating company An operating company is a legal body which is part of a group. The operating company is engaged in a business that is different from the business of a financial institution. Passive income Passive income is the portion of the gross income that consists of: Dividends and dividend substitute payments (income equivalent to dividend); Interest and income equivalent to interest, rents and royalties, other than rents and royalties derived in the active conduct of a trade or business conducted, at least in part, by employees of the NFFE; Annuities; Income from swap-contracts; Rental income of real estate property provided that this income can be obtained by performing little to no activity. The above list is not exhaustive. A complete overview of passive income can be found on If you are uncertain whether income is passive income, please consult a tax advisor specializing in American tax law. Securities in regular trade Securities are regularly traded on a stock exchange if a meaningful quantity of such securities is being constantly traded. Shares (stocks, etc.) in a financial institution which are not in regular trade constitute an exception to this rule if their holder (other than a financial institution acting as an intermediary) has been recorded on accounts of such financial institution. If shares were recorded on accounts of a financial institution before 1 July 2014, such shares will be classified as securities in regular trade. If shares were recorded on accounts of a financial institution on 1 July 2014 or later, such shares will be treated as securities in regular trade until 31 December As of 1 January 2016 shares which will have been recorded on the accounts on 1 July 2014 or later, will not be treated as securities in regular trade. Third party A third party means the following: An individual or company which is not part of a group; Treasury centre An entity is considered a treasury center if the primary activity of the entity is to enter into hedging and financing transactions. U.S. Person A U.S. Person can be an entity or an individual.

13 Circumstances where an entity is considered a U.S. Person An entity is a U.S. Person if one of the following situations is applicable: The activities of the entity are organized in the United States (excluding U.S. territories: Puerto Rico, Guam, American Samoa, Northern Marianas and United States Virgin Islands). The entity is incorporated under the laws of the United States or one of its separate states. The entity is a trust and meets the following two requirements: o A court within the United States would have authority under applicable law to render orders or judgments concerning substantially all issues regarding administration of the trust, and o One or more U.S. persons have the authority to control all substantial decisions of the trust. Circumstances where an individual is considered a U.S. Person An individual is a U.S. Person if he/she is a citizen or a resident in the USA. Should you have any doubts if you are a U.S. Person, please consult your tax advisor. Disclaimer This glossary is not meant to serve as a legal or tax advice. If you have any doubt as to the effect or rules of filling out this self-certification form in order to determine US tax status, please contact your tax advisor specializing in US tax law.