Self-Certification Form Entity

Transcription

1 Please complete Parts 1-5 in BLOCK CAPITALS Important Notes: Self-Certification Form Entity This is a self-certification form provided by an account holder to Cinda International Securities Limited ( CISL ) for the purpose of automatic exchange of financial account information. The data collected may be transmitted by CISL to the Inland Revenue Department for transfer to the tax authority of another jurisdiction. An account holder should report all changes in its tax residency status to CISL. All parts of the form must be completed (unless not applicable or otherwise specified). If space provided is insufficient, continue on additional sheet(s). Information in fields/parts marked with an asterisk (*) are required to be reported by CISL to the Inland Revenue Department. Part 1 Identification of Entity Account Holder (For joint or multiple account holders, please complete a separate form for each entity account holder.) (1) Legal Name of Entity or Branch * (2) Jurisdiction of Incorporation or Organisation (3) Hong Kong Business Registration Number (4) Current Business Address Line 1 (e.g. Suite, Floor, Building, Street, District) Line 2 (City) * Line 3 (e.g. Province, State) Country * Post Code/ZIP Code (5) Mailing Address (Please complete if different to the current business address) Line 1 (e.g. Suite, Floor, Building, Street, District) Line 2 (City) Line 3 (e.g. Province, State) Country Post Code/ZIP Code Part 2 Entity Type Please tick one of the appropriate boxes and provide the relevant information. Financial Institution Active Non Financial Entity ( NFE ) Passive NFE Custodial Institution, Depository Institution or Specified Insurance Company Investment Entity, except an investment entity that is managed by another financial institution (e.g. with discretion to manage the entity s assets) and located in a non-participating jurisdiction NFE the stock of which is regularly traded on, which is an established securities market Related entity of, the stock of which is regularly traded on, which is an established securities market NFE is a governmental entity, an international organization, a central bank, or an entity wholly owned by one or more of the foregoing entities Active NFE other than the above (Please specify ) Investment entity that is managed by another financial institution and located in a non-participating jurisdiction NFE that is not an active NFE CRS_CISL_ENTITY_

2 Part 3 Controlling Persons (Please complete this part if the entity account holder is a Passive NFE) Please indicate the name of all controlling person(s) of the account holder in the table below. If no natural person exercises control over an entity which is a legal person, the controlling person will be the individual holding the position of senior managing official. Please complete Self-Certification Form - Controlling Person for each controlling person. (1) (5) (2) (6) (3) (7) (4) (8) Part 4 Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent ( TIN ) * Please complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where the account holder is a resident for tax purposes and (b) the account holder s TIN for each jurisdiction indicated. Please indicate all (not restricted to five) jurisdictions of residence. If the account holder is tax resident in more than five countries, please use a separate sheet. If the account holder is a tax resident of Hong Kong, the TIN is the Hong Kong Business Registration Number. If the account holder is not a tax resident in any jurisdiction (e.g. fiscally transparent), indicate the jurisdiction in which its place of effective management is situated. If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below: Reason A - The jurisdiction where the account holder is a resident for tax purposes does not issue TINs to its residents. Reason B - The account holder is unable to obtain a TIN. Explain why the account holder is unable to obtain a TIN if you have selected this reason. Reason C - TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the TIN to be disclosed. Jurisdiction of Residence TIN Enter Reason A, B or C if no TIN is available Explain why the account holder is unable to obtain a TIN if you have selected Reason B (1) (2) (3) (4) (5) Remarks: CRS_CISL_ENTITY_

3 Part 5 Declarations and Signature I acknowledge and agree that (a) the information contained in this form is collected and may be kept by CISL for the purpose of automatic exchange of financial account information, and (b) such information and information regarding the account holder and any reportable account(s) may be reported by CISL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am authorized to sign for the account holder of all the account(s) to which this form relates. I undertake to advise CISL of any change in circumstances which affects the tax residency status of the entity identified in Part 1 of this form or causes the information contained herein to become incorrect, and to provide CISL with a suitably updated self-certification form within 30 days of such change in circumstances. I declare that the information given and statements made in this form are, to the best of my knowledge and belief, true, correct and complete. Signature Name Capacity Date (dd/mm/yyyy) (e.g. director or officer of a company, partner of a partnership, trustee of a trust etc.) WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. HK$10,000). In the event of any discrepancy or inconsistency between the English version and the Chinese version of this form, the English version shall prevail. CRS_CISL_ENTITY_

4 Self-Certification Form Controlling Person Please complete Parts 1-5 in BLOCK CAPITALS Important Notes: This is a self-certification form provided by a controlling person to Cinda International Securities Limited ( CISL ) for the purpose of automatic exchange of financial account information. The data collected may be transmitted by CISL to the Inland Revenue Department for transfer to the tax authority of another jurisdiction. A controlling person should report all changes in his/her tax residency status to CISL. All parts of the form must be completed (unless not applicable or otherwise specified). If space provided is insufficient, continue on additional sheet(s). Information in fields/parts marked with an asterisk (*) are required to be reported by CISL to the Inland Revenue Department. Part 1 Identification of Controlling Person (Please tick whichever is appropriate and provide the relevant information) (1) Name of Controlling Person Title Mr Mrs Ms Miss Other Last Name or Surname * First or Given Name * Middle Name(s) (2) Identity Document Type HKID Passport Other Identity Document Number (3) Current Residence Address Line 1 (e.g. Suite, Floor, Building, Street, District) Line 2 (City) * Line 3 (e.g. Province, State) Country * Post Code/ZIP Code (4) Mailing Address (Please complete if different to the current residence address) Line 1 (e.g. Suite, Floor, Building, Street, District) Line 2 (City) Line 3 (e.g. Province, State) Country Post Code/ZIP Code (5) Date of Birth * (dd/mm/yyyy) (6) Place of Birth (Not compulsory) Town/City Province/State Country CRS_CISL_CONTROLLING PERSON_

5 Part 2 The Entity Account Holder(s) of which you are a controlling person Please enter the name of the entity account holder of which you are a controlling person. Entity Name of the Entity Account Holder (1) (2) (3) Part 3 Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent ( TIN ) * Please complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where the controlling person is a resident for tax purposes and (b) the controlling person s TIN for each jurisdiction indicated. Please indicate all (not restricted to five) jurisdictions of residence. If the controlling person is tax resident in more than five countries, please use a separate sheet. If the controlling person is a tax resident of Hong Kong, the TIN is the Hong Kong Identity Card Number. If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below: Reason A - The jurisdiction where the controlling person is a resident for tax purposes does not issue TINs to its residents. Reason B - The controlling person is unable to obtain a TIN. Explain why the controlling person is unable to obtain a TIN if you have selected this reason. Reason C - TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the TIN to be disclosed. Jurisdiction of Residence TIN Enter Reason A, B or C if no TIN is available Explain why the controlling person is unable to obtain a TIN if you have selected Reason B (1) (2) (3) (4) (5) Remarks: CRS_CISL_CONTROLLING PERSON_

6 Part 4 Type of Controlling Person Please tick the appropriate box to indicate the type of controlling person for each entity stated in Part 2. Type of Entity Type of Controlling Person Entity (1) Entity (2) Entity (3) Legal Person Individual who has a controlling ownership interest (i.e. not less than 25% of issued share capital) Individual who exercises control/is entitled to exercise control through other means (i.e. not less than 25% of voting rights) Individual who holds the position of senior managing official/ exercises ultimate control over the management of the entity Trust Settlor Trustee Protector Beneficiary or member of the class of beneficiaries Legal Arrangement other than Trust Other (e.g. individual who exercises control over another entity being the settlor/trustee/protector/beneficiary) Individual in a position equivalent/similar to settlor Individual in a position equivalent/similar to trustee Individual in a position equivalent/similar to protector Individual in a position equivalent/similar to beneficiary or member of the class of beneficiaries Other (e.g. individual who exercises control over another entity being equivalent / similar to settler / trustee / protector / beneficiary) CRS_CISL_CONTROLLING PERSON_

7 Part 5 Declarations and Signature I acknowledge and agree that (a) the information contained in this form is collected and may be kept by CISL for the purpose of automatic exchange of financial account information, and (b) such information and information regarding the controlling person and any reportable account(s) may be reported by CISL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the controlling person may be resident for tax purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am the controlling person of all the account(s) held by the entity account holder(s) to which this form relates. I undertake to advise CISL 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, and to provide CISL with a suitably updated self-certification form within 30 days of such change in circumstances. I declare that the information given and statements made in this form are, to the best of my knowledge and belief, true, correct and complete. Signature Name Date (dd/mm/yyyy) WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. HK$10,000). In the event of any discrepancy or inconsistency between the English version and the Chinese version of this form, the English version shall prevail. CRS_CISL_CONTROLLING PERSON_

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