Tax Compliance - International Exchange of Information Agreement ENTITY SELF-CERTIFICATION FORM

Transcription

1 Tax Compliance International Exchange of Information Agreement ENTITY SELFCERTIFICATION FORM Please complete, sign and date this form and return it to Richmond Fiduciary Group Limited. Please inform Richmond Fiduciary Group Limited promptly of any change in the future to the information provided on this form. If your entity is resident in the United States or dual resident, you should also provide a completed, signed and dated IRS Form W9. 1. Entity Details 1a. Entity Name 1b. Jurisdiction of Incorporation or Organisation 1c. Registered Address (Do not use a P.O. box (unless this is your registered address) or an in care of address ) Country Postcode 1d. Mailing Address (If different from Registered Address above) Country Postcode 2. Tax Residence 1 2a. Please specify the Jurisdiction in which the entity is resident for tax purposes 2b. (1) The Entity s Tax Identification Number (TIN) 2 or functional equivalent in its jurisdiction of residence OR (2) The Entity s jurisdiction of residence for tax purposes does not issue TINs or a functional equivalent or the entity is otherwise unable to procure a TIN or a functional equivalent from its country of residence (please tick box if relevant).

2 2c. Specified UK Person 3 (Complete this question if the entity is tax resident in the UK) If the entity is tax resident in the UK, please indicate whether the entity is a Specified UK Person. YES NO If NO please specify the basis for certifying that the entity is not a Specified UK Person even though it is resident for tax purposes in the UK 2d. If the entity is tax resident in more than one jurisdiction please indicate ALL jurisdictions in which the entity is resident for tax purposes and complete the following questions as appropriate Jurisdiction TIN (Tax Identification Number) TIN Unavailable 3. UK Guernsey IGA Classification4 Please provide the entity s classification under the UKGuernsey IGA Financial Institutions (other than Sponsored Investment Entity or Trustee Documented Trust) go to Part 4 Sponsored Investment Entity go to Part 4 Trustee Documented Trust go to Part 4 Exempt Beneficial Owner go to Part 5 Passive NonFinancial Entity go to Part 6 Active NonFinancial Entity go to Part 7 4. For a Financial Institution5 to Complete 4a. If the entity is a Financial Institution, please provide its Global Intermediary Identification Number (GIIN) 6 4b. Sponsored Investment Entity and Trustee Documented Trusts7: If the entity does not have a GIIN but is sponsored by another entity or the entity is a Trustee Documented Trust, please provide the name and GIIN of the entity s sponsor or trustee as appropriate: 4b1. Name of sponsoring entity or Trustee 4b2. Sponsor s or Trustee s Global Intermediary Identification Number (GIIN) 6

3 4b3. If the entity is sponsored by another entity and has obtained its own GIIN please tick this box and provide the name of the sponsoring entity and entity s own GIIN. 4b4. Name of sponsoring entity 4b5. Entity s own GIIN 5. Exempt Beneficial Owner 8 If the entity is tax resident in the UK, please provide its Exempt Beneficial Owner classification. If the entity is not tax resident in the UK, please go to part 7: Government Organisation Central Bank International Organisation Exempt Retirement Fund Entity wholly owned by EBOs 6. Passive NonFinancial Foreign Entity 9 Please complete the table below to identify all Controlling Persons 10 of the Passive NonFinancial Foreign Entity. Name Permanent Residential Tax Residence(s) (List all) TIN(s) (Provide all) Place (City/Town & Country) and Date of Birth (dd/mm/yyyy) Have all the Controlling Persons of the entity been identified in the table above? YES NO An Individual SelfCertification Form must be completed for each Controlling Person of the entity. Controlling Persons are defined as natural persons who exercise control over the entity or the shareholders of the entity based on local Anti Money Laundering (AML) requirements. Individual SelfCertification Forms for each Controlling Person can be obtained by clicking this link or by contacting Richmond Fiduciary Group Limited.

4 7. Declaration I declare and certify that the information provided on this form is, to the best of my knowledge and belief, accurate and complete. I hereby agree to provide Richmond Fiduciary Group Limited upon request with any information or documentation which is necessary or desirable for Richmond Fiduciary Group Limited to comply with any obligation Richmond Fiduciary Group Limited may have in connection with US FATCA, the USGuernsey IGA, the UKGuernsey IGA and the CRS. I further undertake to notify you immediately of any change to the above information. To the extent necessary or desirable for Richmond Fiduciary Group Limited to comply with the above obligations, I hereby consent to Richmond Fiduciary Group Limited disclosing information contained in this selfcertification to third parties, including relevant tax authorities. I certify that I am duly authorized and have the requisite capacity to sign this form and provide the certifications in this form on behalf of the entity identified in Part 1 above. Name Signature Capacity Date This information is being gathered in order to meet legal obligations under the automatic exchange of information provisions arising under the US Foreign Account Tax Compliance Act (US FATCA), the USGuernsey Intergovernmental Agreement (USGuernsey IGA) and the UKGuernsey Intergovernmental Agreement (UKGuernsey IGA) and the OECD Common Reporting Standard (CRS). Following review of such information Richmond Fiduciary Group Limited may contact you regarding any further documentation/information that may be required to meet these obligations. In certain circumstances (including if Richmond Fiduciary Group Limited does not receive a selfcertification from the entity on which it can rely or acceptable documentary evidence in support of the entity s selfcertification) Richmond Fiduciary Group Limited may nevertheless be obliged under applicable law to share certain information about account(s) maintained for the entity with the relevant tax authorities based on the information that it holds or is available to it in accordance with published guidance. 1 Tax Residence: Enter the jurisdiction where the entity is resident for the purposes of taxation in that jurisdiction. If the entity is tax resident in more than one jurisdiction, please list each one separately in question 2d. Tax residence is determined by the laws of the relevant local jurisdiction, and may depend on factors such as the place of incorporation, organisation, management and control, or other factors. If you are unsure as to which jurisdiction the entity is resident in for tax purposes please contact the entity s tax adviser. 2 TIN: Enter the tax identification number issued to the entity by the jurisdiction of residence for tax purposes. For example in the UK it will be the Unique Taxpayer Reference (UTR). For the purposes of this form, an equivalent to a TIN is any unique identifying number assigned to the organisation by the local tax authority. 3 Specified UK Person: If the entity is tax resident in the UK, then it must certify whether it should be treated as a Specified UK Person. An entity that is tax resident in the UK will be Specified UK Person unless it confirms it is not a Specified UK Person and provides the reason it is not a Specified UK Person. The term Specified UK Person is defined by reference to local laws in the country where an entity is established. Generally, the term Specified UK Person means any organisations, other than: a. a corporation the stock of which is regularly traded on one or more established securities markets; b. any corporation that is a Related Entity of a corporation described in (a) above; c. a Depository Institution; d. a broker or dealer in securities, commodities, or derivative financial instruments (including notional principle contracts, futures, forwards, and options) that is registered as such under UK law; and e. an Exempt Beneficial Owner as defined in the UKGuernsey IGA.

5 4 IGA Classification: Regardless of whether the entity is identified as a Specified UK Person in Part 2, the entity is required to provide its classification under the UK IGA. Your US IGA FATCA classification is dealt with in the enclosed US IRS Form W8BENE. If you are unsure about the relevant classification for these purposes please contact the entity s tax adviser. 5 Financial Institution: In general, the definition of a Financial Institution includes any entity that meets the definition of: A Depository Institution An institution that accepts deposits in the ordinary course of a banking or similar business. A Custodial Institution An institution which holds financial assets for the account of others as a substantial portion of its business. An Investment Entity An institution which conducts as a business trading in certain financial instruments on behalf of a customer or an entity which is investing, administering or managing funds or money on behalf of other persons. This would also include an institution which is primarily investing, reinvesting or trading in financial assets and is managed by another Financial Institution. A Specified Insurance Company An institution that issues, or is obligated to make payments with respect to, any cash value insurance contract, annuity contract or other financial account or the holding company of such an insurance company. 6 A GIIN is issued by the US IRS when a Financial Institution registers on its FATCA Portal for the purposes of US FATCA. The GIIN is used to verify the entity s classification. 7 Sponsored Investment Entity and Trustee Documented Trusts: If the entity is a Sponsored Investment Entity or Trustee Documented Trust or Sponsored Closely Held Investment Vehicle, please provide name of the Sponsoring Entity or Trustee that has agreed to perform obligations arising under the UKGuernsey IGA on behalf of the entity. The IRS have advised from 1 January 2016 Sponsored Investment Entities will be required to register and obtain their own GIINs and to provide that GIIN on withholding certificates in respect of payments made from and after 1 January If the entity is a Sponsored Entity and has obtained its own GIIN, please enter its own GIIN in the appropriate line and the name of the Sponsoring Entity. 8 Exempt Beneficial Owners: In general, the definition of an Exempt Beneficial Owners includes any organisation that meets the definition of: Governmental Entity A foreign government, any political subdivision of a foreign government or any wholly owned agency or instrumentality of any one or more of the foregoing. Central Bank An institution that is by law or government sanction the principal authority, other than the government of the jurisdiction itself, issuing instruments intended to circulate as currency. International Organisation Any international organization or wholly owned agency or instrumentality thereof. Exempt Retirement Funds A fund that meets certain regulatory criteria and is operated principally to administer or provide pension or retirement benefits. 9 Passive NonFinancial Entity: Any entity that is not a Financial Institution and is not an Active Non Financial Entity. Active NonFinancial Entity: A NonFinancial Entity that meets any of the following criteria: Less than 50 percent of the NonFinancial Entity s gross income for the preceding calendar year or other appropriate reporting period is passive income and less than 50 percent of the assets held by the NonFinancial Entity during the preceding calendar year or other appropriate reporting period are assets that produce or are held for the production of passive income; The stock is regularly traded on an established securities market or the organisation is related to an entity the stock of which is traded on an established securities market; It is a government, a political subdivision of a government, an international organization, a nonus central bank of issue, or an entity wholly owned by one or more of the foregoing;

6 9 Passive NonFinancial Entity (continued): Substantially all of the activities of the NonFinancial Entity 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 NonFinancial Entity shall not qualify for this status if the NonFinancial Entity 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; It 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 NonFinancial Entity shall not qualify for this exception after the date that is 24 months after the date of the initial organization of the Non Financial Entity; It 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; The NonFinancial Entity 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. 10 Controlling Persons: Broadly, the term Controlling Persons means the natural persons who exercise control over an entity. In the case of a trust, such term means the settlor, the trustees, the protector (if any), the beneficiaries or class of beneficiaries, and any other natural person exercising ultimate effective control over the trust, and in the case of a legal arrangement other than a trust, such term means persons in equivalent or similar positions. The term Controlling Persons shall be interpreted in a manner consistent with the Recommendations of the Financial Action Task Force Recommendations. These recommendations are implemented under local money laundering regulations so the specific criteria will vary. Broadly the standard is expected to include natural persons that own directly or indirectly 25% or more of the entity and any other persons exercising effective control. Richmond Fiduciary Group Limited PO Box 374, Richmond House, St Julian s Avenue, St Peter Port, Guernsey, Channel Islands GY1 3YS Registered in Guernsey No Tel: +44 (0) Fax: +44 (0) info@richmondgroup.uk.com richmondgroup.uk.com Richmond Fiduciary Group Limited All rights reserved. Second Edition printed April 2015