FORM for entity self-certification on FATCA (US status) and CRS (tax residency)
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1 Allianz Life Luxembourg S.A. FORM for entity self-certification on FATCA (US status) and CRS (tax residency) Denomination/ type of contract : Number of contract and name (in case the contract already exists) : Please read these instructions before completing the form Regulations based on the FATCA law and the OECD Common Reporting Standard ( CRS ) require Allianz Life Luxembourg to collect and report certain information about an account holder s tax residency. If the account holder qualifies as Specified US Person or if his tax residency is located outside of Luxembourg we may be legally obliged to pass on the information in this form and other financial information with respect to his financial accounts to the Luxemburgish tax administration. An account holder is every person that has access to the policy value. As account holder includes the policy holder, each joint holder, an assignee or an irrevocable beneficiary. In the case of a parent acting as legal guardian for a child, the child is regarded as account holder. A person holding the account for the benefit of another person (agent, custodian, nominee, ) is not regarded as account holder. In case of any change in circumstances relating to the account holders US status/ tax status that makes the information in this self-certification incorrect or incomplete you must notify us within 30 days and provide an up-dated self-certification. This form is intended to request information only where such request is not prohibited by local law. Please complete this form where you need to self-certify on behalf of your entity account holder If you are an individual account holder do not complete this form. Instead please complete an FORM for Individual certification on FATCA and CRS. Where the Account holder is a Passive NFFE (FATCA) and/or Passive NFE (CRS). Please provide in Part 2 information on the natural person(s) who exercise control over the account holder (individuals referred to as Controlling Person(s) ). As a financial institution we are not allowed to give tax advice. If you have any questions about this form, these instructions, or defining your US or tax residency status, please speak to your tax adviser or local tax authority. Concerning FATCA you can find out more on the website of the internal revenue service ( IRS ) Concerning CRS 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 portal. The form will be refused if it is not COMPLETELY filled in, dated and signed. Allianz Life Luxembourg S.A. - 14, Boulevard F.D. Roosevelt - L-2450 Luxembourg Tél.: (+352) Fax: (+352)
2 1. Identification of Account Holder Legal Name of Entity/ Branch : Country of incorporation or organisation : Current Residence Address (e.g. House/ Apt/ Suite Name, Number, Street, Postal Code/ Town/ City/ Country) : Mailing Address (e.g. House/ Apt/ Suite Name, Number, Street, Postal Code/ Town/ City/ Country) : 2. Entity Type (Please provide the Account Holder s Status by ticking one of the following boxes) A. FATCA status An Investment Entity type of Financial Institution under FATCA Financial Institution Depository Institution, Custodial Institution or Specified Insurance Company If you have ticked one of the boxes above, please provide, if held, the Account Holder s Global Intermediary Identification Number ( GIIN ) obtained for FATCA purposes : If you cannot provide a GIIN, please specify the reason : A Corporation the stock of which is regularly traded on an established securities market or a corporation which is a related entity of such a corporation The name of the established securities market is Active NFFE 1 : an International Organisation, an entity (or a holding of an entity) that is actively engaged in manufacturing or commerce or providing non-financial services in B2B or B2C relationship, an entity that is a start-up NFFE or a non-profit NFFE. Passive NFFE 1 : an entity that is (not an Active NFFE and is) typically receiving, income from stocks, shares, bonds or derivatives held for investment purposes and that such investment assets and income are the majority of assets held and income received by the entity. If you are classified as Passive NFFE, please confirm if the entity you are acting for has substantial U.S. owners (any natural specified U.S. Person 2 with > 25% ownership or controlling rights) : No, the entity has no substantial U.S. owners Yes, the entity has substantial U.S. owners In case you have chosen Yes, please provide all substantial U.S. owners including name, address, birth date and U.S. TIN (Tax identification number or social security number) : Name Address Date of birth U.S. TIN Each of these specified U.S. persons has to fill in and sign an IRS W-9 form. 1 For more information how to decide if you are an Active or a Passive NFFE under FATCA see in annex. 2 A specified US person is any person - holding a US passport (also in case of dual citizenship), born in the US (and not having waived the US citizenship), the holder of a permanent residency card (Green Card), a person that resides more than 183 days per year in the United States of America (this year and the two years before). The calculation method is the following : the days of the current year count entirely with a minimum of 31 days, the days of the last year for one third and the days of the year prior to that for one sixth, a person that files its income together with its spouse, in case the spouse is a U.S. person. For more details on the criteria for the determination of the status of fiscal resident of the United States of America or to download W-9 and W-8BEN forms, please go to the web site of the IRS :
3 2. Entity Type (Please provide the Account Holder s Status by ticking one of the following boxes) B. CRS status An Investment Entity type of Financial Institution under CRS. Financial Institution Depository Institution, Custodial Institution or Specified Insurance Company. A Corporation the stock of which is regularly traded on an established securities market or a corporation which is a related entity of such a corporation. The name of the established securities market is Active NFE 3 : which includes an International Organisation, an entity (or a holding of an entity) that is actively engaged in manufacturing or commerce or providing non-financial services in B2B or B2C relationship, an entity that is a start-up NFE or a non-profit NFE. Passive NFE 3 : an entity that is (not an Active NFE and is) typically receiving income from stocks, shares, bonds or derivatives held for investment purposes and that such investment assets and income are the majority of assets held and income received by the entity. If you are classified as Passive NFE, please provide the information requested below for any Controlling person (any natural person with > 25% ownership or controlling rights). Name : Citizenship(s) : Name : Citizenship(s) : * Please choose the status (type) of each Controlling Person A, B or C, as defined below, and indicate it above in the space provided. A. Controlling Person of a legal person control by ownership B. Controlling Person of a legal person control by other means (please specify in this case, e.g. trustee) : C. Controlling Person of a legal person senior managing official Important: Each person is tax resident of at least one jurisdiction, but can also be tax resident of several jurisdictions. Please indicate any or the tax residencies and the TIN for each country indicated. If the person is tax resident of more than two countries, please use a separate sheet. 3 For more information how to decide if you are an Active or a Passive NFE under CRS see in annex 4 TIN: Tax identification number or equivalent number in the absence of a TIN for a physical person For the USA this is the Tax Identification Number or if not available the social security number For Luxembourg this is an identification number of 13 digits attributed by the law of 19th June 2013 For France this is the numéro fiscal de référence or the numéro SPI. It may be found on the first page of the pre-filled tax return for income tax and on the first page of the notice of assessment (avis d imposition) For Belgium this is the numéro national (number received the moment of inscription in the national register) and which appears on the back side of the ID-Card For United Kingdom this is the national insurance number (NINO) or the unique taxpayer reference (UTR) For Germany this is the Steuer-Identifikationsnummer (lifelong valid and same for whole federal Germany since 2008) For Italy this is the number that is allocated by the Revenue agency (Agenzia delle Entrate) For more details and for any other country, please check
4 Name : Citizenship(s) : Name : Citizenship(s) : * Please choose the status (type) of each Controlling Person A, B or C, as defined below, and indicate it above in the space provided. A. Controlling Person of a legal person control by ownership B. Controlling Person of a legal person control by other means (please specify in this case, e.g. trustee) : C. Controlling Person of a legal person senior managing official Important: Each person is tax resident of at least one jurisdiction, but can also be tax resident of several jurisdictions. Please indicate any or the tax residencies and the TIN for each country indicated. If the person is tax resident of more than two countries, please use a separate sheet. 3. Country of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent ( TIN 5 ) for the entity account holder Please complete the following table indicating where the Account Holder is tax resident and the Account Holder s TIN 5 for each country indicated. If the Account Holder is not tax resident in any jurisdiction (e.g., because it is fiscally transparent), please indicate that on line 1 and provide its place of effective management or country in which its principal office is located. If the Account Holder is tax resident in more than three countries please use a separate sheet. Country of residence TIN 5 If no TIN available : reason: A, B or C If a TIN is unavailable please provide the appropriate reason A, B or C. Reason A The country where I am liable to pay tax 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 (Note: only select this reason if the authorities of the country of tax residence entered below do not require the TIN to be disclosed) If you selected reason B please explain in the following boxes why you are unable to obtain a TIN : TIN: Tax identification number or equivalent number in the absence of a TIN for an entity For Luxembourg this is an identification number of 11 digits For France this is the SIREN, a 9-digit number For Belgium this is the Banque-Carrefour des Entreprises (BCE), a 9-digit number For United Kingdom this is the unique taxpayer reference (UTR), a 10-digit number For Italy this is a 11-digit number allocated by the Revenue agency (Agenzia delle Entrate)
5 4. Declaration and Signature I understand that Allianz Life Luxembourg is responsible to treat the information that I have provided in the context of this self-certification. I acknowledge that the information contained in this form and any further information I may have given to you regarding the Account Holder and any Reportable Account(s) as well as any Controlling person may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder or Controlling Person may be tax resident pursuant to intergovernmental agreements to exchange financial account information with the country/ies in which this account(s) is/are maintained. If I fail to complete this form properly and completely Allianz Life Luxembourg may refuse to enter into business relationship with me or may refuse to execute a transaction that I request. Every person concerned has the right to access the information transferred to the local tax administration and has the right to correct in case of inaccurate information. I certify that I am authorised to sign for the Account Holder in respect of all the accounts to which this form relates. I declare that all statements made in this self-certification are, to the best of my knowledge and belief, correct and complete. I undertake to advise Allianz Life Luxembourg within 30 days of any change in circumstances which affects the tax residency status of the Account Holder identified in Part 1 of this form or causes the information contained herein to become incorrect (including any changes to the information on Controlling Persons identified in part 2, and to provide Allianz Life Luxembourg with a suitably updated self-certification and Declaration within 30 days of such change in circumstances. In on Print name : Capacity : Note: Please indicate the capacity in which you are signing the form (e.g. Authorised Officer ). If signing under a power of attorney please also attach a certified copy of the power of attorney. Signature
6 Annex Active NFFE (Active Non Financial Foreign Entity) under FATCA reglementation : The term Active NFFE means any 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 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 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 government (other than the U.S. government), a political subdivision of such government (which, for the avoidance of doubt, includes a state, province, county, or municipality), or a public body performing a function of such government or a political subdivision thereof, 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, or 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 shall 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 operated in its jurisdiction 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 NFFE s jurisdiction of residence or the NFFE s formation documents do not permit any income or assets of the NFFE 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 NFFE s charitable activities, or as payment of reasonable compensation for services rendered, or as payment representing the fair market value of property which the NFFE has purchased; and v. The applicable laws of the NFFE s jurisdiction of residence or the NFFE s formation documents require that, upon the NFFE 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 NFFE s jurisdiction of residence or any political subdivision thereof.
7 Active NFE under CRS reglementation An NFE is an Active NFE if it meets any of the criteria listed below. In summary, those criteria refer to : a. active NFEs by reason of income and assets; b. publicly traded NFEs; c. Governmental Entities, International Organisations, Central Banks, or their wholly owned Entities; d. holding NFEs that are members of a nonfinancial group; e. start-up NFEs; f. NFEs that are liquidating or emerging from bankruptcy; g. treasury centres that are members of a nonfinancial group; or h. non-profit NFEs. An entity will be classified as Active NFE if it meets any of the following criteria: a. less than 50% of the NFE s gross income for the preceding calendar year or other appropriate reporting period is passive income and less than 50% of the assets held by the NFE 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 NFE is regularly traded on an established securities market or the NFE is a Related Entity of an Entity the stock of which is regularly traded on an established securities market; c. the NFE is a Governmental Entity, an International Organisation, a Central Bank, or an Entity wholly owned by one or more of the foregoing; d. substantially all of the activities of the NFE consist of holding (in whole or in part) the outstanding stock of, or 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 Entity does not qualify for this status if the 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; e. the NFE is not yet operating a business and has no prior operating history, (a start-up NFE ) but is investing capital into assets with the intent to operate a business other than that of a Financial Institution, provided that the NFE does not qualify for this exception after the date that is 24 months after the date of the initial organisation of the NFE; f. the NFE was not a Financial Institution in the past five years, and is in the process of liquidating its assets or is reorganising with the intent to continue or recommence operations in a business other than that of a Financial Institution; g. the NFE 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; or h. the NFE meets all of the following requirements (a non-profit NFE ) : i. it is established and operated in its jurisdiction 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 organisation, business league, chamber of commerce, labour organisation, agricultural or horticultural organisation, civic league or an organisation 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 NFE s jurisdiction of residence or the NFE s formation documents do not permit any income or assets of the NFE 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 NFE s charitable activities, or as payment of reasonable compensation for services rendered, or as payment representing the fair market value of property which the NFE has purchased; and v. the applicable laws of the NFE s jurisdiction of residence or the NFE s formation documents require that, upon the NFE s liquidation or dissolution, all of its assets be distributed to a Governmental Entity or other non-profit organisation, or escheat to the government of the NFE s jurisdiction of residence or any political subdivision. ALL_FATCA_CRS_PM (EN) 0516
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