Know Your Customer (KYC) Application Form (For Diplomatic Missions Only) (Please fill in ENGLISH and in BLOCK LETTERS with black ink) CIF No. A/c. No. KYC No. 1. (If available) Name of Applicant (Please write complete name as per Certificate of Incorporation / Registration) : 2. Constitution : Embassy Consulate Other (specify) 3. PAN No.: Form 60 : Yes No 4. Place of Incorporation : 5. Date of Incorporation : 6. Country of Incorporation*: 7. Registration No.: 8. Date of Commencement of Business : 9. Country of Residence as per tax laws*: 10. TIN : TIN Issue Country*: 11. Registered Address : Address Type : Business Residence Registered Office Unspecified Others 12. Correspondence / Mailing Address : Same as Registered Address Address Type : Business Residence Registered Office Unspecified Others 13. Address where entity is Residence outside India for tax purpose : Same as Registered Address Same as Correspondence Address Address Type : Business Residence Registered Office Unspecified Others (*Please refer to the enclosed annexure for state code & country code) Page 1
14. Number of Controlling person(s) resident outside India for Tax purpose : 15. Beneficial owner details : Government Others 16. Business : Government Others Nature of Business Details : 17. Additional Information : (i) No. of Branches (ii) No. of Employees (iii) Physical Business (iv) Main Geographies of Business : (v) Expected Account Activity in INR / Month a) Cash b) Non Cash c) Wire Transfer (vi) Expected Account Acivity in other currency (a) Cash (b) Non Cash (c) Wire Transfer 18. Existing Banking Relations : I/we do not enjoy any credit facility with any other bank I/we enjoy credit facility with the following banks Sr. No. Bank Name Bank Address Type of Facility Amount 19. FATCA Details : I. Please indicate the nature of your entity : (a) US Entity : A Company Corporation, Association, Partnership, or Trust ("US Tax Obligor) created/organised in the United States or under the laws of the United States of America. (b) Non Us Entity (Indian or Foreign Entity) : A Company Corporation, Association, Partnership, or Trust created organised outside the borders of the United States of America. II. If you have selected I (a)-us Entity, please submit the W9 Form and Provide the Employer Identification Number (EIN) III. If you have selected I (b) - Non US Entity, then please further specify your FATCA status under the option of (a) or (b) below: (a) FI (Financial Institution) - Please choose the entity's applicable status: Non Participating FI Participating FI India or Partner Jurisdiction FI Registered Deemed Complain FI Entity Wholly Owned by Exempt Beneficial Owners Certified Deemed Compliant FI If the entity has a global Intermediary Identification Number ("GIIN") please indicate it here If the entity does not have a GIIN, please submit a W8-Ben-E, if applicable (b) NFFE (Non-Financial Foreign Entity) - Please choose the entity's applicable status : Active NFFE Passive NFFE : with no US Controlling Person / Substantial US Owners (please submit the W8 BEN-E) Passive NFFE : with US Controlling Person / Substantial US Owners (please submit the W 8 BEN-E with US owners details) IV. U.S Taxpayer Identification Number (SSN or ITIN ) : Page 2
20. CRS Details : Are you liable to pay taxes outside India? Yes No Entity Type : 1. Please indicate the type of your entity: a. Financial Institution (Depository institution, custodial institution, specified insurance company and investment entity in a CRS participating jurisdiction) b. Financial Institution that is a professionally managed investment entity located in CRS non-participating jurisdiction. c. Non-financial entity. Please further specify your entity status : i. Active NFE - a corporation the stock of which is regulatory traded on an established securities market or a corporation which is related entity of such a corporation. ii. Active NFE - a government entity or central bank. iii. Active NFE - an international organisation. iv. Active NFE - Other than (i), (ii) and (iii) v. Passive NFE 2. If you have selected 1(a) please complete Declarations section. 3. If you have selected 1(b) please complete Self certification for controlling person(s) section and Declaration section. 4. If you have selected 1(c) (i) or 1(c) (ii) or 1(c) (iii), please complete Declarations section. 5. If you have selected 1(c) (iv), please complete Tax Residency section and Declaration section. 6. If you have selected 1(c) (v), please complete Self certification for controlling person(s) section, Tax Residency section and Declaration section. Tax Residency : Please list all jurisdictions in which you are treated as tax resident and provide the tax identification number for each one. If you are tax resident in more than three countries, please use a separate sheet. Country of Tax Residency Taxpayer Identification Number (TIN) TIN Issue Country Reasons for not providing TIN (enter reason A, B, C or D) Reason A - The country where the Account Holder / Controlling Person is tax resident does not issue TINs to its residents. Reason B - the Account Holder / Controlling Person is otherwise unable to obtain a TIN or equivalent number (Please explain why the Account Holder / Controlling Person is unable to obtain a TIN in the table below 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 above do not allow the TIN to be disclosed to third parties). Reason D - the Account Holder / Controlling Person has got no tax residence, therefore TIN is not applicable. In this case, please write "NONE" in the "Country of Tax Residency" Column. If you indicated 'Reason B', please explain in the following boxes why the Account Holder is unable to obtain a TIN. Reasons : 1 2 3 Page 3
21. Details of Related Person : CIF No. (if available) : KYC No. (If available) : Related Person Type : Court Appointed Official Other means Name (as appearing in supporting identification document) Mr./Mrs./Ms. Gender : M F T - Transgender Name : Maiden Name (if any) : Spouse Name : Father Name : Mother Name : Marital Status : Married Unmarried Other Residential Status : Resident Individual Non-Resident Indian Foreign National Person of Indian Origin Date of Birth : Country of Birth*: Place of Birth : Country of Residence*: (for tax purpose) TIN : TIN Issuing Country*: Nationality : Indian Other (specify) Category : General OBC SC NT Other Passport No.: Date of Issue : Date of Expiry : Place of Issue : Valid Visa : Type of Visa : Date of Issue : Date of Expiry : Place of Issue : KYC Documents Details : PAN Card Election ID Driving License (Expiry Date ) Diplomat ID Aadhar Card Occupation (please tick) : Service Politician Diplomat Others ID Number Self-employed Business Professional Others (please specify) Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB) Other (Please specify) Designation : Address : Address Type : Owned Rental / Leased Ancestral / Family Company provide Other Please tick, if applicable : Politically Exposed Person (PEP) Related Politically Exposed Person Reasons for not providing TIN : A B C D (Please refer to Tax Residency Section for Reasons descriptions) If you indicate reason "B", please explain PHOTOGRAPH Please affix the recent passport size photograph and sign across it. (*Please refer to the enclosed annexure for state code & country code) Page 4
DECLARATION (i) I/we hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I/we am/are aware that I/we may be held liable for it. I/we confirm that the details submitted above are for updating the Bank's records and abide by Terms and Conditions as applicable from time to time. I/we agree and undertake to notify the Bank within 30 days if there is a change in any information which I/we have provided to the Bank. (ii) FATCA / CRS Declaration : I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Accounts Holder's relationship with ADCB setting out how ADCB may use and share the information supplied by me. I acknowledge, and undertake to inform the Controlling Persons identified herein, that I have provided the above information to ADCB in order for ADCB to comply with its legal obligations on reporting and exchanging financial information, and that the information provided by me will be stored by ADCB until it is required for this purpose. I further acknowledge, and undertake to inform the Controlling Persons, that the information contained in this form and information in relation to the Account Holder and any Reportable Account may be reported to the local tax authority and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax resident. I certify that I am authorized to sign for the Account Holder in respect of all the account(s) to which this form relates and have provided evidence of such authority. The Account Holder shall notify ADCB within a reasonable time frame if there is a change of circumstances that affects the tax resident status of the Account Holder identified in this document or causes the information contained herein to become incorrect or incomplete (including any changes to the information on Controlling Persons identified in Self Certification for controlling person). In such circumstances the Account Holder agrees to provide an updated self-certification document. I understand that the Bank is relying on the information provided herein for the purpose of determining the status of the applicant named above in compliance with FATCA / CRS. The Bank cannot offer any tax advice on CRS or FATCA or its impact on the applicant. I shall seek advice from any professional tax advisor for any tax related query. I agree that as may be required by domestic regulators / tax authorities, the Bank may also be required to report reportable details to CBDT or close or suspend my account (as may be necessary). (iii) I/We hereby consent to sharing KYC details/receiving information to/from Central KYC Registry, through SMS/Email on the above registered number/email address. Name Signature Date Place 1 Politically Exposed Persons (PEP ) : PEPs are individuals who are or have been entrusted with prominent public functions in a foreign country. Examples of PEPs include, but not limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii) Senior government/judicial (iv) Senior executives of state -owned corporations (v) important political party officials (vi) Senior Indian Diplomatic personnel posted outside the country. The term PEP also include the families and close associates of the PEPs mentioned. Families: The families incluides close family members such as spouses, children, parents and siblings and may also include other blood relatives and relatives by marriage. Close associates: The term closely associated persons in the context of PEPs includes close business and personal advisors / consultants to the PEP as well as persons who obviously benefit significantly from being close to such a person. Note : If the details cannot be captured in the above, the same should be provided on the letterhead of the entity, duly attested. Page 5
State Code & Country Code Annexure Page 6
KYC Documents Checklist KYC Application Form 2 Page 7