Account Opening Supplementary Form (including FATCA)
This form must be completed by any individual who wishes to open a banking account.
Please complete in BLOCK LETTERS
Name :
Alias :
Country of Residence :
Country of Birth :
Nationality/Citizenship :
(Incase of multiple nationalities, please list ALL Nationalities/Citizenships held)
Please check “√ ” Yes or No for each of the following questions:
Yes / No
1. Are you a U.S. Resident?
2. Are you a U.S. Citizen?
3. Are you holding a U.S. Permanent Resident Card (Green Card)?
I hereby confirm the information provided above is true, accurate and complete.
Subject to applicable local laws, I hereby consent for Standard Chartered PLC or any of its
affiliates (collectively ‘‘the Bank’’) to share my information with domestic and overseas tax authori-
ties where necessary to establish my tax liability in any jurisdiction.
Where required by domestic or overseas regulators or tax authorities, I consent and agree that the
Bank may withhold from my account(s) such amounts as may be required according to applicable
laws, regulations and directives.
I undertake to notify the bank within 30 calendar days if there is a change in any information which
I have provided to the bank.
Name :
Signature :
Date :
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