Fillable CRS Individual Self-Certification Form (CRS-I) (Hang Seng Bank)

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CRS Individual Self-Certification Form (CRS-I) (Hang Seng Bank)

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Country of origin: HONG-KONG
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D618a-R3(YX) 1-4 06/18 E
Page 1/4
Why are we asking you to complete this form?
To help protect the integrity of tax systems, governments around the world are introducing a new information-gathering and
reporting requirement for financial institutions. This is known as the Common Reporting Standard (“the CRS”).
Under the CRS, we are required to determine where you are “tax resident” (this will usually be where you are liable to pay income
taxes by reason of residence in a jurisdiction). If you are tax resident outside the jurisdiction where your account is held we may
need to give our local tax authority this information, along with information relating to your accounts. That may then be shared
between different jurisdictions’ tax authorities.
Completing this form will ensure that we hold accurate and up to date information about your tax residency.
If your circumstances change and any of the information provided in this form becomes incorrect, please let us know immediately
and provide an updated self-certification.
Who should complete the CRS Individual Self-Certification Form?
Personal banking customers or sole traders should complete this form.
If you need to self-certify on behalf of an entity (which includes businesses, trusts and partnerships) complete an “CRS Entity
Self-Certification Form” (CRS-E). Similarly, if you are a controlling person of an entity, complete a “CRS Controlling Person
Self-Certification Form” (CRS-CP). You can find these forms at http://bank.hangseng.com/1/2/crs.
For joint account holders, each individual will need to complete a copy of the form.
Even if you have already provided information in relation to the United States Government’s Foreign Account Tax Compliance
Act (“FATCA”), you may still need to provide additional information for the CRS as this is a separate regulation.
If you are completing this form on behalf of someone else, please ensure that you let them know that you have done so and tell
us in what capacity you are signing in Part 3. For example, you might be completing this form as a custodian or nominee of an
account, under a Power of Attorney or as a legal guardian on behalf of an account holder who is a minor.
Where to go for further information
If you have any questions about this form or these instructions please visit: http://bank.hangseng.com/1/2/crs, contact your
Relationship Manager, visit a branch or call us.
The ‘Organisation for Economic Co-operation and Development’ (OECD) has developed the rules to be used by all governments
participating in the CRS and these can be found on the OECD’s “Automatic Exchange of Information” (AEOI) website,
www.oecd.org/tax/automatic-exchange/.
If you have any questions on how to define your tax residency status, please visit the OECD website,
www.oecd.org/tax/automatic-exchange/ or speak to your tax advisor as we are not allowed to give tax advice.
CRS Individual Self-Certification Form (CRS-I)
Please read these instructions before completing this form
>>OPS>BOS
Print Form
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D618a-R3(YX) 2-4 06/18 E
Page 2/4
CRS Individual Self-Certification Form
______________
•
•
•
This is a self-certification form provided by an account holder to Hang Seng Bank Limited for the purpose of automatic exchange of
financial account information. The data collected may be transmitted by Hang Seng Bank Limited to the Inland Revenue Department for
transfer to the tax authority of another jurisdiction.
An account holder should report all changes in his/her tax residency status to Hang Seng Bank Limited.
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 Hang Seng Bank Limited to the
Inland Revenue Department.
Important Notes
Please complete parts 1-3 in BLOCK CAPITALS.
Part 1 – Identification of Individual Account Holder
A. Name of Account Holder
Mr Mrs Ms Miss
Other
__________________________________________________________________________
Family Name or Surname(s)* First or Given Name* Middle Name(s)
ID Document No.
_______________________________________________________________________________________________________
ID Document Type HKID Passport Other
______________________________________________________________
B. Current Residence Address
C. Mailing Address (Please only complete if different to the address shown in Section B)
D. Date of Birth*
(DD/MM/YYYY)
Line 1
(e.g. Suite, Floor, Building,
Street, District)
Line 2
(e.g. City)*
Line 3
(e.g. Province/State)
Country*/Territory*
Postal Code/ZIP Code
Line 1
(e.g. Suite, Floor, Building,
Street, District)
Line 2
(e.g. City)
Line 3
(e.g. Province/State)
Country/Territory
Postal Code/ZIP Code
>>OPS>BOS
For Bank Use
For Part 1, refer to AO Form of A/C No.:
_____________________________________
dated(DD/MM/YYYY):
__________________________
For Part 1, refer to Insurance Application Form of No.:
_______________________________
dated(DD/MM/YYYY):
____________________
D618a-R3(YX) 3-4 06/18 E
Page 3/4
Part 2 – Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)*
Jurisdiction of Residence
TIN
If no TIN available enter
Reason A, B or C
Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.
1
2
3
>>OPS>BOS
1
2
3
For Part 1, refer to Insurance Application Form of No.:
_______________________________
dated(DD/MM/YYYY):
____________________
Please complete the following table indicating (i) each jurisdiction of residence (including Hong Kong) where the Account Holder is a
resident for tax purposes and (ii) the Account Holder’s TIN for each jurisdiction indicated. Indicate all (not restricted to three) jurisdictions
of residence.
If the Account Holder is tax resident in more than three jurisdictions please use a separate sheet.
If the Account Holder 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:
1.
2.
3.
•
•
•
•
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. (Please explain why you are unable to obtain a TIN in the below table 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.
D618a-R3(YX) 4-4 06/18 E
Page 4/4
Part 3 – Declarations and Signature
I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder’s
relationship with Hang Seng Bank Limited (“Hang Seng Bank”) setting out how Hang Seng Bank may use and share the information supplied
by me.
I acknowledge and agree that (a) the information contained in this form is collected and may be kept by Hang Seng Bank 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 provided by Hang Seng Bank 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 purpose pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue
Ordinance (Cap.112).
I also agree that the information contained in this form may be shared to and used by any member of the Hang Seng Bank Group (including
any affiliates, subsidiaries and associated entities of Hang Seng Bank and their branches and offices) for the purposes of automatic
exchange of financial account information provided under the Inland Revenue Ordinance as set out above.
I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form relates.
I certify that where I have provided information regarding any other person (such as a Controlling Person or other Reportable Person to which
this form relates) that I will, within 30 days of signing this form, notify those persons that I have provided such information to Hang Seng Bank
and that such information may be provided 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 person may be resident for tax purposes
pursuant to the legal provisions for exchange of financial account information provided under the Hong Kong Inland Revenue Ordinance
(Cap.112).
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).
I declare that the information given and all statements made in this form and declarations are, to the best of my knowledge and
belief, true, correct and complete.
I undertake to advise Hang Seng Bank within 30 days 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 Hang Seng Bank with a
suitably updated self-certification and Declaration within 90 days of such change in circumstances.
Signature
X ____________________________________________________________
Print Name
Note: If you are not the Account Holder please indicate the capacity in which you are signing the form. If signing under a power of attorney please also
attach a certified copy of the power of attorney.
Date(DD/MM/YY)
Capacity:
>>OPS>BOS
In the event of any discrepancy or inconsistency between the English version and the Chinese version of this form, the English version shall
prevail.
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CRS Individual Self-Certification Form (CRS-I) (Hang Seng Bank)

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Completed 25 March 2021

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