D618a-R3(YX) 4-4 06/18 E
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
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
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
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.
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.
In the event of any discrepancy or inconsistency between the English version and the Chinese version of this form, the English version shall
Please use signature(s)/chop(s) field with the Bank