Fillable CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS

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CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS

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VER 1.3/SCSC FORM INDV/WPC/09-20
As a financial institution, Citi does not provide tax advice to its customers. If you have any questions about whether you are a tax resident in any
particular country, please contact your tax advisor or visit the OECD AEOI portal for country-by-country information on tax residence at
http://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/.
This Form will remain valid unless there is a change in circumstances that makes this Form incorrect or incomplete. In that case, you must notify
Citi within 30 days of any such change and provide us with an updated CRS self-certification.
Definitions of an account holder and other terms are included in the Appendix.
Items that are marked with an asterisk (*) are required to be completed.
Please read these instructions carefully before completing the form.
Citi offices located in countries that have adopted the Common Reporting Standard (CRS) are required to collect and report certain information
about an account holder’s tax residence status. Please note that Citi may be legally required to report certain information provided in this
form and other financial information with respect to your financial accounts to the tax authorities of the country where your account is
maintained. In turn, the local tax authorities will exchange the reported information with the tax authorities in the country or countries in
which you are a tax resident. Please complete this form only if the account holder is an individual (including a sole proprietor or a decedent).
For joint or multiple account holders, use a separate form for each individual.
Please note that this self-certification form is for CRS purposes only. Its completion is not a substitute for the completion of any IRS Form W-9,
Form W-8 or FATCA Self-certification that may otherwise be required for U.S. tax purposes.
If you are completing this form on behalf of someone else, please indicate the capacity (custodian, nominee, executor, under power of attorney,
etc.) in which you are signing in Part 4.Aparent or legal guardian should complete the form on behalf of an account holder who is a minor.
Do not use this form for an entity account holder. Trusts (but not sole proprietors or decedents) are considered entities for this purpose. Instead use
the CRS Self-certification Form for Entities.
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
INSTRUCTIONS
PART I - IDENTIFICATION OF INDIVIDUAL ACCOUNT HOLDER
1
VER 1.3/SCSC FORM INDV/WPC/09-20
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
PART II – COUNTRY OF TAX RESIDENCE AND RELATED TAXPAYER IDENTIFICATION NUMBER
(TIN) OR EQUIVALENT
VER 1.3/SCSC FORM INDV/WPC/09-20
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
V2016-01 CBI RBI
4
VER 1.3/SCSC FORM INDV/WPC/09-20
1
Jurisdictions as of 3Q 2020: Antigua and Barbuda, Bahamas, Bahrain, Barbados, Cyprus, Dominica, Grenada, Malta, Qatar, Saint Kitts and Nevis, Saint Lucia,
Seychelles, Turks and Caicos Islands, United Arab Emirates (UAE), and Vanuatu.
Under Section VII of the CRS, financial institutions are required to perform additional due diligence for any individual or controlling
person(s) opening an account in a participating CRS jurisdiction where the sole tax residence on the CRS self-certification form is a CBI or
1
RBI jurisdiction (per the OECD list) .
1. Did you obtain residence rights under a CBI / RBI scheme? Yes No
2. Do you hold residence rights in any other jurisdiction(s)? Yes No
Citizenship by Investment (CBI) and Residence by Investment (RBI) programs are being offered by a substantial number of jurisdictions
and allow foreign individuals to obtain citizenship or temporary or permanent residence rights based on a local investment for a flat fee.
If you answered “Yes” to any of the above questions, please update Part 2 – Country of Tax Residence and related Taxpayer
Identification Number (TIN) or equivalent reflecting the above resulting jurisdictions or provide a reasonable explanation of why the
jurisdiction is not a tax residency.
4. Have you filed income tax returns in any other jurisdiction(s) during the previous year? Yes No
3. Have you spent more than 90 days in any other jurisdiction(s) during the previous year? Yes No
Complete Part 3 if you have listed only one “Country of residence” in Part 2 AND that country is included
1
in the list below
PART III - DUE DILIGENCE FOR CITIZENSHIP/RESIDENCY BY INVESTMENT
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
5
VER 1.3/SCSC FORM INDV/WPC/09-20
Customer Account Number:
*
PART IV - DECLARATIONS AND SIGNATURE
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
V2016-01 CBI RBI
6
VER 1.3/SCSC FORM INDV/WPC/09-20
“Financial Account” -An account maintained by a Financial Institution and includes:Depository Accounts;Custodial Accounts;an equity or
debt interest in certain Investment Entities; Cash Value Insurance Contracts; andAnnuity Contracts.
”Entity”- A legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or foundation.
“Reportable Jurisdiction Person” - An individual who is tax resident in a Reportable Jurisdiction under the laws of that jurisdiction.
“Controlling Person” - A natural person who exercise control over an entity. This definition corresponds to the term “beneficial owner”
of an entity, as described in Recommendation 10 (and the Interpretative Note) of the Financial Action Task Force Recommendations (as
adopted in February 2012). Where an entity Account Holder is treated as a Passive Non-Financial Entity (“NFE”), a Financial Institution
must determine whether such Controlling Persons are Reportable Jurisdiction Persons. If you are a Controlling Person of a Passive NFE,
you should complete a CRS self-certification for Controlling Persons instead of this Form.
“Participating Jurisdiction” -A jurisdiction (i) with which an agreement is in place pursuant to which it will provide the informationset out
in the Common Reporting Standard and required for the automatic exchange of financial account information, and (ii) which is identified
in a published list.
“Reportable Jurisdiction” – A jurisdiction (i) with which an agreement is in place pursuant to which there is an obligation to provide
financial account information set forth in the Common Reporting Standard, and (ii) which is identified in a published list.
“Account Holder” - The person listed or identified as the holder of a Financial Account. A person holding a Financial Account for the
benefit of another person as an agent, a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian,
is not treated as the Account Holder.For example in the case of a parent/child relationship where the parent is acting as a legal guardian,
the child is regarded as the Account Holder.With respect to a jointly held account, each joint holder is treated as an Account Holder. In the
case of an estate, the decedent should be identified as the Account Holder.
“TIN” -The Taxpayer Identification Number or a functional equivalent in the absence of a TIN. A TIN is a unique combination of letters or
numbers assigned by a jurisdiction to an individual or an Entity and used to identify the individual or Entity for the purposes of
administering the tax laws of such jurisdiction.
Some jurisdictions do not issue a TIN. However, these jurisdictions often utilise some other high integrity number with an equivalent level
of identification (a “functional equivalent”). Examples of that type of number include, for individuals, a social security/insurance number,
citizen/personal identification/service code/number and resident registration number.
Note: The following selected definitions are provided to assist you with the completion of this form. If you have any questions about
these definitions or require further detail, please contact your tax adviser.
APPENDIX OF DEFINED TERMS
CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS
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Completed 1 November 2020

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