Annexure - 3
FATCA declaration
(Please consult your professional tax advisor for further guidance on FATCA classification)
Part A
(to be filled by Financial Institutions or Direct Reporting NFFEs)
1 We are a
Financial institution
or
Direct reporting NFE
(please tick as appropriate)
GIIN:
Note: If you do not have a GIIN but you are
sponsored by another entity, please provide
your sponsor’s GIIN above and indicate your
sponsor’s name below:
Name of sponsoring entity:
M/s
GIIN not available (please tick as
applicable):
Applied for:
Following options available only for Financial
Institutions:
Not required to apply for (Please specify
sub-category
________________________)
Please provide with Form W8-BEN-E, duly
filled in
Not obtained Non-participating FFI
Part C
( please fill any one as appropriate)
1
Is the Entity a publicly
traded company (that is, a
company whose shares are
regularly traded on an
established securities
market)
Yes or No
(
If yes, please specify any
one stock exchange upon which the stock is regularly traded)
Name of the stock exchange
______________________________________________________________________
2
Is the Entity a related entity
of a publicly traded
company - a company
whose shares are regularly
traded on an established
securities market
Yes or No
If yes : Name of the listed company, the stock of which is regularly traded
______________________________________________________________________
If yes, please specify any one stock exchange upon which the stock is regularly traded
Name of the stock exchange
______________________________________________________________________
Nature of relation:
a) Subsidiary of the listed company
b) Controlled by a listed company
3 Is the Entity an active NFE
Yes or No
I
f yes , then Nature of business
______________________________________________________________________
Please specify the sub-category of Active NFE
______________________________________________________________________
4 Is the Entity a passive NFE
Yes or No
If
yes then,
Nature of business
Part C
Please list below the details of each controlling person(s), confirming ALL countries of tax residency/ permanent residency/
citizenship and ALL Tax Identification Numbers for EACH controlling persons (Please attach additional sheets if necessary):
Owner-documented FFI’s
should provide FFI Owner Reporting Statement and Auditor’s Letter with required details as
mentioned in Form W8 BEN E
Controlling Person -1 Controlling Person -2 Controlling Person -3 Controlling Person- 4
Name
Country of tax
residency *
Address details
(include City State,
Country & Pin code)
Telephone/mobile
number with ISD
code
# Tax identification
number (or
functional
equivalent) for each
country identified in
relation to each
person
# Identification Type
(TIN or Other,
please specify)
% of share
holding in Company/
Entity
Controlling person
type (share holder
etc)
Additional details to be filled below by controlling persons having tax residency/permanent residency/citizenship in any country
other than UAE including green card holders:
Controlling Person- 1 Controlling Person- 2 Controlling Person -3 Controlling Person -4
Gender
City of Birth
Country of birth
Occupation Type
(Service, Business,
Others)
Nationality
Father’s Name
Birth Date
Emirates ID /
Passport No
Identification Type
(Documents
submitted as
Identification proof of
of the individual)
Identity Number
*To include US, where controlling person is a US citizen or green card holder
%In case Tax Identification Number is not available, kindly provide functional equivalent
# These details are mandatory for passive NFEs as per the FATCA declaration @ Permissible values are: Passport No / Visa /Emirates ID PIO/OCI Card
FATCA Terms and Conditions
Towards compliance with tax information sharing laws, such as FATCA and CRS, we would be required to seek additional
personal, tax and beneficial owner information and certain certifications and documentation from our account holders. Such
information may be sought either at the time of account opening or any time subsequently. In certain circumstances we may be
obliged to share information on your account with relevant tax authorities. If you have any questions about your tax residency,
please contact your tax advisor. Should there be any change in any information provided by you, please ensure you
advise us promptly, i.e., within 30 days. Towards compliance with such laws, we may also be required to provide information
to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the account or any
proceeds in relation thereto. As may be required by domestic or overseas regulators/ tax authorities, we may also be
constrained to withhold and pay out any sums from your account or close or suspend your account(s).
If any controlling person of the entity is a US citizen or resident or green card holder, please include United States in
the foreign country information field along with the US Tax Identification Number.
It is mandatory to supply a TIN or functional equivalent if the country in which you are tax resident issues such identifiers. If no
TIN is yet available or has not yet been issued, please provide an explanation and attach this to the form.
Foreign Account Tax Compliance provisions (commonly known as FATCA) are contained in the US Hire Act 2010. Please note
that you may receive more than one request for information if you have multiple relationships with ABC. Therefore, it is
important that you respond to our request, even if you believe you have already supplied any previously requested information.
Certification
I /we have understood the information requirements of this Form (read along with the FATCA-CRS Instructions & Definitions)
and hereby confirm that the information provided by us on this Form is True, Correct, and Complete. I/we also confirm that I
/we have read and understood the FATCA-CRS Terms and Conditions above and hereby accept the same.
Name
Designation
Signature of Partner /Share
holder / POA holder/ Authorised
Signatory
Place:_____________
Date : _________/________/_____________
Seal of the
Co./Entity
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