IDENTIFICATION FORM
INDIVIDUALS & SOLE TRADERS
19 May 2017 version – Refer to FSC/FPA GUIDANCE - MANAGING AML/CTF AND FATCA/CRS CUSTOMER IDENTIFICATION OBLIGATIONS for conditions of use
Copyright © May 2017 Financial Services Council Limited and Financial Planning Association of Australia Limited
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GUIDE TO COMPLETING THIS FORM
o Complete one form for each individual. Complete all applicable sections of this form in BLOCK LETTERS.
o Tax information must be collected from the individual
o Contact your licensee if you have any queries.
SECTION 1: PERSONAL DETAILS
Surname
Date of Birth dd/mm/yyyy
Full Given Name(s)
Residential Address (PO Box is NOT acceptable)
Street
Suburb
State Postcode Country
COMPLETE THIS PART IF INDIVIDUAL IS A SOLE TRADER
Full Business Name (if any)
ABN (if any)
Principal Place of Business (if any) (PO Box is NOT acceptable)
Street
Suburb
State Postcode Country
SECTION 2: TAX INFORMATION
Tax Residency rules differ by country. Whether an individual is tax resident of a particular country is often (but not always) based on the amount of time a person
spends in a country, the location of a person’s residence or place of work. For the US, tax residency can be as a result of citizenship or residency.
Please answer both
tax residency questions:
Is the individual a tax resident of Australia? Yes No
Is the individual a tax resident of another Country? Yes No
If the individual is a tax resident of a country other than Australia, please provide their tax identification number (TIN) or equivalent below. If
they are a tax resident of more than one other country, please list all relevant countries below.
A TIN is the number assigned by each country for the purposes of administering tax laws. This is the equivalent of a Tax File Number in Australia or a Social
Security Number in the US. If a TIN is not provided, please list one of the three reasons specified (A, B or C) for not providing a TIN.
1. Country TIN If no TIN, list reason A, B or C
2. Country TIN If no TIN, list reason A, B or C
3. Country TIN If no TIN, list reason A, B or C
If there are more countries, provide details on a separate sheet and tick this box.
.
Reason A The country of tax residency does not issue TINs to tax residents
Reason B The individual has not been issued with a TIN
Reason C The country of tax residency does not require the TIN to be disclosed
IDENTIFICATION FORM INDIVIDUALS & SOLE TRADERS
19 May 2017 version Refer to FSC/FPA GUIDANCE - MANAGING AML/CTF AND FATCA/CRS CUSTOMER IDENTIFICATION OBLIGATIONS for conditions of use
Copyright © May 2017 Financial Services Council Limited and Financial Planning Association of Australia Limited
2/2
SECTION 3: VERIFICATION PROCEDURE
Verify the
individual’s
full name; and
EITHER
their date of birth or residential address.
o Complete Part I (or if the individual does not own a document from Part I, then complete either Part II or III.)
o Contact your licensee if the individual is unable to provide the required documents.
PART I ACCEPTABLE PRIMARY PHOTOGRAPHIC ID DOCUMENTS
Tick
Australian State / Territory driver’s licence containing a photograph of the person
Australian passport (a passport that has expired within the preceding 2 years is acceptable)
Card issued under a State or Territory for the purpose of proving a person’s age containing a photograph of the person
Foreign passport or similar travel document containing a photograph and the signature of the person*
PART II ACCEPTABLE SECONDARY ID DOCUMENTS
should only be completed if the individual does not own a document from Part I
Tick
Australian birth certificate
Australian citizenship certificate
Pension card issued by Department of Human Services (previously known as Centrelink)
Tick
A document issued by the Commonwealth or a State or Territory within the preceding 12 months that records the provision of financial
A document issued by the Australian Taxation Office within the preceding 12 months that records a debt payable by the individual to the
Commonwealth (or by the Commonwealth to the individual), which contains the individual’s name and residential address. Block out the TFN
A document issued by a local government body or utilities provider within the preceding 3 months which records the provision of services to
and residential address; and records the period of time that the individual attended that school
PART III ACCEPTABLE FOREIGN PHOTOGRAPHIC ID DOCUMENTS should only be completed if the individual does not own a document from Part I
Tick
Foreign driver's licence that contains a photograph of the person in whose name it issued and the individuals date of birth*
National ID card issued by a foreign government containing a photograph and a signature of the person in whose name the card was issued*
*Documents that are written in a language that is not English must be accompanied by an English translation prepared by an accredited translator.
IMPORTANT NOTE:
Either attach a legible certified copy of the ID documentation used to verify the individual (and any required translation) OR
Alternatively, if agreed between your licensee and the product issuer, complete the Record of Verification Procedure section below and
DO NOT attach copies of the ID Documents
SECTION 4: RECORD OF VERIFICATION PROCEDURE
ID DOCUMENT DETAILS Document 1 Document 2 (if required)
Verified From
Original Certified Copy Original Certified Copy
Document Issuer
Issue Date
Expiry Date
Document Number
Accredited English Translation
N/A
Sighted N/A Sighted
By completing and signing this Record of Verification Procedure I declare that:
an identity verification procedure has been completed in accordance with the AML/CTF Rules, in the capacity of an AFSL holder or their authorised
representative and
the tax information provided is reasonable considering the documentation provided.
AFS Licensee Name AFSL No.
Representative/ Employee Name Phone No.
Signature
Date
Verification
Completed