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Tax regulations require ANZ and its Controlled Entities (“ANZ”) to collect a Self-Certication that includes your tax residence(s). ANZ may be required
to provide your information to relevant tax authorities (including where you do not provide a valid Self- Certication).
Automatic Exchange of Information may include the Foreign Account Tax Compliance Act (FATCA), and the Common Reporting Standard (CRS).
Before you begin:
(a) Complete this Self-Certication: If you are an Individual Account
Holder, Sole Trader or Sole Proprietor. For joint or multiple Account
Holders each Individual Account Holder must complete a separate
Self-Certication.
(b) Refer to the Australian specic terms/information at www.anz.com/aeoi
(c) Obtain tax/legal/other professional advice (if required) before you
complete this Self-Certication and sign Section 3
Once completed mail to: ANZ
AEOI Documents
Reply Paid 89576
SOUTH MELBOURNE VIC 3205
AUSTRALIA
SECTION 1: ACCOUNT HOLDER DETAILS
1.1 Full Name
First or Given Name(s) Surname
1.2 Residence Address (Do not provide a PO Box or in-care-of Address)
Address Line 1 Province/State/County
Address Line 2 Postal Code/Zip Code
City/Town Country
1.3 Date of Birth
(DD/MM/YYYY)
SECTION 2: ACCOUNT HOLDER TAX RESIDENCE(S)
(Please note, US Citizens are considered to be Tax Residents of the US).
2.1 I conrm:
a) I am only Tax Resident in Australia OR
b) I have included below all countries in which I am Tax Resident (other than Australia).
Country of Tax Residence
(Do not include Australia)
Tax payer identication number (TIN)
(or country equivalent)
Reason Code
(if TIN not provided)
Explanation
(only if Reason code is “Z”)
Reason codes:
A – TIN Not Issued (The Country does not issue TINs) B – TIN Not Required (The Country does not require collection of a TIN)
C – TIN Applied For (I have applied for a TIN and will inform you upon receipt) Z - TIN Unobtainable (I am unable to obtain a TIN) Please provide explanation.
SECTION 3: DECLARATIONS AND SIGNATURE
I certify that:
1. I am the Account Holder and/or authorised to sign/disclose for the
Account Holder.
2. I have consulted an independent advisor where necessary and
acknowledge that ANZ has not provided any advice.
3. I will notify ANZ of changes to any information (including TIN changes)
within 30 days of the change occurring and, where required, will
provide ANZ with a new Self-Certication.
4. I have attached all relevant documents (eg. Power of Attorney).
5. I have provided true, correct and complete information.
6. I will provide ANZ with any additional information and/or
documentation as requested.
7. I understand that provision of false, inaccurate or incomplete
information may constitute an oence(s) and penalties may apply.
Signature Name Date
Oce Use Only
(Please print rst and last name) (DD/MM/YYYY)
Australia and New Zealand Banking Group Limited (ANZ) ABN 11 005 357 522. Item No. 94350 07.2017 W577880
INDIVIDUAL SELF-CERTIFICATION
(FOR AUTOMATIC EXCHANGE OF INFORMATION)
