Branch Name
Account Name
Account Number
Identification of Account Holder Name of Legal Entity or Branch
Place of Incorporation
Country/Jurisdiction of Incorporation or Organisation: Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Current Residence Address Address line 1
Address line 2
City/Town
Province/State/County:
Postal Code/ZIP Code:
Country/Jurisdiction: Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Please provide the Account Holder's Status by by selecting one option. Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution (Note: if ticking this box please also complete Part 2 (2) below) Other Investment Entity Depository Institution Custodial Institution Specified Insurance Company A corporation the stock of which is regularly traded on an established securities market or a corporation which is a related entity of such a corporation (e.g Public Limited Liability Companies, PLC) A Government Entity or Central Bank An International Organisation (for example the United Nations or World Health Organisation) Non-Profit Organization/Non-Governmental Organization Other types of Non Financial Entities (Passive NFE) (Note: if ticking this box please also complete Part 2 below)
Note: If there are no natural person(s) who exercise control of the Entity then the Controlling Person will be the natural person(s) who hold the
position of senior managing official.
Tax Residence Information Country/Jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent (“TIN”) Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the Account Holder's TIN for each
country/jurisdiction indicated.
Kindly note that TIN/ is mandatory if you are non-resident in Nigeria, and where this is provided by the foreign jurisdiction of residence
Country/Jurisdiction of tax residence Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Tax Identification Number (TIN))
If no TIN available enter Reason The country/jurisdiction where I am liable to pay tax does not issue TINs to its residents The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason) No TIN is required. (Note. Only select this reason if the authorities of the country/jurisdiction of tax residence entered below do not require the TIN to be disclosed)
Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.
CRS Controlling Person(s) Tax Residency Certification Section 1 Identification of a Controlling Person (A controlling person can either be by major ownership of shares, director/senior management, trustee position, beneficial owner and so on. Note: If there are no
individual(s) who exercise control of the Entity then the Controlling Person will be the individual(s) who hold the position of senior managing official.)
Controlling Person 1 Family Name or Surname(s)
Other Title
First or Given name(s)
Middle Name(s)
Address Line 1 House/Apt/Suite Name, Number, Street
Line 2 Town/City Province/County/State
Country Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Nature of Control Major shareholder/Owner Director Senior Management Trustee Beneficial Owner Others (Specify)
Mailing Address: (please only complete if different from the address shown in Section B above
Address
Country Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Postal Code / ZIP code
Please enter the legal name of the relevant entity Account(s) in the bank of which you are a Controlling Person Legal name of Entity(ies)
Family Name or Surname(s)
Other Title
First or Given name(s)
Middle Name(s)
Address Line 1 House/Apt/Suite Name, Number, Street
Line 2 Town/City Province/County/State
Country please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Nature of Control Major shareholder/Owner Director Senior Management Trustee Beneficial Owner Others (Specify)
Mailing Address: (please only complete if different from the address shown in Section B above
Address
Country Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Postal Code / ZIP code
Please enter the legal name of the relevant entity Account(s) in the bank of which you are a Controlling Person Legal name of Entity(ies)
Family Name or Surname(s)
Other Title
First or Given name(s)
Middle Name(s)
Address Line 1 House/Apt/Suite Name, Number, Street
Line 2 Town/City Province/County/State
Country Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Nature of Control Major shareholder/Owner Director Senior Management Trustee Beneficial Owner Others (Specify)
Mailing Address: (please only complete if different from the address shown in Section B above
Address
Country Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
Postal Code / ZIP code
Please enter the legal name of the relevant entity Account(s) in the bank of which you are a Controlling Person Legal name of Entity(ies)
Section 2 Country/Jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent (“TIN”) Please complete the following table indicating:
i. where the Controlling Person is tax resident; ii. The Controlling Person's TIN for each country/jurisdiction indicated. (You can also find out more about whether a country/jurisdiction is a Reportable Jurisdiction on the OECD automatic exchange of information portal).
If the Controlling Person is tax resident in more than one country/jurisdiction please use a separate sheet. If a TIN is unavailable please provide the appropriate reason A, B or C:
Reason A The country/jurisdiction where the controlling person is liable to pay tax does not issue TINs to its residents
Reason B The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)
Reason C No TIN is required. (Note. Only select this reason if the authorities of the country/jurisdiction of tax residence entered below do not require the TIN to be disclosed)
Country/Jurisdiction of tax residence Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
TIN
If no TIN available enter Reason The country/jurisdiction where the controlling person is liable to pay tax does not issue TINs to its residents The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason) No TIN is required. (Note. Only select this reason if the authorities of the country/jurisdiction of tax residence entered below do not require the TIN to be disclosed)
Country/Jurisdiction of tax residence Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
TIN
If no TIN available enter Reason The country/jurisdiction where the controlling person is liable to pay tax does not issue TINs to its residents The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason) No TIN is required. (Note. Only select this reason if the authorities of the country/jurisdiction of tax residence entered below do not require the TIN to be disclosed)
Country/Jurisdiction of tax residence Please select country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos [Keeling] Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Côte d’Ivoire Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Germany Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories French Southern and Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Metropolitan France Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam Northern Mariana Islands Norway Oman Pacific Islands Trust Territory Pakistan Palau Palestinian Territories Panama Panama Canal Zone Papua New Guinea Paraguay People's Democratic Republic of Yemen Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis LC:Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria São Tomé and Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Miscellaneous Pacific Islands U.S. Virgin Islands Uganda Ukraine Union of Soviet Socialist Republics United Arab Emirates United Kingdom United States Unknown or Invalid Region Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Nigeria
TIN
If no TIN available enter Reason The country/jurisdiction where the controlling person is liable to pay tax does not issue TINs to its residents The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason) No TIN is required. (Note. Only select this reason if the authorities of the country/jurisdiction of tax residence entered below do not require the TIN to be disclosed)
Declaration and Signature I understand that this Self-certification and the information supplied in it are subject to the terms and conditions governing the account(s) maintained with Sterling which this Self-Certification relates. I acknowledge that the information contained in this Self-certification and
information regarding the Account Holder and any Reportable Account(s) may be provided to the tax authorities of the country/jurisdiction in
which this/these account(s) is/are maintained and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in
which this Account Holder may be a tax resident, pursuant to bilateral or multilateral agreements between governments to exchange financial
account information.
I certify that I am authorised to complete and sign this Self-certification for the Account Holder of all of the account(s) to which this
Self-certification relates.
I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete. I undertake to notify the recipient of this Self-certification within 30 days of any change in circumstances which affects the tax residency status of the Account Holder or which causes the information contained herein to become incorrect (including any changes to the information on
Controlling Persons identified in Part 3 Question 2, if applicable), and to submit a suitably updated Self-certification and declaration within 30 days of such change in circumstances and to provide any additional information as may be required by Sterling and/or applicable law.
Signature of Account Holder (or individual authorised to sign for the Account Holder)
Full Name
Date
Please note that in providing the certification, a statement that is false, misleading or incorrect may be regarded as an offence and, therefore may be subject to
penalties under relevant law or regulation.
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