Form Crs-1 - Individual Tax Residency Self-Certification printable pdf download

Individual Tax Residency Self-certification Form (CRS-1)

Please read these instructions before completing the form.

Regulations based on the OECD Common Reporting Standard (“CRS”) require OM Financial Limited to collect and report certain

information about an account holder’s tax residence. Each jurisdiction has its own rules for defining tax residence, and jurisdictions

have provided information on how to determine if you are resident in the jurisdiction on the following website: OECD automatic

exchange of information portal. In general, you will find that tax residence is the country/jurisdiction in which you live. Special

circumstances may cause you to be resident elsewhere or resident in more than one country/jurisdiction at the same time (dual

residency). If you are a U.S. citizen or tax resident under U.S. law, you should indicate that you are a U.S. tax resident on this form

and you may also need to fill in an IRS W-9 form. For more information on tax residence, please consult your tax adviser or the

information at the OECD automatic exchange of information portal.

If your tax residence (or the account holder, if you are completing the form on their behalf ) is located outside New Zealand,

we may be legally obliged to pass on the information in this form and other financial information with respect to your financial

accounts to Inland Revenue Department and they may exchange this information with tax authorities of another jurisdiction or

jurisdictions pursuant to intergovernmental agreements to exchange financial account information.

You can find summaries of defined terms such as an account holder, and other terms, in the Appendix.

This form will remain valid unless there is a change in circumstances relating to information, such as the acount holder’s tax status

or other mandatory field information, that makes this form incorrect or incomplete. In that case you must notify us and provide an

updated self-certification.

This form is intended to request information consistent with local law requirements.

Please fill in this form if you are an individual account holder, sole trader or sole proprietor.

For joint or multiple account holders, use a separate form for each individual person.

Where you need to self-certify on behalf of an entity account holder, do not use this form. Instead, you will need an “Entity Tax

Residency Self-certification Form”. Similarly, if you are a controlling person of an entity, please fill in a “Controlling Person Tax

Residency Self-certification Form” instead of this form.

If you are filling in this form on behalf of someone else.

Please tell us in what capacity you are signing in Part 4. For example, you may be the custodian or nominee of an account on

behalf of the account holder, or you may be completing the form under a power of attorney.

A legal guardian should complete the form on behalf of an account holder who is a minor.

As a financial institution, we are not allowed to give tax advice.

Your tax adviser may be able to assist you in answering specific questions on this form. Your domestic tax authority can provide

guidance regarding how to determine your tax status.

You can also find out more, including a list of jurisdictions that have signed agreements to automatically exchange information,

along with details about the information being requested, on the OECD automatic exchange of information.

Individual Tax Residency

Auckland

Wellington

Level 2, 37 Galway Street, Britomart |

Level 8, ASB Bank Tower, 2 Hunter Street

Self-certification Form

Form Crs-1 - Individual Tax Residency Self-Certification