Form Crs-1 - Individual Tax Residency Self-Certification (Page 2 of 4) in pdf

Form Crs-1 - Individual Tax Residency Self-Certification Page 2

Individual Tax Residency Self-certification

Please complete Parts 1-3 in BLOCK CAPITALS

Part 1 – Identification of Individual Account Holder

Title

Surname

First name

Middle name

Any other name known by

Date of birth

Town/Country of Birth

Residential address

Postcode

Country of residence

Mailing address

Part 2 – Country/Jurisdiction of Residence for Tax Purposes and Related Taxpayer Identification Number or Equivalent

Number* (“TIN”)

(see Appendix)

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. Countries/Jurisdictions adopting the wider approach may require that the self-certification

include a tax identifying number for each country/jurisdiction of residence (rather than for each Reportable Jurisdiction).

If the Account Holder is tax resident in more than three countries/jurisdictions, please use a separate sheet.

If a TIN is unavailable please provide the appropriate reason A, B or C where indicated below:

Reason A – The country/jurisdiction where the Account Holder is resident 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 domestic law of the relevant jurisdiction does not require the

collection of the TIN issued by such jurisdiction).

Country/Jurisdiction of tax residence

TIN

If no TIN available enter Reason A, B or C

Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.

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 Page 2