Form Crs-1 - Individual Tax Residency Self-Certification (Page 3 of 4) in pdf

Part 3 - New Zealand Tax Effect

N.Z. Tax on Interest Earnings (please tick one)

Approved Issuer Levy (“AIL”)

Non-Resident Withholding Tax (“NRWT”)

AIL is an alternative to NRWT. If AIL is elected a 2% levy will be paid instead of NRWT. By electing AIL, you may not be able to get a

credit for the levy against your tax liability in your country of residence.

Part 4 – Declaration and Signature*

I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the

Account Holder’s relationship with OMF setting out how OMF may use and share the information supplied by me.

I acknowledge that the information contained in this form 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 account(s) is/are maintained and

exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax

resident pursuant to intergovernmental agreements to exchange financial account information.

I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form

relates.

I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable

Account(s) may be provided to the tax authorities of the country in which this account(s) is/are maintained and exchanged with

tax authorities of another country or countries in which the Account Holder may be tax resident pursuant to intergovernmental

agreements to exchange financial account information. I further certify that where I have provided information regarding any

other person (such as a Controlling Person or other Reportable Person to which this form relates) that I will, within 30 days of

signing this form, notify those persons that I have provided such information to OMF and that such information may be provided

to the tax authorities of the country in which the account(s) is/are maintained and exchanged with tax authorities of another

country or countries in which the person may be tax resident pursuant to intergovernmental agreements to exchange financial

account information.

I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.

I undertake to advise OMF within 30 days of any change in circumstances which affects the tax residency status of the individual

identified in Part 1 of this form or causes the information contained herein to become incorrect or incomplete, and to provide OMF

with a suitably updated self-certification and Declaration within 30 days of such change in circumstances.

Signature*

Print name*

Date*

Note: If you are not the Account Holder please indicate the capacity in which you are signing the form. If signing under a power of

attorney please also attach a certified copy of the power of attorney.

Capacity*

Appendix – Summary Descriptions of Select Defined Terms

Note: These are selected summaries of defined terms provided to assist you with the completion of this form. Further details can

be found within the OECD Common Reporting Standard for Automatic Exchange of Financial Account Information (the CRS”), the

associated Commentary to the CRS, and domestic guidance. This can be found at the OECD automatic exchange of information

portal.

If you have any questions then please contact your tax adviser or domestic tax authority.

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 3

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