Entity Tax Self-Certification Form (Page 2 of 4) in pdf

Entity Tax Self-Certification Form Page 2

ENTITY TAX SELF-CERTIFICATION FORM

C. Entity type (continued)

2) Please complete this question only if the entity is identiﬁ ed as a Passive NFFE above.

In the box below, please provide the name, address and U.S. TIN of any U.S. person(s) who are controlling person(s)

of the entity. Alternatively, an IRS

W tax form can be completed for each U.S. person who is a controlling person of the entity.

Person 1

Person 2

Person 3

Person 4

Name

Address

U.S. TIN

–

(Attach a separate page if more space is required.)

Number of additional sheet(s) attached? __________________________________________

Certiﬁ cation

I declare that the information I have provided on this form is, to the best of my knowledge and belief, correct and complete. I agree to notify my

registered dealer within 30 days if there are any changes in circumstances that cause any information provided on this certiﬁ cation to become

incomplete, inaccurate, false or misleading, and to provide my registered dealer with a new Tax Self-Certiﬁ cation form upon request. I acknowledge that

information contained in this form and information regarding my account(s) with my registered dealer (including information on account balances and

payments received) may be reported to the CRA, and that the CRA may provide this information to the IRS.

Name:

Title:

Signature:

Date:

Name:

Title:

Signature:

Date:

Name:

Title:

Signature:

Date:

Please note that the information contained in this form should not be construed as tax or legal advice. Please consult with your own tax or legal advisors for information

regarding your own circumstances.

Entity Tax Self-Certification Form Page 2

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