Customers Declaration Of His Her Being A Non Resident printable pdf download

_________________

" ‫י‬

‫בוצע ע‬

________

‫תאריך‬

__________________

____

________________________________

‫העובד‬

‫שם‬

_________________

‫אסמכתא‬

_________

‫פעולה‬

Name and Identification No.

Date: _____________

Bank Leumi Le-Israel B.M. (hereinafter: “the Bank”)

‫' א‬

2402

‫טופס מס הכנסה‬

To be signed once in 3 years

Customer’s Declaration of His/Her Being a Non-Resident

For The Purpose of The Income Tax Ordinance

I wish to open a non-resident account by virtue of my being a non-resident for the purpose of the Income Tax Ordinance.

A. The Customers’ Particulars:

Name:

Passport No./Corporation:

Type of customer:

legal entity

Individual

Trust

Partnership all of whose members are non- residents

Address for sending mail:

Permanent address (country, town, street, house number and apartment number):

Customer’s telephone:

Authorized account signatory's telephone:

In respect of an individual:

Year of birth:

Country of residence:

Country of citizenship:

Country issuing the

Validity of

passport:

In respect of a legal entity:

The country in which it was incorporated:

The country in which control and management are conducted:

With regard to an individual:

I declare that I am a non-resident because: (mark all the relevant boxes with an x.)

The State of Israel is not my permanent place of residence.

The State of Israel is not my place of residence or my family’s place of residence.

My ordinary or permanent place of activity is not in the State of Israel.

I do not engage in an occupation in the State of Israel.

I do not own a business or part of a business in the State of Israel.

This year I did not stay and I do not intend staying in the State of Israel for 183 days or more.

This year I did not stay in Israel and I also do not intend staying in Israel for 30 days or more and my total stay in Israel this

year and in the two preceding years will not reach 425 days.

I am not insured with the National Insurance Institute in the State of Israel.

I do not hold an Israeli passport

I do not have Israeli citizenship

This does not exclude from being a "non-resident".

"A Non Resident" - a person who is not an Israeli resident within the definition thereof in section 1 of the Income Tax Ordinance.

Signature ___________________________ Signature ___________________________ Signature ___________________________

‫אוגדן‬

Page 1 of 3

1. for the branch 2. for the customer

26.09.06

684-42

Customers Declaration Of His Her Being A Non Resident

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