CRS Self Certification Form Corporate

Step 1 of 4

Part 1 – Identification of Entity/Branch Account Holder

Legal Name of Entity/Branch*

Country of Incorporation or Organization*

Account Number 1*

Account Number 2

Account Number 3

Current Residence Address*

Mailing Address*

Same as Current Residential Address

Mailing Address*

Part 2 - Account Holder’s Status

Please provide the Account Holder’s Status by indicating one of the following*

(a)(i) Financial Institution – Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution.

(a)(ii) Financial Institution – Other Investment Entity

(b) Financial Institution – Depository Institution, Custodial Institution or Specified Insurance Company

(c) Active NFE – A corporation the stock of which is regularly traded on an established securities market for a corporation which is a related entity of such a corporation

(d) Active NFE – A Government Entity or Central Bank

(e) Active NFE – An International Organization

(f) Active NFE – Other than (c) - (e) (for example a start-up NFE or a non-profit NFE)

(g) Passive NFE

Global Intermediary Identification Number*

Name of the established securities market on which the corporation is regularly traded*

Please provide the name of the regularly traded corporation*

Controlling Person tax residency self-certification FORM

Please read these instructions before completing the form.

If you’re filling in this form on behalf of a controlling person
Please tell us in what capacity you’re signing in Part 4.
For example, you may be the Passive NFE Account Holder, or completing the form under a power of attorney.

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 portal.

Please note that the information provided will be treated with the same level of confidentiality as other information provided in the course of opening account with us.

For clarification, kindly send an email to CRSProject@fidelitybankng.azurewebsites.net or contact your Relationship Manager.

We would appreciate your response within two weeks of receipt of this correspondence.

Controlling Person tax residency self-certification*

Full Name of Controlling Person

Address (House No. & Street)

Country

Address Type: Residential, Business or Office Address

Birth Date (DD-MM-YYYY)

Country of Birth

Controlling Person Type (E.g.:Owner, Senior Manger, Beneficiary)

Controlling Person's Tax Identification Number (TIN)

TIN Issued Country

Part 4 – Declarations 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 (the Financial Institution/insert FI’s name) setting out how (that Financial Institution /insert FI’s name) 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 authorized to sign for the Account Holder) of all the account(s) to which this form relates.

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 [the Financial Institution/insert FI’s name] within [XX] 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 [the Financial Institution that maintains the account/FI’s name] with a suitably updated self-certification and Declaration within [up to XX] days of such change in circumstances.

Kindly upload your signature*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Print Name*

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

Name

This field is for validation purposes and should be left unchanged.

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CRS Self Certification Form – Corporate