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    FATCA Application Form Annexure

    Uploaded by

    blossomkdc
    This document is a FATCA/CRS declaration form for a customer of ICICI Bank Limited in India. It collects information about the customer's country of birth, citizenship, residence for tax purposes, and current residence. It asks if the customer has US person status and requires them to provide their Taxpayer Identification Number if any of their countries are not India or they have US person status. The customer must declare under penalty of perjury their tax status and agrees to submit a new form if any information changes. It includes definitions of US person and functional equivalent of a TIN.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    FATCA Application Form Annexure

    Uploaded by

    blossomkdc
    446 views3 pages
    This document is a FATCA/CRS declaration form for a customer of ICICI Bank Limited in India. It collects information about the customer's country of birth, citizenship, residence for tax purposes, and current residence. It asks if the customer has US person status and requires them to provide their Taxpayer Identification Number if any of their countries are not India or they have US person status. The customer must declare under penalty of perjury their tax status and agrees to submit a new form if any information changes. It includes definitions of US person and functional equivalent of a TIN.

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    FATCA Application Form

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    This document is a FATCA/CRS declaration form for a customer of ICICI Bank Limited in India. It collects information about the customer's country of birth, citizenship, residence for tax purposes, and current residence. It asks if the customer has US person status and requires them to provide their Taxpayer Identification Number if any of their countries are not India or they have US person status. The customer must declare under penalty of perjury their tax status and agrees to submit a new form if any information changes. It includes definitions of US person and functional equivalent of a TIN.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    446 views3 pages

    FATCA Application Form Annexure

    Uploaded by

    blossomkdc
    This document is a FATCA/CRS declaration form for a customer of ICICI Bank Limited in India. It collects information about the customer's country of birth, citizenship, residence for tax purposes, and current residence. It asks if the customer has US person status and requires them to provide their Taxpayer Identification Number if any of their countries are not India or they have US person status. The customer must declare under penalty of perjury their tax status and agrees to submit a new form if any information changes. It includes definitions of US person and functional equivalent of a TIN.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    FATCA/CRS Declaration Form

    To: ICICI Bank Limited India


    Customer ID: ______________________

    Bar Code: ____________________________

    Name: ____________________________________________________________________________
    Primary Holder

    Jt Holder 1

    Jt Holder 2

    Jt Holder 3

    Mandate Holder

    Residential Status (Resident / Non-Resident):_______________________

    FATCA/CRS Declaration Form


    Part I- Please fill in the country for each of the following (Applicable for all
    customers):
    1

    Country of:

    a)

    Birth

    b)

    Citizenship

    c)
    d)

    Residence for Tax Purposes


    Current Residence (Overseas
    Country for NRI)

    US Person (Yes / No)


    Refer definition on page 2

    Part II- Please note:


    a.

    If in all fields above, the country mentioned by you is India (except in case of seafarers) and if
    you do not have US person status, please proceed to Part III for signature.

    b. If for any of the above field, the country mentioned by you is not India and/or if your US person
    status is Yes, please provide the Tax Payer Identification Number (TIN) or Functional equivalent
    as issued in the specific country in the table below:
    TIN or
    Functional equivalent
    (please
    specify name and number)
    i)

    ii)

    Country of Issue
    TIN or
    Functional equivalent
    (please specify name and number)

    iii)

    Country of Issue
    TIN or
    Functional equivalent
    (please specify name and number)

    Country of Issue
    c.

    If you satisfy the criteria mentioned in II (b) above but do not have Taxpayer Identification
    Number/functional equivalent, please tick the reason for the same as given below:

    I am a person resident out of India with (choose only if applicable):

    OR

    Country not issuing TIN/Functional equivalent _______________________________


    (mention
    Visa /
    Residence /
    Work permit number)
    Dependent visa _________________________ (mention dependent visa number)
    Student visa________________________________(mention student visa number)
    Seafarer status ________________________________ (mention CDC/visa number)
    Going to the country of residence for first time ___________________________(mention
    visa number. TIN/functional equivalent to be communicated to the bank within 90 days, else
    account will get closed).

    I am a person resident in India as well as resident for tax purposes in India (Please
    also fill Part IV self-certification)
    d. In case you are declaring US person status as No but your Country of Birth is US, please provide
    document evidencing Relinquishment of Citizenship. If not available provide reason/s for not
    having relinquishment certificate _________________________________________________________.
    Please also fill Part IV Self-Certification.
    Part III- Customer Declaration (Applicable for all customers)
    (i) Under penalty of perjury, I certify that:
    1. The applicant is (i) an applicant taxable as a US person under the laws of the United States
    of America (U.S.) or any state or political subdivision thereof or therein, including the
    District of Columbia or any other states of the U.S., (ii) an estate the income of which is
    subject to U.S. federal income tax regardless of the source thereof. (This clause is
    applicable only if the account holder is identified as a US person) or
    2. The applicant is taxable as a tax resident under the laws of country outside India. (This
    clause is applicable only if the account holder Is a tax resident outside of India)
    (ii)

    I understand that the Bank is relying on this information for the purpose of determining my
    status in compliance with FATCA/CRS. The Bank is not able to offer any tax advice on
    FATCA/CRS or its impact. I shall seek advice from professional tax advisor for any tax
    questions.
    (iii) I agree to submit a new form within 30 days if any information or certification on this form
    becomes incorrect.
    (iv) I agree that as may be required by domestic regulators/tax authorities the Bank may also be
    required to inform reportable details to CBDT or close or suspend my account.
    (v) I certify that I provide the information on this form and to the best of my knowledge and belief
    the certification is true, correct, and complete including the taxpayer identification number /
    functional equivalent number of the applicant.

    Signature :

    Name :
    Date (DD/MM/YYYY) :

    Part IV- Self-Certification (Not Applicable for NRI customers except for point (b) below):
    To be filled only if(a) Any of the indicia parameters is outside India and TIN or functional equivalent is not available
    since not a resident for tax purpose outside India, or
    (b) Country of Birth is US and US person is mentioned as No in Part I
    I confirm that I am not a US person or
    a resident for Tax purpose in any
    country other than India, though one
    or more parameters suggest my
    relation with the country outside
    India. Therefore, I am providing the
    following document as proof of my
    Signature
    citizenship and / or residency.
    Document Proof submitted (Pls tick document being submitted)
    Passport
    Election Id Card
    PAN Card
    NREGA Job Card
    Govt. Issued ID Card
    _________________

    Driving License

    UIDAI Letter

    NoteThe term United States person means:


    a. an individual, being a citizen or resident of the United States of America;
    b. partnership or corporation organized in the United States of America or under the laws of the United
    States of America or any State thereof;
    c. a trust if: i. a court within the United States of America would have authority under applicable law
    to render orders or judgements concerning substantially all issues regarding administration of the
    trust; and ii. one or more U.S. persons have the authority to control all substantial decisions of the
    trust;
    d. an estate of a decedent who was a citizen or resident of the United States of America.
    Functional Equivalent of TIN includes the following:
    A social security/insurance number, citizen/personal identification/services code/national identification
    number, a resident / population registration number, Alien card number, etc.

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