Individual SelfCertification Instructions For Completion We Are Required Pursuant

individual self-certification instructions for completion we are required pursuant to the mutual legal assistance (tax matters) act, 2

Individual Self-Certification
Instructions for completion
We are required pursuant to the Mutual Legal Assistance (Tax Matters)
Act, 2003 and Orders and Guidance Notes made thereunder (implementing
legislation), to collect certain information about each account
holder’s tax arrangements. These requirements implement
intergovernmental agreements (IGAs) entered into by the British Virgin
Islands in relation to the automatic exchange of information for tax
matters (FATCA). Please complete the sections below as directed and provide
any additional information that is requested. Please note that in certain
circumstances (including if we do not receive a valid
self-certification from you) we may be obliged to share information on
your account with the BVI International Tax Authority.
Terms referenced in this Form shall have the same meaning as
applicable under the relevant IGA and/or implementing legislation.
If any of the information below about your tax residence or FATCA classification
changes in the future, please ensure you advise us of these changes promptly.
If you have any questions about how to complete this form, please contact
your tax advisor.
Please note that where there are joint account holders each account
holder is required to complete a separate self-Certification form.
Section 1: Account Holder Identification
Account Holder Name
Date of Birth (dd/mm/yyyy)
Country of Birth
Permanent Residence Address:
Number & Street
City/Town
State/Providence/County
Post Code
Country
Mailing address (if different from above):
Number & Street
City/Town
State/Providence/County
Post Code
Country
Section 2: Declaration of U.S. Citizenship or U.S. Residence for Tax
purposes
Please tick either (a) or (b) or (c) and complete as appropriate.
a.
I confirm that I am a U.S. citizen and/or resident in the U.S.
for tax purposes (green card holder or resident under the
substantial presence test) and my U.S. federal taxpayer
identifying number (U.S. TIN) is as follows:
b.
I confirm that I was born in the U.S. (or a U.S. territory) but
am no longer a U.S. citizen as I have voluntarily surrendered my
citizenship as evidenced by the attached documents.
c.
I confirm that I am not a U.S. citizen or resident in the U.S.
for tax purposes.
Complete section 3 if you have non-U.S. tax residencies.
Section 3: Declaration of Tax Residency (other than U.S.)
I hereby confirm that I am, for the purposes of that country’s tax
system, resident in the following countries (indicate the tax
reference number type and number applicable in each country).
Country/ countries of tax residency
Tax reference number type
Tax reference number
Section 4: Declaration and Undertakings
I declare that the information provided in this form is, to the best
of my knowledge and belief, accurate and complete. I undertake to
advise the recipient promptly and provide an updated
Self-Certification form within 30 days where any change in
circumstances occurs which causes any of the information contained in
this form to be inaccurate or incomplete. Where legally obliged to do
so, I hereby consent to the recipient sharing this information with
the relevant tax information authorities.
Signature
Date: (dd/mm/yy)