FATCA/CRS Declaration Form

To, B.N. Rathi Securities Limited Client Code{{ $user_id }}
Name{{ $name_on_pan}}
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 : INDIA
a) Birth INDIA
b) Citizenship INDIA
c) Residence for Tax Purpose
d) Current Residence (Overseas Country for NRI)
2 US Person (Yes / No)Refer definition on page 2 YES ☐ NO ☐
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, pleaseprovide the Tax Payer Identification Number (TIN) or Functional equivalent as issued in the specific country in the table below :
i) ☐ TIN or
☐ Functional equivalent
i.) (please specify name and number 		 
 
Country of Issue
ii) ☐ TIN or
☐ Functional equivalent
i.) (please specify name and number 		 
 
Country of Issue
iii) ☐ TIN or
☐ Functional equivalent
i.) (please specify name and number 		 
 
Country of Issue
 



☐ I am a person resident out of India with (choose only if applicable) :
    ☐ Country not issuing TIN/Functional equivalent
    (mention ☐ Visa / ☐ Residence / ☐ Work permit number)
    ☐ Dependent visa ______________________________(mention dependent visa number)
    ☐ Student visa ______________________________(mention dependent visa number)
    ☐ Seafter status ______________________________(mention dependent visa number)
    ☐Going to the country of residence for first time ______________________________(mention visa number. TIN/functional equivalent to be communicated to the BNR within 90 days, else account will get closed).
OR
☐ I am a person resident in India as well as resident for tax purposes in India (Please also fill Part IV self-certification)
   
  1. 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)

  1. 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 i s 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)
  2. I understand that the BNR is relying on this information for the purpose of determining my status in compliance with FATCA/CRS. BNR 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.
  3. I agree to submit a new form within 30 days if any information or certification on this form becomes incorrect.
  4. I agree that as may be required by domestic regulators/tax authorities BNR may also be required to inform reportable details to CBDT or close or suspend my account.
  5. 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: {{$name_on_pan}}
 
Date (DD/MM/YY) {{$doc_date}}