1507 TAX RESIDENCE DECLARATION

SELF-DECLARATION OF RESIDENCE
TAX OF INDIVIDUAL AND LEGAL ENTITY
(For Legal Entity, it is necessary to also complete the `Certification of Legal Entity´.
(AP6.1) and/or the document 'Mixed Declaration CRS-FATCA Person'
Legal (2X)

Page No: 1

Declaration for the purpose of the obligation to provide information about financial accounts in the context of mutual assistance (article 37 bis)
The present declaration is submitted for the purpose of compliance by the financial institution with the obligation of residence identification, or
in your case, nationality referred to in article 37 bis of the RGAT, with the aim of preventing and combating tax fraud.

Identifying Data
NIF/NIE Passport No

Last Name and First Name or Business Name

Date of Birth Place of Birth Country of Birth/

Constitution Constitution Constitution Nationality

Domicilio en el Extranjero(tipo de vía, nombre de vía, portal, escalera, piso, puerta)

Locality Province/Region/State Country Phone

(ZIP)

Address in Spanish Territory (type of road, name of road, portal, stairs, floor, door)

Locality Province/Region/State Country Telephone

(ZIP)

Tax Residences
I only have tax obligations in Spain.
Otherwise, specify the countries where there are tax obligations, due to filing income tax returns (IRPF) or
heritage in another country.
Tax ID other country/countries Country or Tax Jurisdiction Country or Territory Code

Relationship with the U.S.

Check with X what is applicable:

I have the citizenship of the United States of America.

I have legal residency (Green Card) of the United States of America.

In the case of Legal Entities, I have SOME shareholder with more than 25% U.S. capital or controlling person.
American.

If no relationship with the U.S. is indicated, for FATCA purposes, this form will be used to certify as a physical or legal person non-
American in replacement of the W-8BEN (individual) or W-8BEN-E (entity) form of the U.S. tax administration (IRS).

EVO BANK, S.A.U. ("the Entity") NIF A70386024 I.R.A.E. of the BdE No. 0239. I.R.M. MADRID, T.31840, F.88, J. M-57299 9, Inscription 2nd Social Headquarters: Serrano 45, 28001 [Link]
 SELF-DECLARATION OF RESIDENCE
TAXATION OF INDIVIDUAL AND LEGAL ENTITIES
(For Legal Entities, it is also necessary to complete the 'Legal Entity Certification')
(AP6.1) and/or the document 'Mixed Declaration CRS-FATCA Person'
Legal (2X)

Page No: 2

Declaration

The undersigned declares, under their responsibility:

to be a tax resident in the above-mentioned country/countries or territories.
that the account does not correspond to a permanent establishment in Spain (for the case of accounts; art.28.7 RGAT (1).
that this declaration is complete and true in relation to your nationality and tax residence and therefore includes all of the
countries or jurisdictions where they have their tax residence.
that, for US purposes, this statement is issued under penalty of perjury.

This statement is submitted for the purpose of applying (mark with an X what is applicable):

the exception to communicate the NIF in transactions with credit institutions (article 28 RGAT)
Exceptional assumptions:

Currency exchange or purchase of traveler's checks for an amount less than 3,000 euros (article 28.2 RGAT) ....................
Asset accounts, liability accounts or securities (Article 28.7 RGAT) ........................................................
Holders or possessors of checks, in the cases of D. A. Sixth.3 Law 58/2003, LGT (article 28.8 RGAT). .............

the exception to the withholding obligation on the income from the accounts of non-residents in article 14.1.f) of the Non-Resident Income Tax Act
(D. A. first of the Order EHA/3202/2008, of October 31) ............................................................
Scope of accreditation for the purpose of avoiding withholding on the income of non-resident accounts:
This statement is submitted in accordance with the provisions of the first additional provision of Order EHA/3202/2008, of 31 of
October, for the purposes of the provisions established in article 10.2 of the Regulation on the Income Tax of Non-Residents (2), and will have
validity exclusively in relation to the reporting of non-residents referred to in article 14.1.f) of the text
consolidated text of the Non-Resident Income Tax Law, not exempting from the rest of the obligations arising from the regulations
Spanish State treasury.

the accreditation of Non-Resident status. For the purposes provided in article 2 of Royal Decree 1360/2011, of October 7, by which ...
modifies RD 1816/1991, of December 20, on transactions with abroad ...........................................

RGAT: General Regulations on Tax Procedures and Management and Inspection Procedures and Development of Common Standards of the
procedures for the application of taxes, approved by Royal Decree 1065/2007, of July 27.
Regulation of the Income Tax for Non-Residents, approved by Royal Decree 1776/2004, of July 30.
This statement is presented for the reason of: Registration Modification

This declaration will have indefinite validity, unless there are variations in the reported data. In such case, the declarant assumes the
commitment to communicate any changes regarding the previously declared circumstances and must submit a new substitute declaration for
present it within a maximum period of 30 days from the change in situation.
The Tax Administration may require the filer to verify the data listed in this declaration. It may also communicate
the declared to the tax jurisdictions indicated, as well as to demand the responsibilities that may arise in the event of proven
falsehood of them.

The data provided by you will be incorporated into the file owned by EVO BANCO, S.A.U., responsible for it, located at CL/SERRANO, 45,
to be processed in order to allow EVO BANCO, S.A.U. to comply with the obligations imposed by the FACTA and CRS regulations.

You authorize that this information may also be provided to the entity you contract with, in order to likewise allow it to comply with the
FACTA and CRS obligations without you having to complete this same questionnaire again. In that case, that entity must incorporate the
same data to a file of your ownership and responsibility.

In any of the scenarios mentioned, you may at any time exercise your rights of access, rectification, cancellation, and opposition.
sending a written communication to the person in charge of the file at the addresses indicated above or via email directed to:
EVO BANK, S.A.U.:

Date:

Representative NIF: .............................................................................. Signature of the declarant or their representative:

Surnames and first name or Business Name: ..................................................... Attn.:

..............................................................................................................

EVO BANK, S.A.U. ("the Entity") NIF A70386024 I.R.A.E. of the BdE No. 0239. I.R.M. MADRID, T.31840, F.88, J. M-57299 9, Registration 2nd Social Address: Serrano 45, 28001 [Link]