State Bank of India

FATCA & CRS Individual self-certification for the purpose of section 285BA of the Income-tax Act, 1961
(All fields are mandatory)

S.NO Please fill the information First Account Holder Second Account Holder
below as requested
1 Customer ID (CIF)

2 Account No.

3 Account Holder Name

4 Father’s Name

5 Date of Birth

6 Place of Birth

7 Country of Birth

8 Gender □ Male □ Female □ Others □ Male □ Female □ Others

9 Occupation □ Service □ Business □ Others □ Service □ Business □ Others

10 Identification Type- □ Passport (Date of Expiry DD /MM /YYYY) □ Passport (Date of Expiry DD /MM /YYYY)
Documents submitted as
□ PAN □ PAN
proof of
identity of the individual □ Election / Voter’s ID card □ Election / Voter’s ID card
□ Driving License (Date of Expiry DD /MM /YYYY) □ Driving License (Date of Expiry DD /MM /YYYY)
□ Aadhaar card / letter □ Aadhaar card / letter
□ NREGA Card □ NREGA Card
□ Govt ID Card □ Govt ID Card
□ Others (pls. specify) □ Others (pls. specify)

11 Identification Number
12 Permanent Account
Number (PAN)
13 Country of Nationality
14 Country of Citizenship
15 Mobile No.
16 Email id
17 Mailing Address ( Complete
address consisting of house
number, building name, street,
Locality, city, postal code, state and
country)

18 Permanent Address
(Complete address consisting of
house number, building name,
street, Locality, city, postal code,
state and country)

19 Please tick if Address Type □ Residential and Business □ Residential and Business
is other than Residential □ Business □ Business
□ Registered Office □ Registered Office
20 Residential Status for tax □ Resident of India □ Resident of India
purposes □ Non-Resident of India □ Non- Resident of India.
 Declaration of Tax Residency

If you are tax resident of India only, please confirm below:

I confirm that I am not a US person nor a resident for Tax purpose in any
country other than India, though one or more parameters (Indicia) suggest
my relation with the country outside India. Therefore, I am providing the Signature of 1st account Signature of 2nd account
following document as proof of my tax residency only in India. holder holder

Documents Required:
i) Certificate of residence issued by authorised government body (including Government Agency or Municipality) (or)
ii) Any Valid identification (Passport, Election ID Card, PAN Card, Driving License, Aadhar copy, NREGA job card, Govt. Issued ID card)

OR
I/We am/are resident/s of following countries for tax purpose: -

Holders Country/ ies of Tax identification Numbers TIN/Functional Documentary evidence # If no TIN available specify one
Tax Residency (TIN)/Functional Equivalent Equivalent number enclosed for country of tax of the reasons given below
number) $ issuing country/ies residence and TIN
1st
Account
Holder

2nd
Account
Holder

Reasons for non-furnishing of TIN: 1. Country does not issue TIN 2. Country does not require the collection of TIN
3.TIN not yet obtained (please provide once it is obtained)

$ It is mandatory to supply a TIN or functional equivalent if the country in which you are tax resident issues such identifiers. Functional Equivalent
of TIN includes the following: social security/insurance number, citizen/personal identification/services code/national identification number,
resident / population registration number, Alien card number, etc.

❖ In case of US Citizenship, US Nationality, unambiguous place / country of birth is US but not resident in US for tax purposes fill
Annexure I

❖ If the jurisdiction of tax residence is outside India and the jurisdiction features in the list of High-Risk Countries specified by the OECD,
please complete Annexure -II.

Please refer the following link for list of High-Risk Countries featured in OECD: https://www.oecd.org/tax/automatic-exchange/crs-
implementation-and-assistance/residence-citizenship-by-investment/#faqs (Examples: Antigua and Barbuda, Bahamas, Bahrain, Barbados,
Cyprus, Dominica, Grenada, Malta, Saint Kitts and Nevis, Saint Lucia, Seychelles, Turks and Caicos Islands, United Arab Emirates and Vanuatu)

# Documentary evidence to be submitted:

i) Self-certified copy of TIN or functional equivalent number if the country in which you are tax resident issues such identifiers. If no
TIN is yet available or has not yet been issued, please furnish reasons, and attach to this form. (AND)
ii) A) A certificate of residence issued by authorized government body (including Government agency or a municipality) of the country
or territory in which the customer claims to be a resident. (OR)
B) Any valid identification issued by an authorized government body, including a government agency or a municipality, that
includes the individual’s name and is typically used for identification purposes.

CHANGE OF CIRCUMSTANCE / CEASING OF TAX RESIDENCY

If your tax residency has ceased or changed recently, please furnish details below:

Date or Year of Change in or Earlier country of tax Present country tax Documents submitted
Ceasing of Tax Residency residency residency
1st account holder

2nd account holder

 Customer Declaration
I /we certify that:

a) The information provided above is in accordance with Rules 114F to 114H of the Income Tax Rules ,1962 read with section 285BA of the
Income Tax Act ,1961.
b) I/We understand that State Bank of India is relying on this information for the purpose of determining the status of the account holder
named above in compliance with FATCA/CRS. State Bank of India is not able to offer any tax advice on CRS or FATCA or its impact on the
account holder. I/we shall seek advice from professional tax advisor for any tax questions.
c) The information and documentary evidence provided by me is to the best of my knowledge and belief, true, correct and complete and I
have not withheld any material information that may affect the assessment/categorization of my account as a reportable account or
otherwise.
d) I undertake the responsibility to declare and disclose immediately and in no case beyond 30 days from the date of change, any changes
that may take place in the information provided herein/or otherwise, as well as in the documentary evidence provided by me or if any
certification becomes incorrect or undergoes a change. I further undertake to provide fresh and valid self–certification along with
documentary evidence.
e) I / We also agree that my/our failure to disclose any material fact known to me/us, now or in future, may invalidate me from transacting
in the account and State Bank of India would be within its right to put restrictions in the operations of my/our account or close it or
report to any regulator and/or any authority designated by the Government of India (GOI) /RBI for the purpose or take any other action
as may be deemed appropriate by State Bank of India, under the guidelines issued by CBDT/RBI from time to time, if the deficiency is not
remedied by me within the stipulated period.
f) I permit /authorise the Bank to collect, store, communicate and process information relating to the account and all transactions therein,
by the Bank and any of its affiliates wherever situated including sharing, transfer and disclosure between them and to the authorities in
and/ or outside India of any confidential information for compliance with any law or regulation whether domestic or foreign.
g) I/We also agree to furnish and intimate to State Bank of India any other particulars that are called upon me / us to provide on account
of any change in law either in India or abroad in the subject matter herein.
h) I/We shall indemnify State Bank of India for any loss that may arise to State Bank of India on account of providing incorrect or incomplete
information by me/us.

Signature of the first account holder Signature of the second account holder

Date: Date:

Place: Place:

For Bank use only:

Documents Received : Self Certified True Copies Notary

Only India Tax residence Yes / NO PAN:

US Reportable: YES/ NO CRS Reportable: YES/ NO Name of the CRS country of Tax residence:

Tax Residence of OECD High Risk Jurisdiction: Yes / NO Name of such High-Risk Jurisdiction:

Alternative Tax residence of any other country: Yes/ NO Name of such alternate country of Tax residence:

TIN Provided: Yes / No. TIN Number:

RM/ Branch Staff Name ______________________________ Signature ___________________________

Date: Bank Seal:

 Annexure -I

In case of US Citizenship, US Nationality, and/ or unambiguous place of birth in US but not resident in US for tax purposes:

First Account Holder Second Account Holder

I confirm that I was born in the U.S. (or a U.S. territory) but am no longer
a U.S. citizen/ U.S. Tax resident as I have voluntarily surrendered my
Yes / No Yes / No
citizenship as per following documentary evidenced.

Documentary evidence to be provided:

a) Non-US passport or any non-US government issued document evidencing nationality or citizenship in a country other than the US.
AND
b) Certified Copy of “Certificate of Loss of Nationality or a reasonable explanation of: Why the customer does not have such a
certificate despite relinquishing US citizenship or Reason the customer did not obtain U.S. citizenship at birth.

Signature of the first account holder Signature of the second account holder

Annexure -II

Additional Self Certification/Declaration for Tax Resident of High-Risk Jurisdictions as per OECD

1st account holder 2nd account holder

I have obtained residence rights under Citizenship by Investment (CBI)/ Residence

by Investment (RBI) scheme. Yes/No Yes/No
I have held Tax residence rights in any other jurisdiction(s) Yes/No Yes/No
I have spent more than 90 days in any other jurisdiction(s) during the previous year. Yes/No Yes/No
I have filed personal income tax returns during the previous year in any other Yes/No Yes/No
jurisdiction.

If the answer to (2) / (3) / (4) above is YES, please fill the name of the Countries / Jurisdictions in the table below and provide the tax
identification number / functional equivalent number in those jurisdictions:

Name of countries/ Name of countries/ Name of countries/ Tax Identification / Documentary Proof of
jurisdictions in jurisdictions where jurisdictions where Functional Tax Identification
which tax residency more than 90 days personal income tax Equivalent Number / Functional
rights are held spent in previous returns filed during Number Equivalent Number
year the previous year

1st account
holder

2nd account
holder

Signature of the first account holder Signature of the second account holder

Kindly note that the reporting will also be done to such other country (s).