FATCA and CRS - Self Certification Form For Entities

(Please consult your professional tax advisor on your tax residency and related FATCA and CRS guidance)

A. FATCA and CRS Information (Self Certification)

Part I
A. Is the account holder a Government body/International Yes No

Organization/listed company on recognized stock exchange

If “No”, then proceed to point B

If “yes” please specify name of stock exchange, if you are listed company
________________________ , and proceed to sign the declaration

B. Is the account holder a (Entity/Financial Institution) tax resident of Yes No

any country other than India
If “yes”, then please fill of FATCA/ CRS Self certification Form If “No”,
proceed to point C

C. Is the account holder an Indian Financial Inst. Yes No

If “yes”, please provide your GIIN, if any
If “No”, proceed to point D

D. Are the Substantial owners or controlling persons in the entity or chain of Yes No
ownership res ident for tax purpose in any country outside India or not an Indian
citizen
If “yes”, (then please fill FATCA/ CRS self - certification form).
If “No”, proceed to sign the declaration

Customer Declaration
( ) Under penalty of perjury, I/we 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 to 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)
2. The applicant is an applicant taxable as a tax resident under the lows of country outside India.
(ii) I/We understand that the DPLI is relying on this information for the purpose of determining the status of the applicant named
above in compliance with FATCA/CRS. The DPLI is not able to offer any tax advice on FATCA/CRS or its impact on the applicant.
I/we shall seek advice from professional tax advisor for any tax questions.
(iii) I/We agree to submit a new form within 30 days if any information or certification on this form becomes incorrect.(iv) I/We agree
that as may be required by domestic regulators/tax authorities the DPLI may also be required to report, reportable details to CBDT or close or
suspend my account.
(v) I/We certify that I/we provide the information on this form and to the best of my/our knowledge and belief the certification is true, correct,
and complete including the taxpayer identification number of the applicant.

Name of the Entity

Signature1 Signature 2

Signature3 ( As per MOP)

Date :_____________________________
 Part II
Self-Certification Form (Entity) for Foreign Account Tax Compliance Act (“FATCA”) and Common Reporting Standards (CRS)

Section 1: Entity information

Name of Entity

Customer id (if existing)

Entity Constitution Type B C D E F G H I J K Z X

(Refer Annexure A)

Entity Identification type T G C E O

(Refer Annexure A)

Entity Identification No

Entity Identification issuing country

Country of Residence for tax purpose

Section 2: Classification of Non-Financial entities

I/We (on behalf of the entity) certify that the entity is:

a) An entity incorporated and taxable in US (Specified US person)

If “Yes”, please provide your U.S. Taxpayer Identification

Number (TIN)

b) An entity incorporated and taxable outside of India (other than US)

If “Yes”, please provide your TIN or its functional equivalent

Provide your TIN issuing country ___________________________________

c) Please provide the following additional details if you are not a Specified US Person :

FATCA / CRS classification for Non-financial entities (NFE)

Active NFE

Passive NFE without any controlling Person

Passive NFE with Controlling Person(s):

US Others

Direct Reporting NFE (Choose this if any entity has registered itself for direct reporting for FATCA and thus DPLI is not required
to do the reporting)

Please provide GIIN number: ____________________

Section 3: Classification of financial institutions (including Banks)

I/We (on behalf of the entity) certify that the entity is : Yes No

a. An entity is a U.S. financial institution

If “Yes”,

(i) Please provide your Taxpayer Identification Number (TIN)

(ii) Please provide GIIN, if any __________________________________

If “No”, please tick one of the following boxes below:

Please provide the Global Intermediary

Identification number (GIIN) or other
FATCA classification
information where

Reporting Foreign Financial Institution in a Model 1

Inter-Governmental Agreement (“IGA”) Jurisdiction

Reporting Foreign Financial Institution in a Model 2

IGA Jurisdiction

Participating FFI in a Non-IGA Jurisdiction

Non-reporting FI

Non-Participating FI

Owner-Documented FI with specified US owners

Section 4: Controlling person declaration

or
If you are classified as “Passive NFFE with Controlling Person(s)” or “Owner documented FFI” “Specified US person”,
please provide the following details:

Correspondence TIN TIN issuing Controlling person

Country of
Name of Address country type
residence for tax
controlling person
purpose

Controlling person 1 Controlling person 2 Controlling person 3 Controlling person 4 Controlling person 5
Details

Identification Type

Identification Number

Occupation Type

Occupation

Birth Date

Nationality

Country of Birth
Section 5: Declaration

(i) Under penalty of perjury, I/we certify that:

1. The number shown on this form is the correct taxpayer identification number of the applicant, and
2. 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, or
3. The applicant Is an applicant taxable as a tax resident under the laws of country outside India.
(ii) I/We understand that the DPLI is relying on this information for the purpose of determining the status of the applicant named
above in compliance with CRS/FATCA. The DPLI is not able to offer any tax advice on CRS or FATCA or its impact on the applicant. I/we
shall seek advice from professional tax advisor for any tax questions.
(iii) I/We agree to submit a new form within 30 days if any information or certification on this form gets changed. .(iv) I/ We agree
as may be required by /Regulatory authorities, DPLI shall be required to comply to report, reportable details to CBDT or close or
suspend my account.
(v) I/We certify that I/we provide the information on this form and to the best of my/our knowledge and belief the certification is true,
correct and complete including the tax payer identification number of the applicant.

I/We hereby confirm that details provided are accurate, correct and complete

_________________________________________________________________________

Authorized Signatories and Company Seal (if applicable)

Name _______________________________________________

Date (DD/MM/YYYY) __________________________________

_____________________________________________________
Annexure A

Entity Constitution Type

B – Partnership Firm
C – HUF
D – Private Limited Company
E – Public Limited Company
F – Society
G – AOP/BOI
H – Trust
I – Liquidator
J – Limited Liability Partnership
K – Artificial Juridical Person
Z – Others
X – Not Categorized

Entity Identification Type

T – TIN
C – Company Identification Number
G – US GIIN
E – Global Entity Identification Number (EIN) O –
Other
Definitions
Note: The following selected definitions are provided to assist you with the completion of this form. If you have any questions about
substantive tax principles please contact your tax advisor or the applicable tax authority
Entity
A legal person or a legal arrangement, such as a corporation, organization, partnership, trust or foundation. This term covers any
person other than an individual (i.e. a natural person).

Financial Institution
A Custodial Institution, a Depository Institution, an Investment Entity, or a Specified Insurance Company.

Active Non Financial Entity (NFE)

Means any non-financial entity which fulfils any of the following criteria, namely:-
(i) less than fifty per cent of the entity’s gross income for the preceding financial year is passive income and less than fifty per cent
of the assets held by the entity during the preceding financial year are assets that produce or are held for the production of passive
income; or
(ii) the stock of the NFE is regularly traded on an established securities market or the non-financial entity is a related entity of an
entity, the stock of which is regularly traded on an established securities market.
(iii) the NFE is a Governmental entity, an International Organization, a Central Bank, or an entity wholly owned by one or more of
these entities; or
(iv) Substantially all of the activities of the NFE consist of holding (in whole or in part) the outstanding stock of, or providing
financing and services to, one or more subsidiaries that engage in trades or businesses other than the business of a financial institution:
(v) the NFE is not yet operating a business and has no prior operating history, but is investing capital into assets with the intent to
operate a business other than that of a financial institution, This exception is limited to 24 months from the date of the initial
organization of the NFE; or
(vi) the NFE was not a financial institution in the past five years, and is in the process of liquidating its assets or is reorganizing with
intent to continue or recommence operations in a business other than that of a financial institution; or
(vii) the NFE primarily engages in financing and hedging transactions with, or for, related entities which are not financial institutions,
and does not provide financing or hedging services to any entity which is not a related entity, provided that the group of any such related
entities is primarily engaged in a business other than that of a financial institution; or
(viii) the NFE fulfils all of the following requirements, namely:-
(a) it is established and operated in India exclusively for religious, charitable, scientific, artistic, cultural, athletic, or educational
purposes; or it is established and operated in India and it is a professional organization, business league, chamber of commerce, labor
organization, agricultural or horticultural organization, civic league or an organization operated exclusively for the promotion of social
welfare;
(b) it is exempt from income-tax in its jurisdiction of residence;
(c) it has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
(d) the applicable laws of the NFE’s jurisdiction of residence or the NFE’s formation documents do not permit any income or assets of
the NFE to be distributed to, or applied for the benefit of, a private person or non-charitable entity; and
(e) the applicable laws of the NFE’s jurisdiction of residence or the NFE’s formation documents require that, upon the NFE’s
liquidation or dissolution, all of its assets must be distributed to a Governmental entity or other non-profit organization, or escheat to the
Government of the NFE’s jurisdiction of residence or any political sub-division thereof.

Passive Non Financial Entity (NFE) Passive Non

Financial Entity means:
(i) any non-financial entity which is not an active non-financial entity; or
(ii) an Investment entity located in a Non-Participating Jurisdiction and managed by another Financial Institution

Investment Entity – includes two types of Entities:

(i) an Entity that primarily conducts as a business one or more of the following activities or operations for or on behalf of a customer:
a. Trading in money market instruments (cheques, bills, certificates of deposit, derivatives, etc.); foreign exchange; exchange,
interest rate and index instruments; transferable securities; or commodity futures trading; b. Individual and collective portfolio
management; or
c. Otherwise investing, administering, or managing Financial Assets or money on behalf of other persons. However, such activities
or operations do not include re4ndering non-binding investment advice to a customer.
(ii) an Entity managed by another Financial Institution is any Entity the gross income of which is primarily attributable to investing,
reinvesting, or trading in Financial Assets where the entity is managed by another entity that is a Depository Institution, a Custodial
Institution, a specified Insurance Company of an Investment Entity described in (i) above.

Control:
Control is generally exercised by the natural person(s) who ultimately has a controlling ownership interest (typically on the basis of a
certain percentage (e.g. 25%)) in the Entity. Where no natural person(s) exercises control through ownership interests, the Controlling
Person(s) of the Entity will be the natural person(s) who exercises control of the Entity through other means. Where no natural person(s)
is/are identified as exercising control of the Entity (for example where no underlying person has control of greater than 25% of the
entity) then under the CRS the Reportable Person is deemed to be the natural person who holds the position of senior managing official.

Controlling Person:
A natural person who exercises control over an entity. Where that entity is treated as a Passive Non Financial Entity
(“Passive NFE”) then a Financial Institution is required to determine whether or not these Controlling Persons are
Reportable Persons. This definition corresponds to the term “beneficial owner” of an entity as described in the Financial Action Task
Force (FATF) recommendations. In the case of a trust, the Controlling Person(s) are the settlor(s), the trustee(s), the protector(s) (f any),
and the beneficiary(ies) or class(es) of beneficiaries, regardless of whether or not any of them exercises control over the activities of the
trust. In addition, any other natural person(s)
exercising ultimate effective \ control over the trust (including through a chain of control or ownership) is a Controlling Person of a
trust.

Specified Insurance Company:

Specified Insurance Company means any Entity that is an insurance company (or the holding company of an insurance company) that
issues, or is obligated to make payments with respect to, a Cash Value Insurance Contract or an Annuity Contract

TIN:
The Taxpayer Identification Number or a functional equivalent in the absence of a TIN. A TIN is a unique combination of letters or
numbers assigned by a jurisdiction to an individual or an Entity and used to identify the individual or Entity for the purposes of
administering the tax laws of such jurisdiction. Some jurisdictions do not issue a TIN.
However, these jurisdictions often utilise some other high integrity number with an equivalent level of identification (a “functional
equivalent”). Examples of that type of number include, for Entities, a Business/company registration code/number.