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FATCA _CRS_ADDITIONAL DATA REQUIRED FROM CLIENTS

Name of Account Holder*:

Account Number:*

Country of Birth:

Place of Birth*:

Address Type*:

Pincode*:

Address for Tax Residence*:

Primary Source of Wealth*:

Details of Other Source of Wealth:

(Min. 4 characters is required)

Date:

Place*:

PAN No.*:

DECLARATION:

I, being the beneficial owner of the account hereby declare that the details furnished above are true and correct to the best of my knowledge and belief. In case of any change in the above given status on a future date, I undertake to inform KSBL DP of the same within 30 days. I understand that in certain circumstances (including if KSBL DP does not receive a valid self certification from me) KSBL DP may be obliged to share information about my account with relevant tax authorities. I hereby confirm that details as provided by me above can be shared by KSBL DP with Indian or foreign governmental or statutory or judicial authorities / agencies including but not limited to the Financial Intelligence Unit India (FIU IND), the tax / revenue authorities in India or outside India wherever it is legally required and other investigation agencies without any obligation of advising me of the same.

I Declare the above

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FATCA _CRS_ADDITIONAL DATA REQUIRED FROM CLIENTS [INDIVIDUALS] Required from first, second and third holder
Kindly provide the below additional information to comply with requirement under Foreign Account Tax Compliance Act, 2010 (FATCA) and the Multilateral Competent Authority agreement (MCAA) pursuant to amendments made to Income Tax Act, 1961 read with Income Tax Rules, 1962. The same maybe required to be shared with Indian tax authorities which in turn would forward reportable information to US IRS and member countries of OECD and G20 countries. For any queries about your tax residency please contact your tax advisor
NAME OF ACCOUNT HOLDER:		COUNTRY OF BIRTH:
ACCOUNT NUMBER:		PLACE OF BIRTH:
ADDRESS FOR TAX RESIDENCE:		ADDRESS TYPE (Tick whichever is applicable):	☐Residential ☐Business
DO YOU SATISFY ANY OF THE CRITERIA MENTIONED BELOW:		PRIMARY SOURCE OF WEALTH :	☐Personal Savings ☐Salary ☐Pension ☐Business Income ☐Inheritance ☐Sale of shares ☐Income from Agriculture ☐Rental Income ☐Dividend on Investments ☐Interest on Investments ☐Others (Please specify)
You are Citizen of any country other than India (dual/ multiple) [including Green Card holder]	☐Yes ☐No
Your address or telephone number is of outside India	☐Yes ☐No
You have a POA/ Mandate holder who has address outside India	☐Yes ☐No
Your country of birth is other than India	☐Yes ☐No
You are a tax resident of any country/ies other than India*	☐Yes ☐No
*If Yes, please specify the details of all countries where you hold tax residency and its Tax Identification number and type
Sr No.	Country of Tax Residency#	Tax Payer Identification Number / Functional Equivalent	Identification Type [TIN or other,please specify]
1
2
3

# to include all countries of tax residency/ permanent residency/ citizenship other than India and all Tax Identification Numbers

I, being the beneficial owner of the account hereby declare that the details furnished above are true and correct to the best of my knowledge and belief. In case of any change in the above given status on a future date, I undertake to inform KSBL DP of the same within 30 days. I understand that in certain circumstances (including if KSBL DP does not receive a valid self certification from me) KSBL DP may be obliged to share information about my account with relevant tax authorities. I hereby confirm that details as provided by me above can be shared by KSBL DP with Indian or foreign governmental or statutory or judicial authorities / agencies including but not limited to the Financial Intelligence Unit India (FIU IND), the tax / revenue authorities in India or outside India wherever it is legally required and other investigation agencies without any obligation of advising me of the same.
Date:		Place:

Fatca

FATCA _CRS_ADDITIONAL DATA REQUIRED FROM CLIENTS

DECLARATION:

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