FATCA Questionnaire
FATCA Questionnaire
FATCA Questionnaire
YES
NO
_____________________________________________________________________________
2. Please list all countries for which you hold citizenship: __________________________________________________
Please confirm your status by checking the relevant column and indicate the date the IRS form is signed.
Date of IRS Form
Yes
No
1. US Citizenship (including dual citizen)
2. US Resident - Green Card
3. US Resident - Reside in the US for more than 183 days
If answer to no. 1, 2 or 3 is YES, do not answer no. 4, 5, 6, 7, 8. If NO, please answer no. 4, 5, 6, 7, 8.
Date of IRS Form
Yes
No
4. US Place of Birth
6. US Telephone number
7. Standing instruction to transfer funds to an account maintained
in the US
8. Power of Attorney or signatory authority granted to a person
with US address; or in care of or hold mail address
o
o
IRS Form W-9 Request for Taxpayer Identification and Certification. W-9 are used by US Person.
IRS Form W-8BEN - Certificate of Foreign Status of Beneficial Owner for US Tax Withholding. W-8BEN are used by Non-US Person.
Non-US Person
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____________________________________________________
Signature over Printed Name of Verifier
Position: ____________________________