Declaration form - FATCA and CRS Individual Self-Certification

FATCA Declaration

Are you a US Person+ Yes No

The term 'United States person' means:

(a) an individual, being a citizen or resident of the United States of America;

(b) a partnership or corporation organized in the United States of America or under the laws of the United States of America or any State
thereof;

(c) a trust if:

(i) a court within the United States of America would have authority under applicable law to render orders or judgments concerning
substantially all issues regarding administration of the trust; and
(ii) one or more US persons have the authority to control all substantial decisions of the trust; or

(d) an estate of a decedent who was a citizen or resident of the United States of America;

A US person also includes a person who meet substantial present test in US

Generally, you will meet substantial present test in US if you were physically present in the United States on at least -

1. 31 days during the current calendar year, and

2. 183 days during current year and preceding two years, counting

All the days you were present in the current year (+)

1/3 of the days you were present in the first year before the current year (+)

1/6 of the days you were present in the second year before the current year

For exemptions, as applicable, kindly refer http://www.irs.gov/Individuals/International-Taxpayers/Substantial-Presence-Test

You will also be required to complete a Form W9/W8 with explanation, if any of the information in this form as well as in the account
opening form indicates any US indicia (i.e. if you fulfil the above US criteria). The Form W9/W8 will be available on an external website.
Instructions
CRS Individual Self-Certification
Please read these instructions before completing this form

Why are we asking you to complete this form?

To help protect the integrity of tax systems, governments around the world are introducing a new information-gathering and reporting
requirement for financial institutions. This is known as the Common Reporting Standard (CRS).

To implement the CRS locally, the Government of India joined the Multilateral Competent Authority Agreement (MCCA) on Automatic Exchange
of Financial Account Information on 3 June 2015 and notified the Rules under the Income Tax Rules, 1962 to this effect on
7 August 2015.

Under the CRS, we are required to determine where you are tax resident (this will usually be where you are liable to pay income taxes). If you
are a tax resident outside India, we will need to provide this information to the Indian Income Tax Authorities along with information relating to
your accounts. The same may then be shared between different tax authorities of countries.

Completing this form will ensure that we hold accurate and up-to-date information about your tax residency.

If your circumstances change and any of the information provided in this form becomes incorrect, please let us know immediately and provide
an updated self-certification.

Who should complete the CRS Individual Self Certification Form?

Personal Banking customers or sole traders should complete this form.

If you need to self-certify on behalf of an entity (which includes businesses, trusts and partnerships), you must complete an Entity Self-
Certification Form (CRS-E). Similarly, if you are a controlling person of an 1) Passive Non-Financial entity or 2) Investment entity managed by
another financial institution, you must complete a Controlling Person Self-Certification Form (CRS-CP). You can find these forms at www.crs.
hsbc.com. For joint accountholders, each individual will need to complete a copy of the form.

Even if you have already provided information in relation to the United States Governments Foreign Account Tax Compliance Act (FATCA), you
may still need to provide additional information for the CRS as this is a separate requirement under the local regulation.

If you are completing this form on behalf of someone else, please ensure that you let them know that you have done so and tell us in what
capacity you are signing in Part 3. For example, you might be completing this form as a custodian or nominee of an account, under a Power of
Attorney or as a legal guardian on behalf of an accountholder who is a minor.

Where to go for further information?

If you have any questions about this form or these instructions please visit http://www.crs.hsbc.com/en/rbwm/india or contact
HSBC PhoneBanking or your HSBC Relationship Manager or, visit our nearest HSBC India branch.

The Organisation for Economic Co-operation and Development (OECD) has developed the rules to be used by all governments participating in
the CRS and these can be found on the OECDs Automatic Exchange of Information (AEOI)
website, www.oecd.org/tax/automatic-exchange/. The relevant rules under the Income Tax Rules, 1962 can be found on the Income Tax
Department website, www.incometaxindia.gov.in

If you have any questions on how to define your tax residency status, please visit the OECD website,
www.oecd.org/tax/automatic-exchange/ or speak to your tax advisor as we are not allowed to give tax advice.

You can find a list of definitions in the Appendix.

Individual Tax Residency Self-Certification Form CRS I
Please complete Parts 1 3 in BLOCK CAPITALS.

Part 1

Identification of Individual Accountholder

A. Name of Accountholder:

Family Name or Surname(s)

Title Mr Mrs Ms Miss Other _________________________________________________________
First or given Name(s)
Middle Name(s)
(ii) Fathers Name
(iii) Spouses Name (if available)

B. Current Residence Address:

Line 1 House/Apt/Suite Name, Number, Street

Line 2 Town, City, Province, State
Country Postal code/Zip code

Is this address residential and business (Y/N): __________

C. Mailing Address: (please only complete if different from the address shown in Section B above)

Line 1 House/Apt/Suite Name, Number, Street

Line 2 Town, City, Province, State
Country Postal code/Zip code

Address Type
1. Residential Or Business
2. Residential
3. Business
4. Registered Office

D. Date of birth

D D MM Y Y Y Y

E. Place of birth

Town or city of birth

Country of birth

F. Aadhaar Number [Unique identification number issued by Unique Identification Authority of India (UIDAI)]
Individual Tax Residency Self-Certification Form
Please complete Parts 1 3 in BLOCK CAPITALS.

Part 2

Country of Residence for tax purposes and related Taxpayer Identification Number or functional equivalent (TIN) (see Appendix)

Please complete the following table indicating

(i) Where the accountholder is tax resident.
(ii) The accountholders TIN for each country indicated.

If the accountholder is tax resident in more than three countries please use a separate sheet.

If a TIN is unavailable please provide the appropriate reason A, B or C where appropriate:

Reason A The country where I am liable to pay tax does not issue TINs to its residents.

Reason B The accountholder is otherwise unable to obtain a TIN or equivalent number.

(Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)

Reason C No TIN is required. (Note: Only select this reason if the authorities of the country of tax residence entered below do not require the
TIN to be disclosed)

Country of tax residence/Country of TIN issuance TIN If no TIN available enter Reason A, B or C
1.
2.
3.

Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.

1.

2.

3.
Part 3

Declarations and Signature

I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the accountholders
relationship with The Hongkong and Shanghai Banking Corporation Limited (The Bank) setting out how The Bank may use and share the
information supplied by me.

I acknowledge that the information contained in this form and information regarding the accountholder and any Reportable Account(s) may be
provided to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or
countries in which the accountholder may be tax resident pursuant to intergovernmental agreements to exchange financial account information.

I certify that I am the accountholder (or am authorised to sign for the accountholder) of all the account(s) to which this form relates.

I certify that where I have provided information regarding any other person (such as a Controlling Person or other Reportable Person to which this
form relates) that I will, within 30 days of signing this form, notify those persons that I have provided such information to HSBC and that such
information may be provided to the tax authorities of the country in which the account(s) is/are maintained and exchanged with tax authorities of
another country or countries in which the person may be tax resident pursuant to intergovernmental agreements to exchange financial account
information.

I declare that all statements made in this declaration are, to the Signature:
best of my knowledge and belief, correct and complete.
I undertake to advise The Hongkong and Shanghai Banking Corporation
Limited within 30 days of any change in circumstances which affects
the tax residency status of the individual identified in Part 1 of this
Print name:
form or causes the information contained herein to become incorrect,
and to provide HSBC with a suitably updated self-certification and
declaration within 90 days of such change in circumstances.
Date:
D D MM Y Y Y Y

Note:
If you are not the accountholder please indicate the capacity in
which you are signing the form. If signing under a Power of Attorney
please also attach a certified copy of the Power of Attorney which
includes specific authority to sign this form under CRS. If signing
under a guardianship order please also attach a certified copy of the
guardianship order.
Capacity:
Appendix Definitions

Note: These are selected definitions provided to assist you with the completion of this form. Further details can be found within the Income
Tax Rules, 1961 and OECD Common Reporting Standard for Automatic Exchange of Financial Account Information (the CRS), the associated
Commentary to the CRS, and domestic guidance. This can be found at the following link www.oecd.org/tax/automatic-exchange/.
If you have any questions then please contact your tax adviser or domestic tax authority.
Accountholder The term 'accountholder' means the person listed or identified as the holder of a Financial Account by the financial institution
that maintains the account. A person, other than a Financial Institution, holding a Financial Account for the benefit of another person as an agent,
a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated as the accountholder. In these
circumstances that other person is the accountholder. For example in the case of a parent/child relationship where the parent is acting as a legal
guardian, the child is regarded as the accountholder. With respect to a jointly held account, each joint holder is treated as an accountholder.
Controlling Person This is a natural person who exercises control over an entity and includes a beneficial owner as determined under sub-rule (3)
of rule 9 of the Prevention of Money-Laundering (Maintenance of Records) Rules, 2005.
In determining the beneficial owner, the procedure specified in the following circular as amended from time to time shall be applied, namely:
(i) DBOD.AML.BC. No.71/14.01.001/2012-13, issued on 18 January 2013 by the Reserve Bank of India; or
(ii) CIR/MIRSD/2/2013, issued on 24 January 2013 by the Securities and Exchange Board of India; or
(iii) IRDA/SDD/GDL/CIR/019/02/2013, issued on 4 February 2013 by the Insurance Regulatory and Development Authority.
In the case of a trust, the controlling person means the settlor, the trustees, the protector (if any), the beneficiaries or class of beneficiaries, and
any other natural person exercising ultimate effective control over the trust, and in the case of a legal arrangement other than a trust, the said
expression means the person in equivalent or similar position.
Where an entity accountholder is treated as a Passive Non-Financial Entity (NFE) then a Financial Institution must determine whether such
Controlling Persons are Reportable Persons. If the account is maintained for an entity of which the individual is a Controlling Person, then the
'Controlling Person tax residency self-certification' form should be completed instead of this form.
Entity The term 'Entity' means a legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or foundation.
Financial Account A 'Financial Account' is an account maintained by a Financial Institution and includes: Depository Accounts; Custodial
Accounts; Equity and Debt interest in certain Investment Entities; Cash Value Insurance Contracts; and Annuity Contracts.
Reportable Account The term 'Reportable Account' means an account held by one or more Reportable Persons or by a Passive NFE with one
or more Controlling Persons that is a Reportable Person (relevant extract for CRS).
Reportable Jurisdiction A 'Reportable Jurisdiction' is a jurisdiction with which an obligation to provide financial account information is in place.
Reportable Person
Reportable person means,
(a) one or more persons other than,
(i) a corporation, the stock of which is regularly traded on one or more established securities markets;
(ii) any corporation that is a related entity of a corporation mentioned in item (i);
(iii) a Governmental entity;
(iv) an International organisation;
(v) a Central bank; or
(vi) a financial institution,
that is a resident of any country or territory outside India (except the United States of America) under the tax laws of such country or territory or
an estate of a descendent who was a resident of any country or territory outside India (except the United States of America) under the tax laws
of such country or territory; (relevant extract for CRS).
Dual resident individuals may rely on the tiebreaker rules contained in tax conventions (if applicable) to solve cases of double residence for
purposes of determining their residence for tax purposes.

TIN (including functional equivalent) The term TIN means Taxpayer Identification Number assigned to a person in the country or territory in
which he is resident for tax purposes and includes a functional equivalent in case no such number is assigned. 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. Further details of acceptable TINs can be found at the following link:
www.oecd.org/tax/automatic-exchange/.
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 individuals, a social security/insurance number,
citizen/personal identification/service code/number, and resident registration number.
SC CRS F 08/16

Issued by The Hongkong and Shanghai Banking Corporation Limited, India. Incorporated in Hong Kong SAR with limited liability.