Self-Certification of Entity Tax Status

This form may be used to certify your Entity’s tax resident status and classification under international tax regulations including
the Foreign Account Tax Compliance Act (FATCA) and the Common Reporting Standard (CRS) and, in some cases, to identify
the Entity’s Controlling Persons and establish their tax residence. The form can also be used to update us with any change of
circumstances. If you need help to complete this form, please call us on 0800 289 936 (Freephone UK only) or +44 (0)1624
645000. Please complete this form in full and when you have completed it please submit it electronically via DocuSign. We
may be obliged to share this information with relevant tax authorities. A brief glossary of terminology is attached, however, as
we are unable to provide tax advice, if you have any questions about how to complete this form, please refer to the OECD CRS
Commentaries, the OECD AEOI Portal, the FATCA and/or CRS guidance in your jurisdiction or contact your tax adviser.

1. Accountholder information

Legal name of entity/branch

Account number(s)

Jurisdiction of incorporation/
organisation/establishment

Registered address

Postcode

Mailing address (if different)

Postcode

Corporation Partnership Trust with professional trustees

Type of entity
This section is included to assist with our Trust with unlicensed trustees Registered pension scheme
understanding of your entity’s organisation
type and business activity to enable us to Registered charity Registered financial institution
assess the reasonableness of the information
disclosed in section 2, 3, 4 and 5 of the form. Other (please specify)

Primarily engaged in holding investments (not real property)

Primarily engaged in holding real property

Primarily engaged in commercial activities

Type of business activity
(retail, manufacturing, transport, construction etc.)
please tick one box

Primarily engaged in financial services as a depository, custodial insurance entity or
investment entity

Other (please specify)

2. U.S. FATCA
Please complete this section, where applicable, to cover the requirements of U.S. FATCA regulations.
2.1 Entity that is a U.S. person
Please tick and complete as appropriate (if the Entity is not a U.S. Person, please complete section 2.2).
The Entity is a Specified U.S. Person (U.S. incorporated domestic corporation, domestic partnership, or a U.S. trust or estate
subject to U.S. Court direction) and the Entity’s U.S. federal taxpayer identifying number (U.S. TIN or EIN) is as follows:

The Entity is a U.S. Person that is not a Specified U.S. Person (eg, U.S. government entities or corporates listed on an
established securities market). Indicate exemption type:

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Self-Certification of Entity Tax Status
2.2 Classification for all non-U.S. entities
Please complete this section if the Entity is not a U.S. Person:
2.2.1 If the Entity is a Registered Financial Institution, please tick one of the categories below, and provide the Entity’s Global
Intermediary Identification Number (GIIN).
IGA Partner Jurisdiction Foreign Financial Institution
Participating Foreign Financial Institution
Registered Deemed Compliant Foreign Financial Institution
(include certain local banks, non-reporting members of participating FFI groups, qualified collective investment vehicles and
restricted funds)
GIIN

2.2.2 If the entity is a Financial Institution but unable to provide a GIIN, please tick one of the the reasons below:
The Entity is a sponsored Financial Institution (including a Sponsored Investment Entity and Sponsored Closely Held
Investment Vehicle) and has not obtained a GIIN but is sponsored by another entity that has registered as a Sponsoring Entity.
Please provide the Sponsoring Entity’s name and GIIN below:
Sponsoring Entity’s Name

Sponsoring Entity’s GIIN

The Entity is a Trustee Document Trust. Please provide your Trustee’s name and GIIN below:
Trustee’s Name

Trustee’s GIIN

The Entity is an Exempt Retirement Plan

Other
The Entity is a Certified Deemed Compliant, or other Non-Reporting Foreign Financial Institution (including a Foreign Financial
Institution deemed compliant under Annex II of an IGA, except for a Trustee Documented Trust or Sponsored Financial
Institution or Exempt Retirement Plans) or an Owner Documented Financial Institution. Indicate exemption:

The Entity is a Non-Participating Foreign Financial Institution

The Entity is an Exempt Beneficial Owner
eg, Registered charities, Government and International Organisations

2.2.3 If the Entity is not a Financial Institution or Exempt Beneficial Owner please confirm the Entity’s FATCA status below:
The Entity is an Active Non-Financial Foreign Entity (including an Excepted NFFE)
The Entity is a Passive Non-Financial Foreign Entity (Passive NFFE)

2.2.4 If the Entity is a passive NFFE, please advise if either of the following apply:
The Entity is a Direct Reporting NFFE, please provide your Entity’s GIIN below:
Entity’s GIIN

The Entity is a Sponsored Direct Reporting NFFE, please provide the sponsoring Entity’s Name and GIIN below:
Sponsoring Entity’s Name

Sponsoring Entity’s GIIN

If you have confirmed that the Entity is a Passive Non-Financial Foreign Entity please provide details of the Controlling Persons
by completing section 5 of this form.

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Self-Certification of Entity Tax Status
3. The Common Reporting Standard (CRS)
Please complete this section, where applicable, to cover the requirements of CRS regulations.
3.1 Declaration of tax residence
Please indicate the Entity’s place of tax residence. If resident in more than one jurisdiction please detail all jurisdictions and
associated Tax Identification Number (TIN) applicable for each jurisdiction.

Jurisdiction of tax residence Tax Identification Number (TIN)

If a TIN is not available please provide a functional equivalent (such as a business or company registration number or other similar
form of identification). If no TIN or functional equivalent is available for any of the jurisdictions listed please advise the reason
why (such as the jurisdiction does not issue such numbers)

Further information on the issuance rules for TINs and their format can be found on the OECD’s AEOI Portal:
www.oecd.org/tax/automatic-exchange (select CRS Implementation and Assistance, and then click on Tax Identification Numbers).
3.2 The common reporting standard (CRS) classification
Please provide your CRS classification by ticking the corresponding box(es) below. Please note, an Entity’s CRS classification may
not necessarily be the same as its classification for US FATCA purposes.

Depository Institution
Custodial Institution
If the entity is a financial institution please
tick the box and specify the type of financial Specified Insurance Company
institution below:
Investment Entity - within the meaning of Section VIII, A.6(a) of the CRS*
‘Managed’ Investment Entity - within the meaning of Section VIII, A.6(b) of the CRS*

If you have ticked ‘Managed’ Investment Entity - within the meaning of Section VIII, A.6(b) of the CRS’ box above and the Entity
is resident in a Non-Participating Jurisdiction, the Entity will be treated as a Passive Non- Financial Institution. Therefore please
provide details of the Controlling Persons by completing section 5 of this form. Please tick here if this applies
*It is important to review the glossary at the end of this form to clearly identify if the entity is an investment entity, or a “managed”
investment entity.

Broad or Narrow Participation Retirement Fund

Trustee Documented Trust
Governmental Entity, International Organisation or Central Bank
Pension Fund of a Governmental Entity, International Organisation or
If the entity is a non-reporting CRS financial Central Bank
institution please specify the type
Exempt Collective Investment Vehicle
Qualified Credit Card Issuer
Other Entity defined under domestic law as low risk of being used to evade tax.
Please specify:

If the entity is not a financial institution please The Entity is an Active Non-Financial Entity
confirm the entity CRS status * The Entity is a Passive Non-Financial Entity

* Note – please review the glossary at the end of the form for guidance on the terms Active and Passive non-financial entities
If you have confirmed that the Entity is a Passive Non-Financial Entity please provide details of the Controlling Persons by
completing section 5 of this form.

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Self-Certification of Entity Tax Status
4. Entity declaration and undertakings
I declare (as the authorised signatory of the Entity) that the information provided in section 2 and 3 of this form is, to the best of my
knowledge and belief, accurate and complete.
I undertake to advise the recipient promptly and provide an updated Entity Self-Certification form within 30 days where any change
in circumstances occurs which causes any of the information contained in this form to be inaccurate or incomplete.
Where legally obliged to do so, I hereby consent to the recipient sharing this information with the relevant tax authorities.

Authorised signatory 1 Authorised signatory 2

Name

Position/title

Signature

Date (dd/mm/yyyy)

This document may be signed in any number of counterparts. Each counterpart is deemed to be an original, and together, all
counterparts form one single document. By completing and signing this form electronically, you agree that the signature(s) will be
the electronic representation of your signature(s) for all purposes, in the same way as a pen-and-paper signature. There is no need
to print and return the original form if you have signed it electronically.

5. Information regarding controlling persons

If the Entity is a Passive NFFE under US FATCA or a Passive NFE under CRS, please supply details of parties with a 25% or greater
interest in the legal entity. This includes:
• For a company, a list of the beneficial owners
• For a partnership, a list of the partners
If there is a Controlling Person of a legal entity other than a beneficial owner or partner, they should also be listed.
A Controlling Person has to be a natural person, an individual who exercises direct or indirect control. Therefore, if an entity
structure is in place, look through to the ultimate beneficial owners.
• For a trust or other similar legal arrangement, with unlicensed trustees or that are otherwise classified as a Passive NFFE / NFE,
the Controlling Persons will include the settlor, the trustee(s), the protector (if any), the beneficiaries, and any other natural
person exercising ultimate effective control over the trust.
5.1 Discretionary trust beneficiaries
It is recognised, specifically in the case of discretionary trusts, that the individual beneficiaries are not always identified until such
time as the first distribution is made to that beneficiary by the trust.
Such beneficiaries do not need to be listed below, however, should distributions be made in the future, the beneficiaries will be
treated as Controlling Persons and will become reportable under FATCA and CRS, if applicable. When this happens, you must
update us by supplying a new Entity Self-Certification form.
5.2 Type of controlling person
The type of Controlling Person should be listed as follows (if a Controlling Person of a trust is, for example, a settlor and trustee,
please include each role):
(a) Controlling Person of a Legal Person – Control by Ownership
(b) Controlling Person of a Legal Person – Control by Other Means
(c) Controlling Person of a Legal Person – Senior Managing Official (if Control cannot be established by either (a) or (b) above)
(d) Controlling Person of a Trust – Settlor
(e) Controlling Person of a Trust – Trustee
(f) Controlling Person of a Trust – Protector
(g) Controlling Person of a Trust – Beneficiary
(h) Controlling Person of a Trust – Other
(i) Controlling Person of a Legal Arrangement (Non-Trust) – Settlor Equivalent
(j) Controlling Person of a Legal Arrangement (Non-Trust) – Trustee Equivalent
(k) Controlling Person of a Legal Arrangement (Non-Trust) – Protector Equivalent
(l) Controlling Person of a Legal Arrangement (Non-Trust) – Beneficiary Equivalent
(m) Controlling Person of a Legal Arrangement (Non-Trust) – Other Equivalent

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Self-Certification of Entity Tax Status
5.3 Identification of controlling persons
Please complete the following section in full for each controlling person.

First controlling person (if applicable) Second controlling person (if applicable)

Title (eg, Mr/Mrs/Miss/Ms/Other)

Forename(s)

Surname

Permanent residence address

Postcode

Mailing address (if different)

Postcode

Type of controlling person

(see section 5.2)

Percentage ownership (%)

(legal persons)

Place of birth

Country of birth

Date of birth (dd/mm/yyyy)

Nationality

Please confirm the jurisdiction(s) where you are tax resident and indicate the applicable Tax Identification Number (TIN)

First country of residence

for tax purposes

National insurance number or Tax

Identification Number (TIN)
(or equivalent identity number)

To be completed below only if you are resident for tax purposes in multiple tax jurisdictions.

Second country of residence

for tax purposes

National insurance number or

Tax Identification Number (TIN)
(or equivalent identity number)

Third country of residence

for tax purposes

National insurance number or

Tax Identification Number (TIN)
(or equivalent identity number)

If a national insurance number or TIN

is not available, please provide your
residency certificate number

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Self-Certification of Entity Tax Status

First controlling person (if applicable) Second controlling person (if applicable)

I confirm that I am a U.S. citizen / or resident I confirm that I am a U.S. citizen / or resident
in the U.S. for tax purposes (Green Card in the U.S. for tax purposes (Green Card
holder or resident under the substantial holder or resident under the substantial
presence test) and I have disclosed my U.S. presence test) and I have disclosed my U.S.
Federal TIN (Social Security Number) above. Federal TIN (Social Security Number) above.
I confirm that I am not a U.S. citizen or I confirm that I am not a U.S. citizen or
Declaration of U.S. / Non-U.S. Citizenship
resident in the U.S. for tax purposes. resident in the U.S. for tax purposes.
or residence for tax purposes
Nedbank Private Wealth Limited will require all Nedbank Private Wealth Limited will require all
U.S. citizens and U.S. tax residents to complete a U.S. citizens and U.S. tax residents to complete a
Form W-9 (unless already completed), which we Form W-9 (unless already completed), which we
can send to you or you can download from the IRS can send to you or you can download from the IRS
website (www.irs.gov) under the Forms and website (www.irs.gov) under the Forms and
Publications section Publications section

I confirm that I was born in the U.S. (or a U.S. I confirm that I was born in the U.S. (or a U.S.
territory) but I am no longer a U.S. citizen as I territory) but I am no longer a U.S. citizen as I
renounced my citizenship and obtained a renounced my citizenship and obtained a
Certificate of Loss of Nationality of the Certificate of Loss of Nationality of the
United States. A certified copy is attached. United States. A certified copy is attached.

Declaration of a loss of U.S. Citizenship or I confirm that I have previously been a U.S. tax I confirm that I have previously been a U.S. tax
a loss of a U.S. tax residence resident by virtue of obtaining a U.S. Green resident by virtue of obtaining a U.S. Green
Card, however, I have now established a Card, however, I have now established a
permanent residence outside of the U.S. and permanent residence outside of the U.S. and
my Green Card has now been revoked as my Green Card has now been revoked as
evidenced by certified copy of the attached evidenced by certified copy of the attached
U.S. Abandonment of Lawful Permanent U.S. Abandonment of Lawful Permanent
Resident Status authority document. Resident Status authority document.

Third controlling person (if applicable) Fourth controlling person (if applicable)

Title (eg, Mr/Mrs/Miss/Ms/Other)

Forename(s)

Surname

Permanent residence address

Postcode

Mailing address (if different)

Postcode

Type of controlling person

(see section 5.2)

Percentage ownership (%)

(legal persons)

Place of birth

Country of birth

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Self-Certification of Entity Tax Status

Third controlling person (if applicable) Fourth controlling person (if applicable)

Date of birth (dd/mm/yyyy)

Nationality

Please confirm the jurisdiction(s) where you are tax resident and indicate the applicable Tax Identification Number (TIN)

First country of residence

for tax purposes

National insurance number or

Tax Identification Number (TIN)
(or equivalent identity number)

To be completed below only if you are resident for tax purposes in multiple tax jurisdictions

Second country of residence

for tax purposes

National insurance number or

Tax Identification Number (TIN)
(or equivalent identity number)

Third country of residence

for tax purposes

National insurance number or

Tax Identification Number (TIN)
(or equivalent identity number)

If a national insurance number or TIN

is not available, please provide your
residency certificate number

I confirm that I am a U.S. citizen / or resident I confirm that I am a U.S. citizen / or resident
in the U.S. for tax purposes (Green Card in the U.S. for tax purposes (Green Card
holder or resident under the substantial holder or resident under the substantial
presence test) and I have disclosed my U.S. presence test) and I have disclosed my U.S.
Federal TIN (Social Security Number) above. Federal TIN (Social Security Number) above.
I confirm that I am not a U.S. citizen or I confirm that I am not a U.S. citizen or
Declaration of U.S. / Non-U.S. Citizenship
resident in the U.S. for tax purposes. resident in the U.S. for tax purposes.
or residence for tax purposes
Nedbank Private Wealth Limited will require all Nedbank Private Wealth Limited will require all
U.S. citizens and U.S. tax residents to complete a U.S. citizens and U.S. tax residents to complete a
Form W-9 (unless already completed), which we Form W-9 (unless already completed), which we
can send to you or you can download from the IRS can send to you or you can download from the IRS
website (www.irs.gov) under the Forms and website (www.irs.gov) under the Forms and
Publications section Publications section

I confirm that I was born in the U.S. (or a U.S. I confirm that I was born in the U.S. (or a U.S.
territory) but I am no longer a U.S. citizen as I territory) but I am no longer a U.S. citizen as I
renounced my citizenship and obtained a renounced my citizenship and obtained a
Certificate of Loss of Nationality of the Certificate of Loss of Nationality of the
United States. A certified copy is attached. United States. A certified copy is attached.

Declaration of a loss of U.S. Citizenship or I confirm that I have previously been a U.S. tax I confirm that I have previously been a U.S. tax
a loss of a U.S. Tax residence resident by virtue of obtaining a U.S. Green resident by virtue of obtaining a U.S. Green
Card, however, I have now established a Card, however, I have now established a
permanent residence outside of the U.S. and permanent residence outside of the U.S. and
my Green Card has now been revoked as my Green Card has now been revoked as
evidenced by certified copy of the attached evidenced by certified copy of the attached
U.S. Abandonment of Lawful Permanent U.S. Abandonment of Lawful Permanent
Resident Status authority document. Resident Status authority document.

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Self-Certification of Entity Tax Status

5.4 Controlling persons declaration and undertakings

I acknowledge that the information provided in this form and regarding the Controlling Persons and any Reportable Account(s)
may be reported to the tax authorities of the jurisdiction in which this account(s) is maintained and exchanged with tax authorities
of another jurisdiction) in which [I/the Controlling Person] may be tax resident pursuant to international agreements to exchange
financial account information.
I certify that I am the Controlling Person, or am authorised to sign on behalf of the Controlling Person, of all the account(s) held by
the Entity Accountholder to which this form relates.
I declare that all of the statements made in this declaration are, to the best of my knowledge, correct and complete.
I undertake to advise the recipient promptly and provide an updated Entity Self-Certification form within 30 days where any change
in circumstances occurs which causes any of the information contained in this form to be inaccurate or incomplete.

First controlling person Second controlling person

Name

Capacity

Signature

Date (dd/mm/yyyy)

Third controlling person Fourth controlling person

Name

Capacity

Signature

Date (dd/mm/yyyy)

Note: If you are not a controlling person

please indicate the capacity in which you
are signing this form. If you are signing
under a Power of Attorney please also
attach a certified copy of the Power of
Attorney.

Date (dd/mm/yyyy)

This document may be signed in any number of counterparts. Each counterpart is deemed to be an original, and together, all
counterparts form one single document. By completing and signing this form electronically, you agree that the signature(s) will be the
electronic representation of your signature(s) for all purposes, in the same way as a pen-and-paper signature. There is no need to print
and return the original form if you have signed it electronically.

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Self-Certification of Entity Tax Status

FATCA/CRS explanatory note and glossary of terminology

Regulations governing the automatic exchange of information, including the U.S. Foreign Account Tax Compliance Act (FATCA)
and OECD’s Common Reporting Standard (CRS), require Nedbank Private Wealth to collect information from our accountholders
to determine whether they are U.S. Specified Persons or tax residents of CRS jurisdictions and where entities are accountholders
whether the Entity or any Controlling Persons are U.S. or CRS Specified Persons. This brief glossary may assist in explaining some
of the terminology used in FATCA and CRS but we are not tax advisers and this glossary is not a substitute for the regulation or
guidance available in each jurisdiction.
Certified Deemed Compliant FFI: This status is reserved for a class of entities that the IRS has deemed to pose a low risk of
tax evasion. These FFIs are treated as compliant for FATCA purposes and are not required to undertake all due diligence and
reporting eg, non-registering local banks and investment advisers who do not hold financial accounts on behalf of others.
Controlling Person: A Controlling Person means a natural person who exercises direct or indirect control over an Entity. In regard
to corporates, a Controlling Person is one who has an ownership interest of more than 25% in the company. If a partnership, the
Controlling Persons include any individual with a 25% or greater interest in the profits or capital of the partnership. In the case of
trusts the Controlling Persons includes the settlors, trustees, beneficiaries and, where applicable, the protectors.
CRS Definitions of Investment Entities: The following is taken from Section VIII 6a and 6b of the CRS. The term “Investment
Entity” means any Entity:
6(a) that primarily conducts as a business one or more of the following activities or operations for or on behalf of a customer:
i. 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;
ii. individual and collective portfolio management; or
iii. otherwise investing, administering, or managing Financial Assets or money on behalf of other persons; or
b) the gross income of which is primarily attributable to investing, reinvesting, or trading in Financial Assets, if the Entity is
managed by another Entity that is a Depository Institution, a Custodial Institution, a Specified Insurance Company, or an
Investment Entity described in subparagraph A(6)(a).
An Entity is treated as primarily conducting as a business one or more of the activities described in subparagraph A(6)(a), or an
Entity’s gross income is primarily attributable to investing, reinvesting, or trading in Financial Assets for purposes of subparagraph
A(6)(b), if the Entity’s gross income attributable to the relevant activities equals or exceeds 50 per cent of the Entity’s gross
income during the shorter of:
i. the three-year period ending on 31 December of the year preceding the year in which the determination is made; or
ii. the period during which the Entity has been in existence. The term “Investment Entity” does not include an Entity that is
an Active NFE.
CRS Specified Person: Means a CRS tax resident individual, a company tax resident in a CRS jurisdiction which usually means
they are incorporated, managed and controlled in that jurisdiction, a partnership where management and control is exercised in a
CRS jurisdiction or a trust, where the trustees are tax resident in a CRS jurisdiction.
Exempt Beneficial Owner: These are entities that are exempt from all aspects of FATCA. They include governments,
international organisations, certain retirement funds and registered charities. Retirement schemes are usually managed by
professional pension trusts and we have put the appropriate option in the financial institution section 2.2.
Foreign Financial Institution (FFI): Under U.S. FATCA the term Foreign Financial Institution (FFI) is used. CRS terminology is
Financial Institution (FI). The definition of an FFI is broad and wide ranging, and includes entities such as banks, custodians, nominees,
certain insurance companies, professionally managed trusts, funds, and certain professionally managed investment companies.
Non-Financial Foreign Entity (NFFE): These are non-U.S. entities that are not Foreign Financial Institutions or Exempt Beneficial
Owners. Under the CRS the term “foreign” is not used and therefore the CRS terminology is an NFE. There are two types of NFFEs
/NFEs:
Active NFFE: Active NFFEs/NFEs include manufacturing, retail and trading companies and non-financial institutions that
are listed on a recognised stock exchange. They are companies that make things or trade in things made by others – these
entities are reportable under CRS, but not under FATCA.
Passive NFFE: Passive NFFEs/NFEs are entities that primarily hold investment assets such as equities and debt securities
that produce investment income eg, dividends and interest. These entities will be reportable under FATCA or the CRS if the
Entity is tax resident in the U.S. or a CRS jurisdiction whilst its financial accounts are held with a financial institution in another
jurisdiction. Where Controlling Person(s) are U.S. and the Passive NFFE Entity is established outside of the U.S., they will be
reportable under FATCA. Where CRS Specified Persons are Controlling Persons of entities whose financial accounts are held
outside of the Controling Persons tax jurisdiction, they will be reportable under the CRS.
Non-Participating Foreign Financial Institution: Under U.S. FATCA this is an FFI that is not a Participating Financial Institution,
and will not obtain a global intermediary identification number from the IRS. These entities will suffer 30% withholding taxes on
U.S. sourced income and after 31 December 2016 on gross proceeds from the sale of assets that could generate such income.
There is no equivalent CRS definition.

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Participating Foreign Financial Institution: This is an FFI resident in a non-IGA jurisdiction which has registered directly
with the IRS and undertakes all due diligence and reporting obligations under FATCA.
Reporting CRS Jurisdiction: Over 100 countries including all EU countries, the Crown Dependencies and many others
are in various stages of adopting the CRS. For more information, search OECD AEOI Portal and CRS Jurisdictions.
U.S. Specified Person: Means a U.S. citizen or U.S. permanent resident individuals, including Green Card holders. A U.S.
partnership or a company incorporated in the U.S. and a U.S. trust, if a court in the U.S. has authority to pass judgement
relating to the administration of the trust, and a U.S. person has the authority to control all substantial decisions relating
to the trust. We will require a U.S. Specified Person to completed a U.S. Form W-9, if one has not already been completed.

Nedbank Private Wealth is a registered trade name of Nedbank Private Wealth Limited.

Nedbank Private Wealth Limited is licensed and regulated by the Isle of Man Financial Services Authority. Registered office: St Mary’s Court 20 Hill Street Douglas Isle of Man.

The Jersey branch is regulated by the Jersey Financial Services Commission. The London branch is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority. Registration No: 313189. The UAE representative office in Dubai is licensed by the Central Bank of UAE.
Representation in South Africa is through Nedbank Limited. Registered in South Africa with Registration No 1951/000009/06, an authorised financial services and registered
credit provider (NCRCP16). C201 08/24

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