Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697749963760.pdf (Georgia)
Self-Certification Questionnaire for Lending Institutions for the purposes of IGA (Internal Government Agreement for Implement FATCA) 1.

Name of the entity: _________________________________________________________________________________________________ 2.

Is the entity organized or incorporated in the United States?

Yes 2.1.

2.1.1.

Specify the EIN (Employer Identification Number): ____________________________________________ or provide a valid W-9 form 2.1.2.
Is the entity a non-specified US person (for definition of non-specified US person, please refer to Annex I): Yes.

Indicate exemption _______________________________________________________________ No No 2.2.

2.2.1.

Specify each residence country other than the United States ____________________________________________ and TIN (Taxpayer Identification Number) in each country _________________________________ 2.2.2.
Does the entity have Global Intermediary Identification Number (GIIN) for FATCA purposes: 2.2.2.1.
Yes Specify the GIIN: _________________________________, please check GIIN of your Sponsoring Entity (until 1 January 2016) if the entity is a Sponsored FFI and the GIIN provided is the Specify FATCA status of the entity: Participating FFI (not covered by IGA) Reporting Model 1 FFI Reporting Model 2 FFI Registered Deemed Compliant FFI Other, please specify _________________________________________________________________________________________ Specify the name of the entity in English as in the FATCA Registration Form: _____________________________________________________________________________ Specify the FATCA Responsible Officer: Full Name __________________________________________________________________ Official Position _______________________________________________________________ Phone and Fax Numbers __________________________ ____________________________ E-mail: ______________________________________________________________________ \ 2.2.2.2.
No, because (select only one): The entity is a Non-participating Foreign Financial Institution (including Limited FFI) The entity is an exempt beneficial owner of payments GIIN has been requested and will be provided within 90 days.
I agree to provide the Bank with a valid W-8 form where I shall state “applied for” in the box for GIIN The entity is governed by a Model 1 IGA and has been granted a registration extension under Notice 2013-43, a valid GIIN will be provided by 31 December 2014 The entity is a certified deemed-compliant FFI Other, please specify ____________________________________________________________________________________________ 3.
Certification and signature: As a representative authorized to sign on behalf of the entity, I declare that I have examined the information on this form and that to the best of my knowledge and belief it is true, correct and complete.

As a representative authorized to sign on behalf of the entity, I agree that I will submit a new form within 30 days if any certification on this form that may occur in above mentioned information becomes incorrect.
I authorize the Bank to provide the U.S. Internal Revenue Service/ Georgian Tax Authority or the appropriate authorized State Body, data on the entity needed for the reporting consistent with the purposes of compliance with the IGA.

______________________________________________________________________ Authorized person (Full Name) ______________________________________________________________________ Title (Work Position) (Signature) L.S.
Date: ______dd______mm_____yyyy Annex I Term Non-specified US person means a person, that is: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.


A corporation the stock of which is regularly traded on one or more established securities markets; Any corporation that is a member of the same expanded affiliated group, as defined in section 1471(e)(2) of the U.S. Internal Revenue Code, as a corporation described in clause 1; The United States or any wholly owned agency or instrumentality thereof; Any State of the United States, any U.S.
Territory, any political subdivision of any of the foregoing, or any wholly owned agency or instrumentality of any one or more of the foregoing; Any organization exempt from taxation under section 501(a) of the U.S. Internal Revenue Code or an individual retirement plan as defined in section 7701(a)(37) of the U.S. Internal Revenue Code; Any bank as defined in section 581 of the U.S. Internal Revenue Code; Any real estate investment trust as defined in section 856 of the U.S. Internal Revenue Code; Any regulated investment company as defined in section 851 of the U.S. Internal Revenue Code or any entity registered with the U.S. Securities and Exchange Commission under the Investment Company Act of 1940 (15 U.S.C.
80a-64); Any common trust fund as defined in section 584(a) of the U.S. Internal Revenue Code; Any trust that is exempt from tax under section 664(c) of the U.S. Internal Revenue Code or that is described in section 4947(a)(1) of the U.S. Internal Revenue Code; A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any State; (xii) a broker as defined in section 6045(c) of the U.S. Internal Revenue Code; or Any tax-exempt trust under a plan that is described in section 403(b) or section 457(g) of the U.S. Internal Revenue Code.