Entity Self-Certification Form
We are obliged to collect certain information about the tax arrangements of each account holder and their ultimate
beneficial owner under the Automatic Exchange of Tax Information on financial accounts: Common ReportingStandard
Please complete the sections below as directed and provide any additional information that is requested. Please
note that in certain circumstances we may be obliged to share this information with the relevant tax authorities.
Terms referenced in this Form shall have the same meaning as applicable under the multilateral competent authority
agreement signed between the various jurisdictions.
If any of the information below changes in the future, please ensure you advise us of these changes promptly(maximum within 30 days). If you have any questions about how to complete this form, please contact your taxadvisor.
Section 1: Identification
Legal Name of Entity
Entity Type

Date of Incorporation

DD/MM/YYYY

Place and Country ofIncorporation
PAN
Business CodeIdentification Type andTIN

If available

NumberCompany Identification number

If available

Global Entity Identification Number

If available

OtherPermanent Address

Mailing Address(if different from permanent address)

StreetBuilding Name
Suite
Floor
District / StateCity / Town
Post CodeCountry

Mobile Number+

Contact Number

Residential Number+

Contact Number

Work Number+Contact Number

Other Telephone Number+Contact Number

CRS Entity Self-Certification Form - India
1Section 2:
2.1 Entity Type
Tick one of the appropriate boxes and provide the relevant information.

FinancialInstitution

Reporting Financial Institution under CRS:
☐ Custodial Institution, Depository Institution or Specific Insurance Company☐ Investment Entity, except an investment entity that is managed by another financial institution (e.g.
with discretion to manage the entity’s assets) and located in a non-participating jurisdiction
GIIN:
All Financial Institutions need to provide GIIN. If not providing, please indicate reason:☐ Non-Reporting Financial Institution under CRS
Specify the type of Non-Reporting Financial Institution below:☐ Governmental Entity☐ International Organization☐ Central Bank☐ Broad Participation Retirement Fund
☐ Narrow Participation Retirement Fund
☐ Pension Fund of a Governmental Entity, International Organization, or Central Bank
☐ Exempt Collective Investment Vehicle☐ Trust whose trustee reports all required information with respect to all CRS Reportable Accounts☐ Qualified Credit Card Issuer☐ Other Entity defined under the domestic law as low risk of being used to evade tax
Specify the type provided in the domestic law:

☐ NFE the stock of which is regularly traded on, which is an established securities market☐ Related entity of, the stock of which is regularly, which is an established securities market

traded on
Active NFE☐ NFE is a governmental entity, an international organisation, a central bank, or an entity wholly owned
by one or more of the foregoing entities☐ Active NFE other than the above (Please specify)

Passive NFE(to completeSection 2.2below)☐ Investment entity that is managed by another financial institution and located in a non-participating
jurisdiction☐ NFE that is not an active NFE

CRS Entity Self-Certification Form - India2

2.2 List of Substantial Ownership / Controlling Persons
Indicate the name of all controlling person(s) of the account holder in the table below. If no natural person
exercises control over an entity which is a legal person, the controlling person will be the individual holding theposition of senior managing official. Complete a self-certification form for each controlling person.
1)_2)_
3)_

Section 3: Tax Information
Please state the name of countries in which you are a tax resident and the corresponding tax identification number
in below table. If you are a tax resident of any country which does not issue tax identification number, please provide
functional equivalent. If you are not issued any tax identification number or the functional equivalents, kindly provide
the reason. Please also inform us once you receive the same.
Country(ies) of Tax Residency(ies)

Name of Tax ID number

Tax ID number

Reason for non-availability of tax identification number:☐ The country where the account holder is resident of does not issue Tax identification number to its residents.
☐ The account holder is unable to obtain a Tax identification number or equivalent number.
Please explain why:

☐ No Tax identification number required. (Only select this reason if the domestic law of the country does not require
collection of Tax identification number.)

CRS Entity Self-Certification Form - India
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Section 4: Declaration and Undertakings
I declare that the information provided in this form is, to the best of my knowledge and belief, true, accurate andcomplete. I undertake to advise the CLSA Group (“CLSA”) promptly and provide an updated 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.
I agree that CLSA may disclose and transfer to its branches, affiliates or representative offices located in any
jurisdiction the information contained in this form, and any information relating to the Account Holder’s accountsand products with CLSA, in connection with or to facilitate their compliance with applicable laws and regulations.
I consent to CLSA collecting, using and disclosing information (including disclosing information to any government
authority or agency) that I have provided for the purpose of complying with applicable laws and regulations.
I am authorized to sign this form for the Account Holder and warrant that I have obtained the consent of any individual
named in this form or have the right to consent on his/her behalf to such collection, use, disclosure and processingof his/her personal data by CLSA for the purposes of this certification.

Authorized Signatory

Authorized Signatory

Print Name

Print Name

Capacity

Capacity

Date (DD / MM / YYYY)

Date (DD / MM / YYYY)

Please feel free to email us at FATCA-CRS @CLSA.COM if you have any queries about this declaration.

CRS Entity Self-Certification Form - India
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