Individual 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 Reporting Standard
Please complete the sections below as directed and provide any additional information that is requested. Please note thatin 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 (maximumwithin 30 days). If you have any questions about how to complete this form, please contact your tax advisor.
Section 1: Identification
Full Legal Name
Salutation
Gender

MaleFirst Name
FemaleMiddle Name

Other

Last Name

Nationality

PAN
Identification Type and Number

Aadhar Number
Passport

Date of Birth (DD/MM/YYYY)
Place, City and Country of Birth
Place
Father’s Name

CityCountry

Mandatory if Tax ID is not available

Spouse’s Name (If available)
ServiceOccupation Type

BusinessOthers, please specify:

Company NameDesignation
Permanent Address

Mailing Address(if different from permanent address)

StreetBuilding Name
Suite
FloorDistrict / StateCity / Town
Postal CodeCountry
Mobile Number+

Contact Number

Residential Number+

Contact Number

Work Number+

Contact Number

Other Telephone Number+Contact Number

CRS Individual Self-Certification Form - India1

Section 2: Tax Information
Please state the name of all countries in which you are a tax resident and their corresponding tax identification number inbelow 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 thereason. 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 or functional equivalent:☐ The country where the account holder is a tax resident of does not issue tax identification number to its residents.
☐ The account holder is unable to obtain a tax identification number or functional equivalent.
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.)
Section 3: Declaration and Undertakings
I declare that the information provided in this form is, to the best of my knowledge and belief, true, accurate and complete.
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 orincomplete.
I agree that CLSA may disclose and transfer to its branches, affiliates or representative offices located in any jurisdiction theinformation contained in this form, and any information relating to the Account Holder’s accounts and 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 certify that I am the Account Holder / I am authorized to sign this form for the Account Holder^ and warrant that I haveobtained 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 processing of his/her personal data by CLSA for the purposes of this certification.
Signature
Print Name
Capacity

Indicate the capacity if you are not the individual identified in Section 1

Date (DD/MM/YYYY)^ Please strike out whichever is not applicable^^ Please attach a certified copy of the power of attorney, or written authorisation / equivalent to sign on behalf of theAccount Holder
For your easy understanding, we have prepared a short list of our most frequently asked questions on our website. For
more information, please email us at FATCA-CRS@CLSA.COM
CRS Individual Self-Certification Form - India

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