FATCA

FATCA/CRS Annexure - Individuals (including sole-proprietors)
(Applicable for Resident and Non-Resident Customers)
Date _____________________ Place __________________________ AOF Reference Number _______________________
Details under FATCA / CRS
Please fill the information below as requested FIRST ACCOUNT HOLDER SECOND ACCOUNT HOLDER THIRD ACCOUNT HOLDER
Name of the Account Holder
Customer ID
Residence Address for Tax purpose

(including city, state, country and pin
code)
Address Type:
1- Residential or Business, 2- Residential,
3-Business, 4-Registered Office
Mobile/ Telephone Number (incl ISD and

STD code)
Date of Birth (DD-MON-YYYY)
City of Birth
Country of Birth
Nationality (if of more than one country,

please mention all the countries
separated by a comma)
Gender (Male, Female, Others)
PAN
Father’s Name (mandatory if PAN not

provided)
Aadhar Number (optional)
Spouse’s Name (optional)
Identification Type- Documents submitted

as proof of identity of the individual
Identification Number - for the

identification type mentioned above
(mandatory if PAN or Aadhaar not
provided)
Are you a tax resident of any country other than India?
First Account Holder Yes No Second Account Holder Yes No

Third Account Holder Yes No
If yes, please indicate all countries in which you are resident for tax purposes and the associated Tax Reference Numbers below
ACCOUNT HOLDER COUNTRY(IES) OF TAX TAX IDENTIFICATION IDENTIFICATION TYPE
NAME OF THE CUSTOMER
DETAILS RESIDENCY* NUMBER (TIN)** (TIN or other, specify)**
First Holder
Second Holder
Third Holder
* To also include USA, where the individual is a citizen / green card holder of USA
** In case Tax Identification Number is not available, please provide functional equivalent
Certification: I / We have understood the information requirements of this Form (read along with the FATCA/CRS Instructions) and hereby confirm that the information
provided by me/us on this Form is true, correct and complete. I/We also confirm that I/We have read and understood the FATCA/CRS Terms and Conditions below and hereby
accept the same.
FIRST/SOLE HOLDER SIGNATURE SECOND HOLDER SIGNATURE THIRD HOLDER SIGNATURE
X
DATE (DD/MM/YYYY) PLACE ________________________________
FATCA/CRS Terms & Conditions
The Central Board of Direct Taxes has notified Rules 114F to 114H, as part of the Income-tax Rules, 1962, which Rules require Indian financial institutions
such as the Bank to seek additional personal, tax and beneficial owner information and certain certifications and documentation from all our account
holders. In relevant cases, information will have to be reported to tax authorities/ appointed agencies. Towards compliance, we may also be required
to provide information to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the account or any
proceeds in relation thereto. Should there be any change in any information provided by you, please ensure you advise us promptly, i.e., within 30 days.
Please note that you may receive more than one request for information if you have multiple relationships with RKSV Securities India Pvt Ltd or its group
entities. Therefore, it is important that you respond to our request, even if you believe you have already supplied any previously requested information.
FATCA/CRS Instructions
If you have any questions about your tax residency, please contact your tax advisor. If your are a US citizen or resident or green card holder, please
include United States in the foreign country information field along with your US Tax Identification Number.
It is mandatory to supply a TIN or functional equivalent if the country in which you are a tax resident issues such identifiers. If no TIN is yet available or
has not yet been issued, please provide an explanation and attach this to the form. In case the customer has the following Indicia pertaining to a foreign
country and yet declares self to be non-tax resident in the respective country, customer to provide relevant Curing Documents as mentioned below
FATCA/CRS INDICIN OBSERVED (Ticked) DOCUMENTATION REQUIRED FOR CURE OF FATCA/CRS INDICIN
U.S. place of birth 1. Self-certification (in attached format) that the account holder is neither a citizen of
United States of America not a resident for tax purposes.
2. Non-US passport or any non-US government issues document evidencing nationality
or citizenship (refer list below) AND
3. Any one of the following documents:
a. Certified Copy of Certificate of Loss of Nationality or
b. Reasonable explanation of why the customer does not have such a certificate despite
renouncing US citizenship; or why the customer did not obtain U.S. citizenship at birth
Residence/mailing address in a country 1. Self-certification (in attached format) that the account holder is neither a citizen of
other than India United States of America not a resident for tax purposes.
2. Documentary evidence (refer list below)
Telephone number in a country other than 1. Self-certification (in attached format) that the account holder is neither a citizen of
India (and no telephone number in India United States of America not a resident for tax purposes.
provided) 2. Documentary evidence (refer list below)
Standing instructions to transfer funds to an 1. Self-certification (in attached format) that the account holder is neither a citizen of
account maintained in a country other than United States of America not a resident for tax purposes.
India 2. Documentary evidence (refer list below)
List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body*
2. Valid indentification issued by an authorized government body* (e.g. Passport, National Identity Card, etc.)
* Government or agency thereof or a municipality.

FATCA

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FATCA/CRS Annexure - Individuals (including sole-proprietors)

(Applicable for Resident and Non-Resident Customers)

Date _ Place AOF Reference Number _____

Details under FATCA / CRS

Name of the Account Holder

Residence Address for Tax purpose

Mobile/ Telephone Number (incl ISD and

Date of Birth (DD-MON-YYYY)

Nationality (if of more than one country,

Gender (Male, Female, Others)

Father’s Name (mandatory if PAN not

Aadhar Number (optional)

Spouse’s Name (optional)

Identification Type- Documents submitted

Identification Number - for the

Are you a tax resident of any country other than India?

First Account Holder Yes No Second Account Holder Yes No

FIRST/SOLE HOLDER SIGNATURE SECOND HOLDER SIGNATURE THIRD HOLDER SIGNATURE

FATCA/CRS Terms & Conditions

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