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Name of relevant person: 1 Declaration regarding status for the purposes of US tax law
For the purpose of establishing the status and qualification of the above-mentioned relevant person as a US person or non-US person the undersigned relevant person hereby makes and confirms the following declarations to Capital Security Bank Limited:
2 US person declaration
In order to verify your status / qualification as a “US person” (relevant person), we request you to answer the following questions by checking the appropriate boxes below:
Are you a US citizen?
Yes
No
Are you a US resident alien?
Yes
No
Are you a US person (citizen or resident for tax purposes) for any other reason?
Yes
No
If you have answered “yes” to any of these questions, please provide us with an IRS form W-9.
3 Indicia of US status (applies only to non-US persons, i.e. if you have answered “no” to all of the above questions)
Were you born in the US?
Yes
No
Do you hold a green card?
Yes
No
Do you have a US residential address or a US correspondence address (including a US P.O. Box)?
Yes
No
Do you regularly transfer funds to or receive funds from an account maintained in the US?
Yes
No
Do you have a “care of” address in the USA?
Yes
No
Did you provide Capital Security Bank Limited with a written “hold mail” instruction?
Yes
No
Have you granted a power of attorney or a signature authority to a person with a US address?
Yes
No
If you have answered “yes” to any of these questions, please provide us with an IRS form W-8BEN, your non-US passport (or similar documentation establishing foreign citizenship), and an explanation why the US tax regulation does not apply to you and / or the relevant business relationship respectively.
4 Change of circumstances in status as a US person / non-US person
The undersigned relevant person undertakes to notify Capital Security Bank Limited in writing, without delay, and no later than thirty days (30) following an event that results in the change of his status from a non-US person to a US person according to US tax principles (or vice versa) or an event that changes his tax residency for double taxation purposes.
5 US tax disclosure statement
The relevant person has been informed by Capital Security Bank Limited that the legal environment in tax matters has been, still is and will be changing. Said changes impact the rights and obligations of the relevant person and Capital Security Bank Limited.
One particular impact of these changes in the legal environment in tax matters is that the relevant person’s tax related information / data (hereinafter “information”) will no longer be protected by the laws of The Cook Islands to the extent formerly known. However, it remains valid that it is the relevant person’s sole responsibility to comply with all relevant tax obligations, i.e. to file his / her tax return and any further information / data he / she might be obliged to file in order to properly disclose his / her accounts.
Forms - Tax Declaration September 2016
CAPITAL SECURITY BANK LIMITED 1
With this statement, the relevant person expressly declares that he / she: –
is aware that he / she is solely responsible to comply with all relevant tax obligations;
–
provided and will provide Capital Security Bank Limited, in each case, with all information necessary or requested and that such information, has been and will be true, correct and complete to his / her best knowledge and belief;
–
has been informed that, due to the changes in the legal environment in tax matters, his / her information regarding his / her business relationship with Capital Security Bank Limited will no longer be protected to the same extent as previously provided;
–
agrees that Capital Security Bank Limited may disclose any such information to any third party entitled to request and / or receive such information;
–
will not hold Capital Security Bank Limited responsible with regard to any consequences resulting from Capital Security Bank
–
will hold Capital Security Bank Limited and all its officials, employees, agents, intermediaries, and parties legally engaged to
Limited’s disclosure of any such information; fulfill any duties together with or instead of Capital Security Bank Limited (e.g. outsourcers) harmless from any demands, claims, inquiries, actions or causes of action (whether of a civil, criminal, administrative or investigative nature), assessments, losses, damages, liabilities, costs and expenses, including without limitation, interest, penalties, attorney’s fees, related disbursements and expenses asserted against, resulting to, imposed upon or incurred by said persons, resulting from the disclosure of any such information; –
agrees that this statement is subject to the laws of The Cook Islands and that the courts of The Cook Islands shall have jurisdiction in relation to any issue or dispute arising hereof
6 Relevant Person Signoff
Place / date:
Signature of the relevant person:
Forms - Tax Declaration September 2016
CAPITAL SECURITY BANK LIMITED 2