FATCA SELF CERTIFICATION FORM

For Individual Applicant / Investors

Category

First Applicant / Guardian

Second Applicant

PAN
Country of Birth
Country of Citizenship / Nationality
[Please specify the country if you hold any
other citizenship than India]
Are you a US Specified Person? (Yes / No)
If Yes, please provide Tax Payer ID.
Country of Tax Residency 1 #
Tax Identification No. 1 %
Country of Tax Residency 2
Tax Identification No. 2
Country of Tax Residency 3
Tax Idenfitication No. 3
# To also include USA, where the individual is a citizen / green card holder of USA
% in case Tax Identification Number is not available, kindly provide functional equivalent

INVESTOR(S) DECLARATION & SIGNATURE(S)

I / We have understood the information requirement of this Form as per the CBDT notifies Rules 114F to 114H and hereby acknowledge and confirm
that the information provided above is/are true and correct to the best of my/our knowledge and belief and provided after consulting necessary tax
professionals. I / We also confirm that I / We have read and understood the Terms and Conditions below and hereby accepts the same. I /
We understand that my personal details as provided / available may be used for CBDT reporting. In case any of the above specified information is
found to be false or untrue or misleading or misrepresenting, I/We am/are aware that I/We may liable for it. I/We also undertake to keep you informed
in writing about any changes / modification to the above information in future and also undertake to provide any other additional information/
documentary proof as may be required at your end.

Signature of Sole/First Applicant

Name of the Sole / First Applicant_________________

Signature of Second Applicant

Name of the Second Applicant_________________

Instruction
Details under FATCA/Foreign Tax Laws: Tax Regulations require us to collect information about each investors tax residency. In certain circumstances (including
if we do not receive a valid self certification form you) we may be obliged to share information on your account with relevant tax authorities. If you have any
question about your tax residency, please contact your tax advisor. Should there be any change in information provided, please ensure you advise us promptly, i.e.,
within 30days.
If you are a US citizen resident or greencard holder, please include United States In the foreign country information field along with your us Tax identification Number.
Foreign Account Tax compliance provisions (commonly known as FATCA) are contained in the US Hire Act 2010.
Note: In case of any doubt or/and for any clarification about your tax residency/any other FATCA aspects,please contact your tax advisor.

FATCA SELF CERTIFICATION FORM

For Non-Individual Applicants / Investors
Details under FATCA/Foreign tax laws (see instructions)
Sr.
No.

Applicant

Category

Is Country of Incorporation / Formation / Tax Residency is in India?

Yes

If no, please specify the Country(ies) of Incorporation / Formation / Tax

residency

No

Sr. No. Country

Tax Residency No.

Other Information
1

Are you a Specified US Person? If yes, please provide Taxpayer Identification No.

We are a financial institution {including an Foreign Financial Institution (FFI)}

(If Yes, please provide the required information)
A. We are a [tick any one]

Yes

No

a. Financial Institution incorporated in India

b. Financial Institution incorporated in another country that has
an intergovernmental agreement (IGA) with the US on FATCA
c. FFI in a country without an IGA that has registered to obtain a GIIN
d. Others________________________________________ [please complete]

B. Global Intermediary Identification Number (GIIN) required if you are

financial institution including FFI
3.

If GIIN not available [tick any one]:

a. Applied for on [_______________________________ ] [insert date]

b. Not required to apply/not obtained for the following reasons:
(i) We are a Non-participating FFI
(ii) We are a Non-reporting India Financial Institution under Annexure II of the
Indian IGA because we are ____________________________________
[please describe]
(iii) We are a Certified deemed-compliant FFI
under U.S. Treasury Regulations
(iv) We are an Exempt beneficial owner under U.S. Treasury Regulations
(v) We have another reason: _____________________________________
[please describe]

4.

We are a listed company

[whose shares are regularly traded on a recognized stock exchange]

Yes

No

If Yes, specify the name of the Stock Exchange(s) where it is traded regularly:
1. ____________________________________________________________
2. ____________________________________________________________

5.

Yes

We are Related Entity / Subsidiary / Controlled by a listed company

No

If Yes, specify the name of the listed company

______________________________________________________________
Specify the name of the Stock Exchange(s) where it is traded regularly:
1. ____________________________________________________________
2. ____________________________________________________________
6.

We are an Active NFFE

Yes

No

If Yes, specify the nature of business

______________________________________________________________
7.

We are an Passive NFFE

(Please fill the Ultimate Beneficial Ownership details under point number 10)

Yes

No

If Yes, please provide:

1. Nature of business: ____________________________________________
2. For all Controlling Persons who are citizens/tax residents/green card holders of
a country other than India [regardless of whether they are also Indian Citizens/
Tax Residents], provide their Name, Address, Taxpayer Identification Number
and Percentage of Holding by filling UBO Form & enclose additionally.

Are you any one of the following

Please Tick:
Participating FFI
Deemed Compliant FFI
Exempt Beneficial Owner
Non-Participating Financial Institution

9.

Unable to confirm my status

(Incase this box is marked as yes, the statement will be taken as default that
applicant is currently unable to confirm FATCA status and will confirm the same in
Future)

Yes

In case of any doubt or/and for any clarification about your organizations tax residency/any other FATCA aspects, please contact your tax advisor.
10. UBO declaration:
Name

Country of Tax
residency

Country of Citizenship

Address
(House no., street, city,
country)

Tax identification
Number
(for each country)

UBO Code
(Please refer Instructions)

Holding
Percentage

UBO - 1

UBO - 2

UBO - 3

UBO - 4

A. If UBO is already KYC compliant, KYC complied proof to be enclosed. Else PAN / Tax Payer Identification Number / any other valid identity proof must be attached
B. If any of the UBO is resident / citizen of other than India or citizen/tax resident/green card holder of country [like USA, UK], please provide Taxpayer ID Number/ Social Security
Number [SSN]
C. Submit documentary proof like Shareholding pattern duly self-attested by Authorized Signatory / Company Secretary.
D. If number of UBOs are more than 4, information in the given format can be enclosed in additional sheet(s)

INVESTOR(S) DECLARATION & SIGNATURE(S)

II / We have understood the information requirement of this Form as per the CBDT notifies Rules 114F to 114H and hereby acknowledge and confirm that the
information provided above is/are true and correct to the best of my/our knowledge and belief and provided after consulting necessary tax professionals. I / We also
confirm that I / We have read and understood the Terms and Conditions below and hereby accepts the same. I / We understand that my personal details as provided /
available may be used for CBDT reporting. In case any of the above specified information is found to be false or untrue or misleading or misrepresenting, I/We am/are
aware that I/We may liable for it. I/We also undertake to keep you informed in writing about any changes / modification to the above information in future and also
undertake to provide any other additional information/ documentary proof as may be required at your end.

Signature of the Applicant

Instruction:
Details under FATCA/Foreign Tax Laws: Tax Regulations require us to collect information about each investor's taxresidency. In certain
circumstances (including if we do not receive a valid self-certification from you) we may be obliged to share information on your account with
relevant tax authorities. If you have any questions about your tax residency, please contact your tax advisor. Should there be any change in
information provided, please ensure you advise us promptly. i.e., within 30 days. If you are classified as a passive NFFE for FATCA purposes, please
include in the section relating to Ultimate beneficial Owner (UBO), details of an) specified US persons having controlling interest in the foreign
country information field along with your US Tax Identification Number for FATCA purposes. Foreign Account Tax Compliance provisions (commonly
known as FATCA) are contained in the US Hire Act 2010.

Instructions for UBO

As per the requirements of Anti-Money Laundering related laws and regulatory guidelines on client due diligence and identification of Beneficial Ownership,
investors (other than Individuals) are required to provide details of ultimate beneficiary owner [UBO] and submit appropriate proof of identity of such UBOs. The
beneficial owner has been defined in the circular as the natural person or persons, who ultimately own, control or influence a client and/or persons on whose
behalf a transaction is being conducted, and includes a person who exercises ultimate effective control over a legal person or arrangement.
1. Ultimate Beneficiary Owner [UBO]:
A. For Investors other than individuals or trusts:
(i) The identity of the natural person, who, whether acting alone or together, or through one or more juridical person, exercises control through
ownership or who ultimately has a controlling ownership interest. Controlling ownership interest means ownership of/entitlement to:
more than 25% of shares or capital or profits of the juridical person, where the juridical person is a company;
more than 15% of the capital or profits of the juridical person, where the juridical person is a partnership;
more than 15% of the property or capital or profits of the juridical person, where the juridical person is an unincorporated association or body
of individuals.
(ii) In cases where there exists doubt under clause (i) above as to whether the person with the controlling ownership interest is the beneficial owner or
where no natural person exerts control through ownership interests, the identity of the natural person exercising control over the juridical person
through other means like through voting rights, agreement, arrangements or in any other manner.
(iii) Where no natural person is identified under clauses (i) or (ii) above, the identity of the relevant natural person who holds the position of senior
managing official.
B. For Investors which is a trust:
The identity of the settler of the trust, the trustee, the protector, the beneficiaries with 15% or more interest in the trust and any other natural person
exercising ultimate effective control over the trust through a chain of control or ownership.
C. Exemption in case of listed companies / foreign investors
The client or the owner of the controlling interest is a company listed on a stock exchange, or is a majority-owned subsidiary of such a company, it is
not necessary to identify and verify the identity of any shareholder or beneficial owner of such companies.
D. KYC requirements
Beneficial Owner(s) is/are required to comply with the prescribed KYC process as stipulated by SEBI from time to time with any one of the KRA &
submit the same to AMC. KYC acknowledgement proof is to be submitted for all the listed Beneficial Owner(s).
E. Country of Tax Residence and Tax ID number: Tax Regulations require us to collect information about each investors tax residency. In certain
circumstances (including if we do not receive a valid self-certification from you) we may be obliged to share information on your account with relevant
tax authorities. If you have any questions about your tax residency, please contact your tax advisor. Should any information provided change in the
future, please ensure you advise us of the changes promptly. If you are a US citizen or resident, please include United States in this related field along
with your US Tax Identification Number.
F. UBO Codes:
UBO Code Description
UBO-1

Controlling ownership interest of more than 25% of shares or capital or profits of the juridical person [Investor], where the juridical person is
a company

UBO-2

Controlling ownership interest of more than 15% of the capital or profits of the juridical person [Investor], where the juridical person is a
partnership

UBO-3

Controlling ownership interest of more than 15% of the property or capital or profits of the juridical person [Investor], where the juridical
person is an unincorporated association or body of individuals

UBO-4

Natural person exercising control over the juridical person through other means exercised through voting rights, agreement, arrangements
or in any other manner [In cases where there exists doubt under clause 4 (a) above as to whether the person with the controlling ownership
interest is the beneficial owner or where no natural person exerts control through ownership interests]

UBO-5

Natural person who holds the position of senior managing official [In case no natural person cannot be identified as above]

UBO-6

The settlor(s) of the trust

UBO-7

Trustee(s) of the Trust

UBO-8

The Protector(s) of the Trust [if applicable].

UBO-9

The beneficiaries with 15% or more interest in the trust if they are natural person(s)

UBO-10 Natural person(s) exercising ultimate effective control over the Trust through a chain of control or ownership.