Individual Tax Residency Self-Certification Form

Please read these instructions before completing this form.

Why are we asking you to complete this form?

Canadian financial institutions have to collect the information on this form to open or maintain an account. It is a
requirement under Canadian regulations relating to the Common Reporting Standard (CRS) and Foreign Account Tax
Compliance Act (FATCA).

If you have tax residency in a jurisdiction outside of Canada or if you’re considered a US Person, we may be required
under Canadian law to report certain account information to the Canada Revenue Agency (CRA). You can always ask
us if we provided information to the CRA and what information was given.

If you’re a tax resident in a foreign jurisdiction, account information reported to the CRA is shared with the government
of that jurisdiction if there’s an information exchange agreement in place with Canada. The CRA shares account
information with the US Internal Revenue Service if you’re a US citizen or resident.

If any of the information submitted on this form changes in the future, please provide us with an updated form within
30 days of the change.

Who should complete this form?

• An individual planning to open a personal (non business) or sole proprietor/sole trader Account.
• In some cases, even though you already have an Account, we may ask for you to complete the form to ensure
your records are up to date.
• For joint accounts, each account holder needs to complete a copy of this form.

Note: Even if you’ve already provided us information related to FATCA, you may still need to provide additional
information for CRS – the CRS is governed by different requirements of Canadian law.

Tax residency and Taxpayer Identification Numbers (TINs)

Each country/jurisdiction has its own rules for defining tax residency. In general, you are tax resident in the country/
jurisdiction where you live, not just because you receive income there. Except for the US, your citizenship or place of
birth generally doesn’t determine your tax residence.

If you’re tax resident in more than one country/jurisdiction, you should list all the countries/jurisdictions and provide
your taxpayer identification number (TIN) for each of them.

In most cases, based on applicable tax treaty rules, you should be tax resident in one country/jurisdiction only. Please
consult your tax advisor about tax treaty rules if you think you are tax resident in more than one country/jurisdiction.

Where to go for more information about CRS and FATCA

• Contact your tax advisor.
• Visit our website, www.crs.hsbc.com/en/rbwm/canada.
• Call 1-888-310-HSBC (4722) or, if calling from outside Canada/US, call +1-604-216-8800 (collect calls accepted
where available).
• Visit the Canadian Bankers Association website and search for FATCA or CRS.
• Contact Canada Revenue Agency at 1-800-959-8281 (Canada and the US) or from elsewhere call 613-940-8495
(collect calls are accepted by the CRA).
• Contact your Relationship Manager, Investment Counsellor or visit a branch.

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Individual Tax Residency
Self-Certification Form
(Please complete parts 1–3 in BLOCK CAPITALS)

Part 1
Identification of Individual Account Holder

Customer Number:

A. Name of Account Holder:

Last Name or
Surname(s):

Title: Mr. Mrs. Ms. Miss Other

First or Given
Name:

Middle Name(s):

B. Current Residence Address:

Line 1 (e.g. House/Apt/Suite
Name, Number, Street)

Line 2 (e.g. Town/City/

Province/County/State)

Country: Postal Code/ZIP Code:

C. Mailing Address: (Please only complete if different to the address shown in Section B.)
Line 1 (e.g. House/Apt/Suite
Name, Number, Street)

Line 2 (e.g. Town/City/

Province/County/State)

Country: Postal Code/ZIP Code:

D. Date of birth (dd/mm/yyyy)

E. Social Insurance Number (SIN)

You need to fill in your SIN if you have one and you are a US person or non-resident. This is required by the Canada
Revenue Agency for tax reporting. If you don’t want your SIN to be used for purposes other than tax reporting (e.g.
credit check), you can opt out by visiting any HSBC Canada branch or calling the number on the back of your debit card.

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Part 2
Instructions: Indicate your tax residency and US Person status below.

You will need to list your Taxpayer Identification Number (TIN) or equivalent for each country/jurisdiction where you are tax
resident. A TIN is a unique combination of letters or numbers assigned to you by the country’s/jurisdiction’s tax authority
and is used to identify you for tax purposes. Some authorities don’t issue a TIN, but they may use a similar type of
number such as a social security/insurance number, or a resident registration number, or personal identification number.
You will normally find your TIN on any letters or correspondence you receive from your tax authority. If you’re not sure
what your TIN (or equivalent) is, further details on acceptable TINs can be found on the OECD website: www.oecd.org/
tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers.
If you’re a US citizen or US resident and don’t have a social security number (or equivalent), you have 90 days to apply
for one and 15 days after you receive it to give it to us. If you’re a resident outside of Canada and the US and don’t have
a TIN from your jurisdiction of residence, you have 90 days to apply for a TIN and 15 days after you receive it to give it
to us – unless your jurisdiction of residence doesn’t issue TINs or doesn’t require the collection of TINs.
If you don’t provide your US social security number or foreign TIN to us when requested and we’re required to report
account information to the Canada Revenue Agency (CRA), you may receive a penalty from the CRA.
Please check all the options that apply to you:

I am a tax resident of Canada.

I am a tax resident or a citizen of the United States.
If you ticked this box, enter your social security number (SSN) or equivalent from the United States:

If you don’t have an SSN or equivalent from the United States, have you applied for one?
Yes No
I am a tax resident of a jurisdiction other than Canada or the United States.

If a foreign TIN is unavailable, please provide the appropriate reason A, B, C or D as indicated below:
Reason A – My country of tax residence doesn’t issue TINs to its residents.
Reason B – I’m unable to get a TIN or equivalent number (If you’ve chosen this reason, please tell us why you’re
unable to get a TIN in the table below.)
Reason C – N
 o TIN is required. (Only choose this reason if the authorities of the country where you are tax resident
don’t require the TIN to be disclosed.)
Reason D – I will apply or have applied for a TIN, but haven’t received it. I will give this TIN to HSBC within 15 days of
receiving it.

If no TIN available enter

Country of tax residence TIN
Reason A, B, C or D
1

If Reason B was selected, please explain in the following boxes why you’re unable to obtain a TIN.

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Part 3
If the addresses in Part 1 are different from the country(ies)/jurisdiction(s) where you are tax resident in Part 2, you need
to tell us why.

A. T
 he country you live in (Part 1B) is different from the country(ies)/jurisdiction(s) where you are tax
resident (Part 2).

Please choose one of the following options:

1. I am a student studying in the country in Part 1B and haven’t lived there long enough to become tax resident.
2. I am working in the country in Part 1B and haven’t lived there long enough to become tax resident.
3. I am a diplomat or a member of the armed forces posted to the country in Part 1B.
4. I’ve recently moved to this country and haven’t become a tax resident yet. I am still tax resident in the
country(ies)/jurisdiction(s) in Part 2.
5. N
 one of the above – Please provide details in the space below.

B. Your mailing address country (Part 1C) is different from the country(ies)/jurisdiction(s) where you are tax
resident (Part 2).

Please choose one of the following options to confirm what the mailing address is:
1. The mailing address is my advisor, accountant, or lawyer.
2. The mailing address is my relative’s address.
3. The mailing address is my work or employer’s address.
4. The mailing address is my holiday home.
5. N
 one of the above – Please provide details in the space below.

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Part 4
Declarations and Signature

Personal information (including the SIN) is collected Signature:

for the purposes of the Income Tax Act and related
programs and activities such as administering tax,
benefits, audit, compliance, and collection. Personal
information may be shared for purposes of other federal I certify that the information given on this form
acts relating to charging or collecting taxes or duties. is correct and complete. I will give my financial
Personal information may also be shared with other institution a new form within 30 days of any change
federal, provincial, territorial or foreign government in circumstances that causes the information on
institutions to the extent authorized by law. this form to become incomplete or inaccurate.

Failure to provide this information may result in Print name:

interest payable, penalties or other actions. The social
insurance number and taxpayer identification number
are collected under sections 237 and 281 of the
Income Tax Act and Article 2 of the Intergovernmental
Agreement between Canada and the US, and are used Date: (format dd/mm/yyyy)
for identification purposes.

Under the Privacy Act, individuals have the right to

access their personal information, request correction, or Note: If you are not the Account Holder, please
file a complaint to the Privacy Commissioner of Canada indicate the capacity in which you are signing the
regarding the handling of the individual’s personal form, along with a written authorization from the
information. Refer to Personal Information Bank CRA
Account Holder permitting you to sign on his or
PPU 047 on Info Source at canada.ca/cra-info-source.
her behalf.
I understand the information supplied by me is covered
Capacity:
by the full provisions of the terms and conditions
governing my relationship with HSBC setting out how
HSBC may use and share the information supplied by me.

Additional Information
“Account” generally means an account maintained by a financial institution and includes: deposit accounts; custodial
accounts; equity and debt interest in certain investment entities; cash value insurance contracts; and annuity contracts.

“HSBC” refers to the following entities: HSBC Bank Canada, HSBC Investment Funds (Canada) Inc. (HIFC), HSBC Private
Investment Counsel (Canada) Inc. (HPIC), and HSBC InvestDirect (HIDC), a division of HSBC Securities (Canada) Inc.

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