INSTRUCTIONS

Individual Tax Residency Self-Certification Form

Please read these instructions before completing the form.

Regulations based on the OECD Common Reporting Standard (“CRS”) require HSBC to collect and report
certain information about an account holder’s tax residence. Each jurisdiction has its own rules for defining
tax residence. In general, tax residence is the country in which you live. Special circumstances (such as
studying abroad, working overseas, or extended travel) may cause you to be resident elsewhere or resident
in more than one country at the same time (“dual residency”).

The country/countries in which you pay income tax are likely to be your country/countries of tax residence.
For more information on tax residence, please consult your tax adviser or the information at the following
link: OECD automatic exchange of information portal.

If your tax residence (or the account holder, if you are completing the form on their behalf) is located
outside the country where the HSBC entity maintaining the account is located, we may be legally obliged to
pass on the information in this form and other financial information with respect to your financial accounts
to the tax authorities in the country where the HSBC entity is located.

You can find definitions of who is classified as an account holder, and other terms, in the Appendix.

This form will remain valid unless there is a change in circumstances relating to the account holder’s
tax status or other mandatory fields included on this form. You must notify us if there is a change
in circumstances that makes this form incorrect or incomplete and provide an updated
self-certification.

This form is intended to request information only where such request is not prohibited by local law.

Please fill in this form if you are an individual account holder, sole trader or sole proprietor.

For joint or multiple account holders, use a separate form for each individual person.

Where you need to self-certify on behalf of an entity account holder, do not use this form. Instead, you will
need an “Entity tax residency self-certification.” Similarly, if you are a controlling person of an entity, please
fill in a “Controlling person tax residency self-certification form” instead of this form.

If you are a US Person under US Internal Revenue Service (”IRS”) regulations, you may also need to fill in
an IRS W-9 form.

If you are filling in this form on behalf of someone else please ensure that you let them know that
you have done so.

Please tell us in what capacity you are signing in Part 3.

For example, you may be the custodian or nominee of an account on behalf of the account holder, or you
may be completing the form under a power of attorney.

A legal guardian should complete the form on behalf of an account holder who is a minor.

As a financial institution, we are not allowed to give tax advice.

If you have any questions about this form, these instructions, or defining your tax residency status, please
speak to your tax adviser or domestic tax authority.

You can also find out more, including a list of jurisdictions that have signed agreements to automatically
exchange information, along with details about the information being requested, on the OECD automatic
exchange of information portal.
Individual Tax Residency CRS – I
Self-Certification Form
Please complete Parts 1– 3 in BLOCK CAPITALS

Part 1
Identification of Individual Account Holder

A. Name of Account Holder:

Family Name or
Surname(s)

Title Mr Mrs Ms Miss Other

First or Given
name(s)

Middle Name(s)

B. Current Residence Address:

Line 1 House/Apt/Suite
Name, Number, Street)
Line 2 Town/City
Province/County/State

Country Postal Code / ZIP code

C. Mailing Address: (please only complete if different from the address shown in Section B above)
Line 1 House/Apt/Suite
Name, Number, Street)
Line 2 Town/City
Province/County/State

Country Postal Code / ZIP code

D. Date of birth

D D M M Y Y Y Y

E. Place of birth
Town or City of Birth

Country of Birth
Individual Tax Residency Self-Certification Form Please complete Parts 1– 3 in BLOCK CAPITALS

Part 2
Country of Residence for Tax Purposes and related Taxpayer Identification Number
or functional equivalent (“TIN”) (See Appendix)

Please complete the following table indicating:

(i) where the Account Holder is a tax resident;

(ii) the Account Holder’s TIN for each country indicated.

If the Account Holder is tax resident in more than three countries please use a separate sheet

If a TIN is unavailable please provide the appropriate reason A, B or C:

Reason A The country where the Account Holder is liable to pay tax does not issue TINs
to its residents

Reason B The Account Holder is otherwise unable to obtain a TIN or equivalent number
(Please explain why you are unable to obtain a TIN in the below table if you have
selected this reason)

Reason C No TIN is required. (Note. Only select this reason if the authorities of the country of
tax residence entered below do not require the TIN to be disclosed)

If no TIN available enter

Country of tax residence TIN
Reason A, B or C

Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.

3
Individual Tax Residency Self-Certification Form Please complete Parts 1– 3 in BLOCK CAPITALS

Part 3
Declarations and Signature
I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing
the Account Holder’s relationship with HSBC setting out how HSBC may use and share the information supplied by me.

I acknowledge that the information contained in this form and information regarding the Account Holder and any
Reportable Account(s) may be provided to the tax authorities of the country in which this account(s) is/are maintained
and exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident
pursuant to intergovernmental agreements to exchange financial account information.

I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this
form relates.

I certify that where I have provided information regarding any other person (such as a Controlling Person or other
Reportable Person to which this form relates) that I will, within 30 days of signing this form, notify those persons that I
have provided such information to HSBC and that such information may be provided to the tax authorities of the country
in which the account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the
person may be tax resident pursuant to intergovernmental agreements to exchange financial account information.

I declare that all statements made in this declaration Signature:

are, to the best of my knowledge and belief, correct
and complete.

I undertake to advise HSBC within 30 days of any change

in circumstances which affects the tax residency status of
the individual identified in Part 1 of this form or causes the
information contained herein to become incorrect, and to Print name:
provide HSBC with a suitably updated self-certification and
Declaration within 90 days of such change in circumstances.

Date

D D M M Y Y Y Y
Note: If you are not the Account Holder please indicate the
capacity in which you are signing the form. If signing
under a power of attorney please also attach a
certified copy of the power of attorney.

Capacity:
Appendix – Definitions
These are selected definitions provided to assist you with the completion of this form. Further details
Note: 
can be found within the OECD Common Reporting Standard for Automatic Exchange of Financial
Account Information (the CRS”), the associated Commentary to the CRS, and domestic guidance.
This can be found at the following link [OECD].

If you have any questions then please contact your tax adviser or domestic tax authority.

“Account Holder” The term “Account Holder” means the person listed or identified as the holder of a Financial
Account. A person, other than a Financial Institution, holding a Financial Account for the benefit of another person as an
agent, a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated
as the Account Holder. In these circumstances that other person is the Account Holder. For example in the case of a
parent/child relationship where the parent is acting as a legal guardian, the child is regarded as the Account Holder. With
respect to a jointly held account, each joint holder is treated as an Account Holder.

“Controlling Person” This is a natural person who exercises control over an entity. Where an entity Account
Holder is treated as a Passive Non-Financial Entity (“NFE”) then a Financial Institution must determine whether such
Controlling Persons are Reportable Persons. This definition corresponds to the term “beneficial owner” as described in
Recommendation 10 of the Financial Action Task Force Recommendations (as adopted in February 2012).
If the account is maintained for an entity of which the individual is a Controlling Person, then the
“Controlling Person tax residency self-certification” form should be completed instead of this form.

”Entity” The term “Entity” means a legal person or a legal arrangement, such as a corporation, organisation,
partnership, trust or foundation.

“Financial Account” A Financial Account is an account maintained by a Financial Institution and includes: Depository
Accounts; Custodial Accounts; Equity and debt interest in certain Investment Entities; Cash Value Insurance Contracts;
and Annuity Contracts.

“Participating Jurisdiction” A Participating Jurisdiction means a jurisdiction with which an agreement is in place
pursuant to which it will provide the information required on the automatic exchange of financial account information set
out in the Common Reporting Standard.

“Reportable Account” The term “Reportable Account” means an account held by one or more Reportable Persons or
by a Passive NFE with one or more Controlling Persons that is a Reportable Person

“Reportable Jurisdiction” A Reportable Jurisdiction is a jurisdiction with which an obligation to provide financial
account information is in place.

“Reportable Person” A Reportable Person is defined as an individual who is tax resident in a Reportable Jurisdiction
under the tax laws of that jurisdiction. Dual resident individuals may rely on the tiebreaker rules contained in tax
conventions (if applicable) to solve cases of double residence for purposes of determining their residence for tax
purposes.

“TIN” (including “functional equivalent”) The term “TIN” means Taxpayer Identification Number or a functional
equivalent in the absence of a TIN. A TIN is a unique combination of letters or numbers assigned by a jurisdiction to
an individual or an Entity and used to identify the individual or Entity for the purposes of administering the tax laws of
such jurisdiction. Further details of acceptable TINs can be found at the following link: OECD automatic exchange of
information portal

Some jurisdictions do not issue a TIN. However, these jurisdictions often utilise some other high integrity number with
an equivalent level of identification (a “functional equivalent”). Examples of that type of number include, for individuals, a
social security/insurance number, citizen/personal identification/service code/number, and resident registration number.