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iron Date; To, The Manager, HOFC Bank it, Link rood Malad _, Branch Mumbai) subjfct~Reasonabl ustiication/ Curing documentation for tax residency for mismatch identified in FATCA-CRS selfcertification provided for customer 10. 899 $220 Dear Sir/Madam, Further to FATCA-CRS self-certification form provided to the Bank on | provide the below details, (a) hereby declare that | am currently residingin GN ITE ARAB EMIRATE S (country name) and Iconfiem that ama taxresident of NO Tames im Apud hats) CURED provided in FATCA- CRS self-certification form and provide reason and additional documents (to be filled if country of residence & country of tax residence are different) as mentioned in $Note1 below, along with this form (Please mention name of all countries where you are tox resident) oR (b) My tax residence has changed with effective from (mention year of change) and | wish to submit a fresh FATCA~CRS self certification form — enclosed herewith, ‘SNoteL 5 Reason/ justification (along with documentary proof in the form of VISA ete.) to establish/ justify country of tax residency being different from country of documented residence (address or contact number) student (Student visa) ‘+ Diplomat (Diplomatic Visa) ‘+ Mariner/ Sea fearer (Continuous Discharge Certificate (CDC)) Temporary visit (Temporary work visa, Teacher, Tourist or other VISA) Athlete or Artist or Professional (Appropriate VISA) «Recently shifted residence (Appropriate VISA) + Not qualifying as tax resident as not meeting requisite no, of days’ stay (Appropriate VISA) Other, please specify with Appropriate VISA In case of U.S. persons, where Nationality or Country of Birth is U.S. but tax residency is of other country, the following documents are provided: ‘© Non-US passport or any non-US government issued document evidencing nationality or citizenship; AND # Certified Copy of Certificate of loss of US Nationality/ Reasonable explanation for not obtaining such certificate Certification: /We have understood the information requirements of this Form a per the CBDT notified Rules 114F to 114H and hereby confirm that the information provided by me/us on this Form is true, correct, and complete. We understand that my personal detalls a5 provided /avallable inthe bank records wil be used for CADT reporting / Central KYC Registry. | hereby consent to receiving information from Central KYC Registry ‘through SMS / Email. ‘As provided in the FATCA-CRS self-certification form, I/We will inform the Bank within 30 days should there be any ‘changes in details provided, In the event of any mismatch in details and sufficient curing documents not provided by me in a timely, /We understand that the Bank may be constrained to report information relating to my accounts to tax authorities. Ke Signature of thaccount holder bate: I /W /20r7 piace: Abu Dhol) MPHAVIR, CHAND SOHANRAT CEM WAT

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