FATCA Declaration Form

FATCA (Foreign Account Tax Compliance Act), Applicable to all Account holders

Reference Circular: BPRD/AMLD-04/2013-17241& BPRD Circular No 16

Issuance Date: November 21, 2013 & April 30, 2014 (respectively)

Customer Name: CNIC No:

Title of Account: Account No:

Primary Nationality 2nd Nationality (if any) 3rd Nationality (if any)
Nationality
Place of Birth (City)
(Country)

In case of multiple Nationalities please filled below:

Passport
Number/Country
Identity Number
including Date & Place
of Issuance

Mailing Address (other

than Pakistan)

PO Box Number (other

than Pakistan)

Contact number (other

than Pakistan)

Taxpayer Identification
Number (TIN)

Resident Status Permanent Temporary(Specify the tenure detail) Day(s)

Declaration:
I hereby confirm the information provided above is true, accurate and complete.
Subject to applicable local laws, I hereby consent for Tameer Microfinance Bank Limited, or any of its affiliates,
subsidiaries (including branches/branchless) (collectively “the Bank”) to share my information with domestic or
overseas regulators or tax authorities where necessary to establish my tax liability in any jurisdiction.

Where required by domestic or overseas regulators or tax authorities, I consent and agree that the Bank may
withhold from my account(s) such amounts as may be required according to applicable laws, regulations and
directives.

I undertake to notify the Bank within 30 calendar days if there is a change in any information which I have provided
to the Bank.

__________________ ____________________
Customer’s Signature Bank Officer’s Signature