BCSI ………………………………

Self-certification of tax residences under CRS and FATCA : individuals

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The law of 16 December 20153 governs the disclosure of information on financial accounts in the context of an
international and automatic exchange of information for tax purposes. The law requires Belgian financial institutions to
report on customers with one or more fiscal residences abroad in countries participating in this exchange of information.
The self-certification form below will allow you to provide us with the required data. For more information, consult our
website on www.ing.be/InternationalRegulations.
If you require further assistance in filling in this form, please contact a tax advisor.
1. Identification
Surname …………………………………….. Name ……………………………………..
Legal address Street ………………………………………………… Number …………… Box ……………
Postcode …………… Town ………………………… Country ……………………………
Place of birth …………………………………….. Date of birth ... / ... / ...... IBAN ……………………………………..

2. Fiscal residence
Please provide ALL the country(ies), including Belgium where applicable, where you are considered to be a tax resident
and the corresponding Tax Identification Number(s) (TIN).

Fiscal residence for tax purposes Taxpayer Identification Number (TIN)

Your fiscal residence is located in the country where you are, as If you want to get more information about the TIN for a given
resident, liable to income tax. country, its structure and syntax, you can visit the websites
of the European Commission or the OECD, which are easily
accessible via www.ing.be/TIN and www.ing.be/TINcheck

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Explanation in case you are not able to provide a TIN, if applicable. If not applicable, you may leave this field empty:

……………………………………………………………………………………………………………………………………………………………………………………………………

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3. Certification
I, the undersigned,
• Declare that the information provided on this form is, to the best of my knowledge, true, accurate and complete.
• Commit to advise ING Belgium of any change which causes the information in this document to become incorrect, and
providing ING Belgium with an updated self-certification within 30 days of the occurrence of such change.
• I agree to the collection, processing and disclosure of personal data and of financial information for the purposes
explained above.
• Understand that Belgian financial institutions are legally required under CRS and FATCA to report account information
on foreign tax residents to the Belgian tax authorities. This means that If my tax residence(s) is/are outside Belgium,
my account information will be reported to the Belgian tax administration, which may in turn transmit the information
to the U.S. Internal Revenue Service and/or to the respective tax administrations of the relevant Participating CRS
Jurisdiction(s) where I am considered to be a tax resident.
Document signed in ……………………………….. on ..... / ..... / ............
Signature
(of the legal representative/provisional administrator
if applicable):

Read more overleaf.

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This document must be completed. Without this certification, ING Belgium cannot open any new accounts.
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Foreign Account Tax Compliance Act (FATCA) and Common Reporting Standard (CRS)
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“Loi réglant la communication des renseignements relatifs aux comptes financiers, par les institutions financières belges et le SPF Finances, dans le cadre d’un
échange automatique de renseignements au niveau international et à des fins fiscales”; “Wet tot regeling van de mededeling van inlichtingen betreffende
financiële rekeningen, door de Belgische financiële instellingen en de FOD Financiën, in het kader van een automatische uitwisseling van inlichtingen op
internationaal niveau en voor belastingdoeleinden.”
 Documentation related to the country for tax purposes

If you declare on your document that you have a country for tax purposes which is different from your legal
address, we need you to provide us with the adequate documentation based on your situation.
Hereunder, you will find some certain number of particular cases and the required corresponding
documentation:

Complementary documentation to provide in addition to the

Status
Diplomat (and spouse / children of diplomats)
EU/NATO/SHAPE/INS civil servant on mission in
Belgium (and spouse / children of civil servants)
Civil servant for an international organization
(EU, UN, NATO, IMF)
self-certification of tax residence
Copy of the diplomatic ID or passport
Form HIS276/ NATO276/ SHAPE276 / IMS276
Certificate issued by the organization which clearly stipulates
where the fiscal residence has been fixed in accordance with the
international legislation determining the status of the civil servant.

Status of “foreign manager” in Belgium (Belgian
circular from 08th August 1983)
1. Proof of recognized “foreign manager” status issued by the
Belgian competent authorities and;
2. A certificate issued by the employer or a consultant outside the
employer’s organization which clearly specifies where the fiscal
residence of the “foreign manager” has been established (home
country of origin) and the TIN.

Taxpayers subject in Belgium to the income tax A certificate of non-fiscal residence in Belgium issued the Belgian
for non-residents (other than those referred ti in tax authorities or a copy of the first page of the most recent tax
the preceding lines) declaration in Belgium or a copy of the most recent assessment
notice from the Belgian tax authorities.

Recent relocation Official proof of the new official address (dated on the current year)
and a copy of the identity card.
Incapable The form must be signed by the legal representative/guardian (the
order of designation must be provided as well).
US Nationality (also if you were born in the USA) Certificate of loss of nationality of the United States