Tax Compliance Declaration

Individuals

Declaration regarding the tax status of ultimate beneficial owner, settlor, founder, beneficiary or controlling person of
any legal entities, partnerships, foundations and trusts (hereinafter ‘Client Entity’ or ‘Client Entities’), the status of
‘U.S. Person’ in connection with the Foreign Account Tax Compliance Act (‘FATCA’) and the status of ‘Tax Resident’ in
connection with the Common Reporting Standard (‘CRS’).
All sections must be completed. Failure to provide appropriate information and supporting documentation shall cause
1
TMF Group to consider the relationship as ‘non-compliant’ which may lead to reporting of the relationship to the
appropriate tax authorities, respectively to the termination of the client relationship.
Should a question be not applicable, please indicate ‘N/A’.
Additional information and supporting documentation and/or execution of further documents might be requested on
the basis of the information provided in this declaration.

PERSONAL IDENTIFICATION

Last name(s): _____________________________________________________________

First name: _____________________________________________________________

Middle name(s): _____________________________________________________________

Date of birth: _____________________________________________________________

Place and country of birth: _____________________________________________________________

Nationality: _____________________________________________________________
(in case of multiple nationalities, please include all of them)

Passport number: _____________________________________________________________

(in case of multiple passports, please include all your passport numbers)

Residential address: _____________________________________________________________

(please note that office address or c/o is not permitted)

Country of residence: _____________________________________________________________

Postal address (if different): _____________________________________________________________

P.O. Box: _____________________________________________________________

Other place of habitual residence: _____________________________________________________________

Telephone number: _____________________________________________________________

Tax Compliance Declaration - Individuals | TMF Switzerland © June 2016 Page 1/4
FATCA ELEMENTS (‘US INDICIA’)

Do you have an American Taxpayer Identification Number (‘US TIN’)?

yes no If yes, indicate the US TIN _______________________________________________

Were you born in the USA?

yes no If yes, indicate the place of birth __________________________________________

Do you hold the citizenship of the USA?

yes no If yes, indicate reference (e.g. social security number) _________________________

Have you renounced your USA citizenship?

yes no If yes, indicate when and provide copy of your Certificate of Loss of Nationality
____________________________________________________________________

Do you hold or have you ever held a passport issued by the USA?
yes no If yes, indicate reference ________________________________________________

Do you hold or have you ever held a Green Card issued by the USA?
yes no If yes, indicate reference ________________________________________________

Do you have a permanent or temporary (more than 30 days/year) residence in the USA?
yes no If yes, indicate where ___________________________________________________

Do you have a ‘care of’ address in the USA?

yes no If yes, indicate address __________________________________________________

Do you have a USA phone number?

yes no If yes, indicate number __________________________________________________

Do you directly or indirectly (e.g. through a legal structure) hold a property/residence in the USA?
yes no If yes, indicate where _________________________________________________

Have you granted a power of attorney on your bank or investment account(s) to a person residing in the USA?
yes no If yes, indicate to whom _________________________________________________

Do you have substantial professional activities or interests in the USA?

yes no If yes, indicate activities and location ______________________________________

COMMON REPORTING STANDARD ELEMENTS

Please indicate your main country of residence for tax purposes and the related Tax Identification Number
Country of tax residence _____________________________________________________________
Tax Identification Number (‘TIN’) _____________________________________________________________

Tax Compliance Declaration - Individuals | TMF Switzerland © June 2016 Page 2/4
Please indicate, if applicable, your secondary country of residence for tax purposes, the reason for the additional
residence and the related Tax Identification Number
Secondary country of tax residence ____________________________________________________________
Reason for taxation ____________________________________________________________
Tax Identification Number (‘TIN’) ____________________________________________________________

TAX COMPLIANCE DECLARATION

I hereby certify that the shares I am the (ultimate) holder of, and/or the assets invested in, and/or the assets
settled in, and/or the assets held on my behalf, and/or the assets distributed to me by the Client Entity to which
1
TMF Group renders services, respectively for me, on my behalf or for my benefit, are duly declared to the relevant
tax authorities.

I further understand that I have a legal obligation to comply with the tax, compliance and reporting requirements
applicable to my personal situation in my own jurisdiction of residence (including residence for tax purposes),
domicile, business or citizenship. I have taken and will take independent legal, accounting and tax advice, as
appropriate, to fully comply with any such obligation in every aspect. I acknowledge and confirm that I am
responsible for the payment of any tax due or payable, including any interest and penalties due thereon. In
1
addition, I understand that TMF Group reserves the right in its absolute discretion to require proof of the
provision of tax and/or other professional advice from me as it deems appropriate.
1
I confirm that I have not been advised by TMF Group in respect of any tax, investment or accounting matters
relating to my personal situation and to any Trust, Foundation, Company, Partnership or other legal entity or
relationship established at my request, including the effectiveness of such Trust, Foundation, Company,
Partnership or other legal entity.
1
I hereby commit to providing TMF Group with all supporting documentation upon first demand, if requested in
writing to do so.

SECRECY WAIVER AND DISCLOSURE OF INFORMATION

I acknowledge that I understand the purpose of this Tax Compliance Declaration. I have been duly informed by
1
TMF Group of the implementation, nature and scope of the FATCA and CRS regulations and agreements as well as
about their possible impact on the Client Entity that TMF Group manages for me, respectively on my behalf or for
my benefit.
1
Therefore, I hereby release TMF Group of any confidentiality duty in every respect to FATCA and CRS in regards to
the information I provided them with and I absolve TMF Group of their duty to comply with the professional
secrecy rules accordingly, waiving any rights I may otherwise have pursuant to such professional secrecy rules, be
they Swiss or of any other jurisdiction.
1
Furthermore, I also expressly authorize and instruct TMF Group to use and disclose any and all information in
every respect relating to FATCA and CRS as mandatory by laws and regulations, especially for the Client Entity
classification, its registration with any and all appropriate tax authorities (including but not limited to the Swiss tax
authorities or U.S. Internal Revenue Service) and its duty of reporting, if applicable.

Tax Compliance Declaration - Individuals | TMF Switzerland © June 2016 Page 3/4
INFORMATION REGARDING ANY CHANGE OF SITUATION
1
I undertake to immediately notify TMF Group of any changes in my personal situation relating to this Tax
1
Compliance Declaration. I furthermore understand that any misrepresentation will be cause for TMF Group to
1
consider the immediate termination of the relationship and may cause TMF Group to report to the appropriate
tax authorities (including but not limited to the Swiss tax authorities or U.S. Internal Revenue Service).

Finally, under penalties of perjury, I declare that:

- I have examined the information on this form and hereby represent and warrant that the information set out in
1
this form is true, accurate and complete as of the date hereof and may be relied upon by TMF Group ; and
- I have consulted, as the case may be, when I was unsure about the information I am being asked for, with an
independent legal and tax adviser to fill out this form and further acknowledge that I have not received any
1
advice from TMF Group concerning the applicable legislation or taxation; and

- I understand that information supplied may be processed for the purposes of client administration by any
1 1 1
company within the TMF Group or by third parties who provide services to TMF Group . TMF Group may also
use such information for marketing activities such as internal market research or contacting by post, telephone,
email, fax or other means regarding my investment and financial needs.

SIGNATURE

_________________________________ _________________________________
Place and Date Signature

1
“TMF Group” means all companies ultimately beneficially owned by TMF Group HoldCo B.V., each of which is a separate legal entity.

Tax Compliance Declaration - Individuals | TMF Switzerland © June 2016 Page 4/4