ICICI Bank
ICICI
singapore Singapore
PART 1

Identification of Account Holder

EDIT
PART 2

Tax Residency / Citizenship Information

EDIT
PART 3

FATCA Certification

EDIT
PART 4

Declaration & Signature

EDIT

Identification of Individual Account Holder /
Joint Account Holder

Name of Account Holder

Date / Place Of Birth

Current Residency Address

(eg. House / Apt / Suite Name, Number, Street)

(e.g. Town / City / Province / County / State)

Mailing Address

(eg. House / Apt / Suite Name, Number, Street)

(e.g. Town / City / Province / County / State)

Is there any difference in either the current residential address or mailing address?

Citizenship

Country/Jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or equivalent number ("TIN")

"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 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.

Please complete the following table indicating:

  • Where the Account Holder is tax resident and
  • The Account Holder's TIN for each country/Reportable Jurisdiction indicated. Countries / Jurisdictions adopting the wider approach may require that the self-certification include a tax identifying number for each jurisdiction of residence (rather than for each Reportable Jurisdiction).

If the Account Holder is not tax resident in any country/jurisdiction (e.g., because it is fiscally transparent), please indicate that on line 1 and provide its place of effective management or jurisdiction in which its principal office is located.

READ MORE

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

Reason A: The country/jurisdiction where the Account Holder is resident 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 domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction)

Country/Jurisdiction
of Tax Residence

Tax Identification
Number (TIN)

If no TIN available,
enter Reason A, B or C

If the account holder is tax resident in more than three countries or jurisdictions, please add relevant data.

Country/Jurisdiction
of Tax Residence

If the account holder is tax resident in more than three countries or jurisdictions, please add relevant data.

Tax Identification
Number (TIN)

If no TIN available,
enter Reason A, B or C

Note: If you have indicated above tax residence in the United States, please also provide a completed and signed Form W-9

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

FATCA Certification

If you are a US person, please provide your US Taxpayer Identification number (TIN):

In addition, you must attach the W-9 Form.

Only JPEG, PNG, or PDF of max size 1 MB

Document 51.pdf
  • Certificate of loss of nationality of the US

    Only JPEG, PNG, or PDF of max size 1 MB

    Document 51.pdf
  • Form I-407

    Only JPEG, PNG, or PDF of max size 1 MB

    Document 51.pdf

Definition of 'US PERSON':

  1. A citizen or permanent resident of the United States (e.g US Green Card holder or someone who meets the requirements to be considered a resident under the 'substantial presence test')

    or

  2. Any other person that is not a foreign person (as defined under US federal tax law)

Declaration and Signature

  1. 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 ICICI Bank Limited, Singapore Branch setting out how ICICI Bank Limited, Singapore Branch may use and share the information supplied by me.
  2. 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/jurisdiction in which this account(s) is/are maintained and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax resident pursuant to intergovernmental agreements to exchange financial account information.
  3. I understand that the Bank is relying on this information for the purpose of determining my status in compliance with FATCA/CRS. The Bank is not able to offer any tax advice on FATCA/CRS or its impact. I shall seek advice from professional tax advisor for any tax questions.
  4. I agree to submit a new form within 30 days if any information or certification on this form becomes incorrect.
  5. I agree that as may be required by domestic regulators/tax authorities the Bank may also be required to inform reportable details to IRAS or close or suspend my account.
  6. I certify that I provide the information on this form and to the best of my knowledge and belief the certification is true, correct, and complete including the taxpayer identification
  7. 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.
    8. READ MORE

I undertake to advise ICICI Bank Limited, Singapore Branch promptly 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 or incomplete, and to provide ICICI Bank Limited, Singapore Branch with a suitably updated self-certification and Declaration within 30 days of such change in circumstances.

I hereby certify that I/we confirm and agree that the undertakings, confirmations, affirmations and information provided by me/ us above namely FATCA and CRS Self Certification form and my / our signature hereunder signifies my / our consent and agreement to be bound by all of the aforementioned declarations, undertakings, confirmations, affirmations and information.

02. 12. 2021 3:14 PM

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.

Only JPEG, PNG, or PDF of max size 1 MB

Document 51.pdf
Appendix to FATCA/ CRS SELF CERTIFCATION
(Summary Descriptions of Select Defined Terms)

Note: These are selected summaries of defined terms provided to assist you with the completion of this form. Further details 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 OECD automatic exchange of information portal

"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.

"FATCA"
FATCA stands for the U.S. provisions commonly known as the Foreign Account Tax Compliance Act, which were enacted into U.S. law as part of the Hiring Incentives to Restore Employment (HIRE) Act on March 18, 2010. FATCA creates a new information reporting and withholding regime for payments made to certain non-U.S. financial institutions and other non-U.S. entities.

"CRS"
To combat the problem of offshore tax evasion and avoidance and stashing of unaccounted money abroad requiring cooperation amongst tax authorities, the G20 and OECD countries working together developed a Common Reporting Standard (CRS) on Automatic Exchange of Information (AEOI). The CRS on AEOI requires the financial institutions of the "source" jurisdiction to collect and report information to their tax authorities about account holders "resident" in other countries, such information having to be transmitted "automatically' on yearly basis. The information to be exchanged relates not only to individuals but also to shell companies and trusts having beneficial ownership or interest in the "resident" countries.

"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 and that is identified in a published list.

"Reportable Account"
The term "Reportable Account" means an account held by one or more Reportable Persons

"Reportable Jurisdiction"
A Reportable Jurisdiction is a jurisdiction with which an obligation to provide financial account information is in place and that is identified in a published list.

"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 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.

Individual FATCA and CRS Self-Certification Form

Enter your Customer ID and Registered Mobile number or Email ID.
A one-time verification code will be sent to you.

Enter the Mobile number with leading zeros followed by ISD code . For Ex : Mobile number 123456789 to be entered as "0065123456789" where in 65 is ISD code for Singapore

Individual FATCA and CRS Self-Certification Form

Please enter the OTP to verify your account.
We have sent OTP on 9702*****9

Please review the details you have entered

Town:Mumbai

Citizenship:India