TAX RESIDENCY SELF CERTIFICATION FORM - PWCCUL

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PWCCUL TAX RESIDENCY SELF CERTIFICATION FORM

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Tax Residency Self-Certification Form

The Public Workers’ Co-operative Credit Union Limited is obliged under the United States of America Foreign Account Tax Compliance Agreement Act, 2015 (the FATCA Act), the Guidance Notes on the International Tax Compliance Requirements of the Intergovernmental Agreement Between the Bahamas and the United States of America (the FATCA Guidance Notes), the Automatic Exchange of Financial Account Information Act, 2016 (as amended) (the CRS Act), the Automatic Exchange of Financial Account Information Regulation, 2017 (as amended) (the “CRS Regulations”) and the Guidance Notes on the Common Reporting Standard for Automatic Exchange of Financial Account Information in Tax Matters (the “CRS Guidance Notes”) to collect information relating to an account holder’s residence for tax purposes. Please complete the sections below, as directed, and provide any additional information which is requested. Please note that the PWCCUL may be obliged to share this information with the Competent Authority of the Government of the Bahamas, which may share it with relevant tax authorities abroad. Terms referenced in this Tax Residency Self-Certification form shall have the same meaning as applicable under the FATCA Act, the FATCA Guidance Notes, the CRS Act, the CRS Regulations or the CRS Guidance Notes. If you have any questions about how to complete this ax Residency Self-Certification form, please contact a tax advisor. Please note that you may be subject to penalties for making flase or misleading declarations in this form.

Identification

Name

Date of Birth

Country of BirthDo Not Abbreviate

AddressPermanent Residence Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Mailing Address(if different from Permanent Address)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Declaration of U.S. Citizenship or U.S. Residency for Tax PurposesI confirm that I am a U.S. citizen and/or resident in the U.S. for tax purposes (green cardholder or resident under the substantial presence test) and my U.S. tax Identification Number (U.S. Tin) is as follows and my IRS W-9 or W-8 Form is attached.I confirm that I was born in the U.S. (or in a U.S. territory) but I am no longer a U.S. Citizen as I have voluntarily surrendered my citizenship; and my U.S. Certificate of Loss of Nationality is attached.I confirm that I am not a U.S. Citizen or resident in the U.S. for tax purposes.Please select either (a) or (b) or (c) and complete as appropriate

U.S. TinTax Identification Number

Text

National Insurance #

Country/Countries of Tax Residency

Tax Reference Number Type

Tax Reference Number

Country/Countries of Tax Residency

Tax Reference Number Type

Tax Reference Number

Declaration

I declare that the information in this form is, to the best of my knowledge and belief is, accurate and complete. For the duration of my contractual relationship with the Credit Union, I undertake to notify the Credit Union, within 30 days on my own initiative , if my status for U.S. tax purposes and/or my country(ies) jurisdiction(s) of residence for tax purposes change(s). If any certification made on this form becomes incorrect, I agree I will submit a new form and /or further necessary forms and documentation within 90 days after such change in circumstances. I further affirm that I am aware that my relationship with the Credit Union may be terminated if I fail to comply with my obligation to submit relevant documentation required to determine my steps as a U.S. citizen or resident for U.S. tax purposes and/or resident for tax purposes in any other country(ies)/jurisdiction(s). I acknowledge that it is an offence to make a self-certification which is false in a material particular. Where legally obliged to do so, I hereby consent to the Credit Union sharing information in this form with the relevant tax information authorities.

Signature

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Date

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(242) 323-6594
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