Know Your Customer (KYC) Application Form (For Non ... · Partnership/Trust and...
Transcript of Know Your Customer (KYC) Application Form (For Non ... · Partnership/Trust and...
1. Name of Applicant (Please write complete name as per Certificate of Incorporation / Registration) :
______________________________________________________________________________________________________________
2. Constitution : Pvt. Ltd. Company Ltd. Company Partnership Ltd. Liability Partnership (LLP)
Trust & Foundation Incorporated Association or Body of Individuals Sole Proprietorship
Hindu Undivided Family (HUF) Society Liquidator Artificial Jurisdicial Person Others____________
3. PAN No.:
4. Place of Incorporation : __________________________ 5. Date of Incorporation : _________________
6. Country of Incorporation*:_____________________ 7. Registration No.:________________________________
8. Date of Commencement of Business : _________________
9. Country of Residence as per tax laws*: _______________________________________
10. TIN : ____________________________ TIN Issue Country*: ______________________
Know Your Customer (KYC) Application Form (For Non-Individuals Only)(Please fill in ENGLISH and in BLOCK LETTERS with black ink)
CIF No. A/c. No. KYC No.(If available)
D D M M Y Y Y Y
D D M M Y Y Y Y
11. Registered Address : Address Type : Business Residence Registered Office Unspecified Others ________
12. Correspondence / Mailing Address : Same as Registered Address
Address Type : Business Residence Registered Office Unspecified Others ___________
13. Address where entity is Residence outside India for tax purpose :
Same as Registered Address Same as Correspondence Address
Address Type : Business Residence Registered Office Unspecified Others ___________
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
STD/ISD Country code No
STD/ISD Country code No
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
STD/ISD Country code No
STD/ISD Country code No
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
(*Please refer to the enclosed annexure for state code & country code)
STD/ISD Country code No
STD/ISD Country code No
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Sr. No.
Directors / Partners / Trustee /Member / Co-parceners etc.
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2
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AuthorisedSignatories
Yes / No
Residentialstatus
(Resident /Non Resident)
If Non-Resident
Country of Non- Resident
DIN/D-PIN (As per
MCAwebsite)
PEP orRelated to
1PEP (Yes/ No)
Particulars % of holding
16. Beneficial Owner Details: ¤(Private Ltd Company/Limited Company/Partnership/Limited Liability Partnership /
Trust and Foundation/Incorporated association or a body of individuals/Hindu Undivided Family/Others ____________)
I. Whether listed in a recognised stock exchange? Yes No
a) If listed in a recognised stock exchange, please provide the below information:
i. Name of the stock exchange: _________________ ii. Date of Listing : DD/MM/YYYY
iii. Ownership Structure/Pattern :
14. List of Directors / Trustee / Member / Co-parceners / Partners etc. :
15. Number of controlling person(s) resident outside India for tax purpose :
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II. Out of the above I (b) :
a) If Owner(s) is/are listed in recognised Stock Exchange, please provide the below information:
i. Name of the stock exchange : ii. Date of Listing : DD/MM/YYYY
iii. Ownership Structure/Pattern :
b) If Owner(s) is/are not listed in recognised Stock Exchange, please provide the below information:
b) If not listed in a recognised stock exchange, please provide the below information : i. Ownership Structure/Pattern :
Particulars % of holding
Details of Shareholding / Capital / Profit / Interest :
¤ For the purpose of classifying Beneficial Owner: i. Controlling ownership interest" means ownership of or entitlement of more than 25% of Shares or capital or profits of the company. ii. Ownership of/entitlement for more than 15% of capital or profits or property or interest in the Partnership/Limited Liability Partnership/Trust and Foundation/Unincorporated association or a body of individuals/Hindu Undivided Family/Others ______________________
DECLARATION
I/we hereby confirm that the above-named person(s) hold or is entitled to more than 25% / 15% of shares capital or profits or property or interest in M/s.
I/we hereby agree, confirm and undertake to provide the KYC documents of the aforesaid Beneficial Owners(s) as thper Reserve Bank of India guidelines RBI/2012-13/385 (DBOD. AML.BC.NO. 21/14.01.001/2012-13) dated January 18 , 2013
Company Secretary† Authorised Signatory/Director†† Authorised Signatory/Director††
(To be signed by the Authorized Signatory of the Company whose account is being opened)(† In case of Company Secretary not available, obtain two directors signatures)(††In case of LLP / Partnership / Association of Persons / Body of Individuals / Trust/HUF to be signed by the Authorized Signatory)
Date Place
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DDMMYYYY
17. Business : Agriculture Manufacture Trade Finance Bank Transport Service
Government Retail Wholesale Others
Nature of Business Details :
IEC Code, if applicable
18. Annual Turnover (In INR) : Upto 1 Crore 1-5 Crores 5-25 Crores 20-50 Crores
50-100 Crores Above 100 Crores
19. Additional Information :
(i) Business Size (ii) No. of Branches iii) No. of Employees
(iv) Physical Business (v) Main Geographies of Business :
(vi) Expected Account Activity in INR / Month
a) Cash b) Non Cash c) Wire Transfer
Financial Information :
a) Total Assets b) Total Liabilities c) Annual Sales
d) Net Profit
20. Existing Banking Relations :
I/we do not enjoy any credit facility with any other bank I/we enjoy credit facility with the following banks
Bank NameSr. No. Bank Address Type of Facility Amount
21. FATCA Details :
I. Please indicate the nature of your entity :
(a) US Entity : A Company Corporation, Association, Partnership, or Trust ("US Tax Obligor)
created/organised in the United States or under the laws of the United States of America.
(b) Non Us Entity (Indian or Foreign Entity) : A Company Corporation, Association, Partnership, or Trust
created organised outside the borders of the United States of America.
II. If you have selected I (a)-US Entity, please submit the W9 Form and Provide the Employer Identification
Number (EIN)
III. If you have selected I (b) - Non US Entity, then please further specify your FATCA status under the option of
(a) or (b) below:
(a) FI (Financial Institution) - Please choose the entity's applicable status:
Non Participating FI Participating FI India or Partner Jurisdiction FI
Registered Deemed Complain FI
Entity Wholly Owned by Exempt Beneficial Owners Certified Deemed Compliant FI
If the entity has a global Intermediary Identification Number ("GIIN") please indicate it here
If the entity does not have a GIIN, please submit a W8-Ben-E, if applicable
(b) NFFE (Non-Financial Foreign Entity) - Please choose the entity's applicable status :
Active NFFE Passive NFFE : with no US Controlling Person / Substantial US Owners (please submit the W8 BEN-E)
Passive NFFE : with US Controlling Person / Substantial US Owners (please submit the W 8 BEN-E
with US owners details)
IV. U.S Taxpayer Identification Number (SSN or ITIN ) : _________________________________________________
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22. CRS Details :
Are you liable to pay taxes outside India ? Yes No
Entity Type :
1. Please indicate the type of your entity:
a. Financial Institution (Depository institution, custodial institution, specified insurance company and investment entity
in a CRS participating jurisdiction)
b. Financial Institution that is a professionally managed investment entity located in CRS non-participating jurisdiction.
c. Non-financial entity. Please further specify your entity status :
i. Active NFE - a corporation the stock of which is regulatory traded on an established securities market or a
corporation which is related entity of such a corporation.
ii. Active NFE - a government entity or central bank.
iii. Active NFE - an international organisation.
iv. Active NFE - Other than (i), (ii) and (iii)
v. Passive NFE
2. If you have selected 1(a) please complete Declarations section.
3. If you have selected 1(b) please complete Self certification for controlling person(s) section and Declaration section.
4. If you have selected 1(c) (i) or 1(c) (ii) or 1(c) (iii), please complete Declarations section.
5. If you have selected 1(c) (iv), please complete Tax Residency section and Declaration section.
6. If you have selected 1(c) (v), please complete Self certification for controlling person(s) section, Tax Residency section
and Declaration section.
Reason A - The country where the Account Holder / Controlling Person is tax resident does not issue TINs to its residents.
Reason B - the Account Holder / Controlling Person is otherwise unable to obtain a TIN or equivalent number (Please explain why the Account Holder / Controlling Person is unable to obtain a TIN in the table below if you have selected this reason).
Reason C - No TIN is required. (Note. Only select this reason if the authorities of the country of tax residence entered above do not allow the TIN to be disclosed to third parties).
Reason D - the Account Holder / Controlling Person has got no tax residence, therefore TIN is not applicable. In this case, please write "NONE" in the "Country of Tax Residency" Column.
If you indicated 'Reason B', please explain in the following boxes why the Account Holder is unable to obtain a TIN.
Reasons :
Country of Tax Residency Taxpayer Identification Number (TIN) TIN Issue CountryReasons for not providing TIN
(enter reason A, B, C or D)
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Tax Residency :
Please list all jurisdictions in which you are treated as tax resident and provide the tax identification number for each one. If you are tax resident in more than three countries, please use a separate sheet.
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(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
23. Self certification for controlling person(s) :
(a) Details of controlling person (Individual) :
CIF No. (if available) : _____________________________ KYC No. (If available) : ___________________________________
Type of Control :
In case of Legal Person : Ownership Senior Managing Official Other means ______________________________
In case of Trust : Settler Trustee Protector Beneficiary Other _________________________________
In case of other arrangement : Settler Equivalent Trustee Equivalent Protector Equivalent
Beneficiary Equivalent Other Equivalent ____________________________
Name (as appearing in supporting identification document) Mr./Mrs./Ms. ___________
Gender : M F T - Transgender
Name : __________________________________________________________________________________________________
Maiden Name (if any) :_____________________________________________________________________________________
Spouse Name : ____________________________________________________________________________________________
Father Name : ____________________________________________________________________________________________
Mother Name : ___________________________________________________________________________________________
Marital Status : Married Unmarried Other _______________________
Residential Status : Resident Individual Non-Resident Indian Foreign National Person of Indian Origin
Date of Birth : __________________
Country of Birth*: _________________________________ Place of Birth : __________________________________________
Country of Residence*: (for tax purpose) __________________________ TIN : _______________________________________
TIN Issuing Country*: ________________________ Nationality : Indian Other (specify) ___________________
Category : General OBC SC NT Other _________________________
Passport No.: ________________________________
Date of Issue : __________________ Date of Expiry : __________________ Place of Issue : ___________________________
Valid Visa : Type of Visa :_______________________ Date of Issue : _________________ Date of Expiry : ________________
Place of Issue : ________________________________
KYC Documents Details :
PAN Card Election ID Driving License (Expiry Date _______________________) NREGA Job Card
Aadhar Card Others ___________________ ID Number ____________________________________
Occupation (please tick) :
Retired Bullion Housewife Student Service Politician Diplomat Money Service Business
Real Estate Jewellery / Diamond / Gems Precious Stones ___________________________
Self-employed _________Business _________Professional _________Others _________ (please specify)
Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB)
Other ______________________________________ (Please specify)
Designation : ____________________________________________________________________________________________
Address : Address Type : Owned Rental / Leased Ancestral / Family Company provide Other _____________
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
Please tick, if applicable : Politically Exposed Person (PEP) Related Politically Exposed Person
Reasons for not providing TIN : A B C D
(Please refer to Tax Residency Section for Reasons descriptions)
If you indicate reason "B", please explain
(*Please refer to the enclosed annexure for state code & country code)
STD/ISD Country code No
STD/ISD Country code No
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DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYYDD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
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CIF No. (if available) : __________________________ KYC No. (If available) : ______________________________
Type Control (same as individual) :
In case of Legal Person : Ownership Senior Managing Official Other means ______________________
In case of Trust : Settler Trustee Protector Beneficiary Other __________________________
In case of other arrangement : Settler Equivalent Trustee Equivalent Protector Equivalent
Beneficiary Equivalent Other Equivalent ____________________________
Name (Please write complete name as per Certificate of Incorporation / Registration) :
______________________________________________________________________________________________________________
Constitution : Pvt. Ltd. Company Ltd. Company Partnership Ltd. Liability Partnership (LLP)
Trust & Foundation Incorporated Association or Body of Individuals Sole Proprietorship
Hindu Undivided Family (HUF) Society Liquidator Artificial Jurisdicial Person Others____________
PAN No.:
Place of Incorporation : __________________________ Date of Incorporation : _________________
Country of Incorporation*:_____________________ Registration No.:________________________________
Date of Commencement of Business : _________________
Country of Residence as per tax laws*: _______________________________________
TIN : ____________________________ TIN Issue Country*: ______________________
Registered Address : Address Type : Business Residence Registered Office Unspecified Others ________
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
STD/ISD Country code No
STD/ISD Country code No
(b) Details of Controlling Person (Non-Individual) :
Reasons for not providing TIN : A B C D
(Please refer to Tax Residency Section for Reasons descriptions)
If you indicate reason "B", please explain
(*Please refer to the enclosed annexure for state code & country code)
DD/MM/YYYY
DD/MM/YYYY
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
(First Name) (Middle Name) (Surname)
24. Details of Related Person :
CIF No. (if available) : _____________________________
KYC No. (If available) : ___________________________________
Related Person Type : Director Promoter Karta Trustee Beneficiary
Authorised Signatory Court Appointed Official Other means ____________________
Name (as appearing in supporting identification document) Mr./Mrs./Ms. ___________
Gender : M F T - Transgender
Name : __________________________________________________________________________________________________
Maiden Name (if any) :_____________________________________________________________________________________
Spouse Name : ____________________________________________________________________________________________
Father Name : ____________________________________________________________________________________________
Mother Name : ___________________________________________________________________________________________
Marital Status : Married Unmarried Other _______________________
Residential Status : Resident Individual Non-Resident Indian Foreign National Person of Indian Origin
Date of Birth : _________________
Country of Birth*: _________________________________ Place of Birth : ________________________________________
Country of Residence*: (for tax purpose) __________________________ TIN : _____________________________________
TIN Issuing Country*: ________________________ Nationality : Indian Other (specify) ___________________
Category : General OBC SC NT Other _________________________
Passport No.: ________________________________
Date of Issue : __________________ Date of Expiry : __________________ Place of Issue : ____________________________
Valid Visa : Type of Visa :_______________________ Date of Issue : __________________ Date of Expiry : ________________
Place of Issue : ________________________________
KYC Documents Details :
PAN Card Election ID Driving License (Expiry Date _______________________) NREGA Job Card
Aadhar Card Others ___________________ ID Number ____________________________________
Occupation (please tick) :
Retired Bullion Housewife Student Service Politician Diplomat Money Service Business
Real Estate Jewellery / Diamond / Gems Precious Stones ___________________________
Self-employed _________Business _________Professional _________Others _________ (please specify)
Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB)
Other ______________________________________ (Please specify)
Designation : ____________________________________________________________________________________________
Address : Address Type : Owned Rental / Leased Ancestral / Family Company provide Other _____________
Flat No :________________________________ Building Name : _____________________________________________
Street : _________________________________ Locality : ___________________________________________________
City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________
Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________
Landline No. (Res.): _______________________ Email ID : _________________________________________________
Please tick, if applicable : Politically Exposed Person (PEP) Related Politically Exposed Person
Reasons for not providing TIN : A B C D(Please refer to Tax Residency Section for Reasons descriptions)
If you indicate reason "B", please explain
(*Please refer to the enclosed annexure for state code & country code)
STD/ISD Country code No
STD/ISD Country code No
PHOTOGRAPH
Please affixthe recent passport
size photograph andsign across it.
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DD/MM/YYYY
DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYY
DECLARATION(i) I/we hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. In case any of the above
information is found to be false or untrue or misleading or misrepresenting, I/we am/are aware that I/we may be held liable for it. I/we confirm that the details submitted above are for updating the Bank's records and abide by Terms and Conditions as applicable from time to time. I/we agree and undertake to notify the Bank within 30 days if there is a change in any information which I/we have provided to the Bank.
(ii) FATCA / CRS Declaration : I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Accounts
Holder's relationship with ADCB setting out how ADCB may use and share the information supplied by me.
I acknowledge, and undertake to inform the Controlling Persons identified herein, that I have provided the above information to ADCB in order for ADCB to comply with its legal obligations on reporting and exchanging financial information, and that the information provided by me will be stored by ADCB until it is required for this purpose. I further acknowledge, and undertake to inform the Controlling Persons, that the information contained in this form and information in relation to the Account Holder and any Reportable Account may be reported to the local tax authority and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax resident.
I certify that I am authorized to sign for the Account Holder in respect of all the account(s) to which this form relates and have provided evidence of such authority.
The Account Holder shall notify ADCB within a reasonable time frame if there is a change of circumstances that affects the tax resident status of the Account Holder identified in this document or causes the information contained herein to become incorrect or incomplete (including any changes to the information on Controlling Persons identified in Self Certification for controlling person). In such circumstances the Account Holder agrees to provide an updated self-certification document.
I understand that the Bank is relying on the information provided herein for the purpose of determining the status of the applicant named above in compliance with FATCA / CRS. The Bank cannot offer any tax advice on CRS or FATCA or its impact on the applicant. I shall seek advice from any professional tax advisor for any tax related query.
I agree that as may be required by domestic regulators / tax authorities, the Bank may also be required to report reportable details to CBDT or close or suspend my account (as may be necessary).
(iii) I/We hereby consent to sharing KYC details/receiving information to/from Central KYC Registry, through SMS/Email on the above registered number/email address.
1 Politically Exposed Persons (PEP ) : PEPs are individuals who are or have been entrusted with prominent public functions in a foreign country. Examples of PEPs include, but not limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii) Senior government/judicial (iv) Senior executives of state -owned corporations (v) important political party officials (vi) Senior Indian Diplomatic personnel posted outside the country. The term PEP also include the families and close associates of the PEPs mentioned. Families: The families incluides close family members such as spouses, children, parents and siblings and may also include other blood relatives and relatives by marriage. Close associates: The term closely associated persons in the context of PEPs includes close business and personal advisors / consultants to the PEP as well as persons who obviously benefit significantly from being close to such a person.
Note : If the details cannot be captured in the above, the same should be provided on the letterhead of the entity, duly attested.
Authorised Signatory Name Signature Date Place
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State Code & Country Code Annexure
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Authorised Signatory Authorised Signatory Authorised Signatory
KYC Documents Checklist
KYC Application Form
FATCA Details: W8 BEN/ W9 (if applicable)
2
KYC documentation of Related Person :
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