CRS Individual

Self-Certification Form
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Please read these instructions before completing the form

Why are we asking you to complete this form?
To help protect the integrity of tax systems, governments around the world are introducing a new information gathering and
reporting requirement for financial institutions. This is known as the Common Reporting Standard (‘the CRS’).
Under the CRS, we are required to determine where you are ‘tax resident’ (this will usually be where you are liable to pay income
taxes). If you are tax resident outside the country/jurisdiction where your account is held we may need to give the national tax
authority this information, along with information relating to your accounts. That may then be shared between different countries’/
jurisdictions' tax authorities.
Completing this form will ensure that we hold accurate and up to date information about your tax residency.
If your circumstances change and any of the information provided in this form becomes incorrect, please let us know immediately
and provide an updated Self-Certification.

Who should complete the CRS Individual Self-Certification Form?

Personal banking customers or sole traders should complete this form.
If you need to self-certify on behalf of an entity (which includes businesses, trusts and partnerships), complete an ‘Entity Tax
Residency Self-Certification Form’ (CRS-E). Similarly, if you are a controlling person of an entity, complete a ‘Controlling Person Tax
Residency Self-Certification Form’ (CRS-CP). You can find these forms at: www.crs.hsbc.com
For joint account holders, each individual will need to complete a copy of the form.
Even if you have already provided information in relation to the United States Government’s Foreign Account Tax Compliance Act
(FATCA), you may still need to provide additional information for the CRS as this is a separate regulation.
If you are completing this form on behalf of someone else, please ensure that you let them know that you have done so and tell
us in what capacity you are signing in Part 3. For example, you might be completing this form as a custodian or nominee of an
account, under a Power of Attorney or as a legal guardian on behalf of an account holder who is a minor.

Where to go for further information

If you have any questions about this form or these instructions please visit: www.crs.hsbc.com contact your Relationship Manager,
visit a branch or call us.
The ‘Organisation for Economic Co-operation and Development’ (OECD) has developed the rules to be used by all governments
participating in the CRS and these can be found on the OECD’s ‘Automatic Exchange of Information’ (AEOI) website: www.oecd.
org/tax/automatic-exchange/
If you have any questions on how to define your tax residency status, please visit the OECD website or speak to a professional tax
adviser as we are not allowed to give tax advice.
You can find a list of definitions in the Appendix.
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Individual Tax Residency CRS - I

Self-Certification Form
Please complete Parts 1– 3 in BLOCK CAPITALS

Part 1
Identification of Individual Account Holder
A. Name of Account Holder:

Family Name or Surname(s)

Title Mr Mrs Miss Ms Other (specify)

First or Given name(s)

Middle Name(s)

B. Current Residence Address:

Line 1 House/Apt/Suite
Name, Number, Street

Line 2 Town/City
Province/County/State

Country Postal Code / ZIP code

C. Mailing Address: (please only complete if different from the address shown in Section B above)

Line 1 House/Apt/Suite
Name, Number, Street

Line 2 Town/City
Province/County/State

Country Postal Code / ZIP code

D. Date of birth D
D D
D M
M M
M Y Y Y Y

E. Place of birth

Town or City of Birth

Country of Birth
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Part 2
Country/Jurisdiction of Residence for Tax Purposes and related Taxpayer Identification Number or functional equivalent (“TIN”) (See
Appendix)
Please complete the following table indicating:

i. where the Account Holder is a tax resident;

ii. the Account Holder’s TIN for each country/jurisdiction indicated.
If the Account Holder is tax resident in more than three countries/jurisdictions please use a separate sheet
If a TIN is unavailable please provide the appropriate reason A, B or C:
Reason A The country/jurisdiction where the Account Holder is liable to pay tax 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 authorities of the country/jurisdiction of tax residence entered
below do not require the TIN to be disclosed)

Country/Jurisdiction of tax residence TIN If no TIN available enter Reason A, B or C

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

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Part 3
Declarations and Signature
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 HSBC setting out how HSBC may use and share the information supplied by me.
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.
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.
I certify that where I have provided information regarding any other person (such as a Controlling Person or other Reportable Person
to which this form relates) that I will, within 30 days of signing this form, notify those persons that I have provided such information
to HSBC and that such information may be provided to the tax authorities of the country/jurisdiction in which the account(s) is/are
maintained and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the person may be
tax resident pursuant to intergovernmental agreements to exchange financial account information.
I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.
I undertake to advise HSBC within 30 days 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, and to provide HSBC with a suitably
updated self-certification and Declaration within 90 days of such change in circumstances.

Signature

Print name

Date D
D D
D M
M M
M Y Y Y Y

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.

Capacity:
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Appendix – Definitions
Note: These are selected definitions 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 following link:
http://www.oecd.org/tax/transparency/automaticexchangeofinformation.htm
If you have any questions then please contact your tax adviser or domestic tax authority.

‘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.
‘Controlling Person’ This is a natural person who exercises control over an entity. Where an entity Account Holder is treated as a
Passive Non-Financial Entity (‘NFE’) then a Financial Institution must determine whether such Controlling Persons are Reportable
Persons. This definition corresponds to the term ‘beneficial owner’ as described in Recommendation 10 of the Financial Action Task
Force Recommendations (as adopted in February 2012).
If the account is maintained for an entity of which the individual is a Controlling Person, then the ‘Controlling Person
tax residency Self-Certification’ form should be completed instead of this form.
‘Entity’ The term ‘Entity’ means a legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or
foundation.
‘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.
‘Reportable Account’ The term ‘Reportable Account’ means an account held by one or more Reportable Persons or by a Passive
NFE with one or more Controlling Persons that is a Reportable Person
‘Reportable Jurisdiction’ A Reportable Jurisdiction is a jurisdiction with which an obligation to provide financial account
information is in place.
‘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 following link: http://www.oecd.org/tax/transparency/automaticexchangeofinformation.htm
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.