TrustQore (Mauritius) Ltd
+230-405-9000 |
info@trustqore.com
19th Floor, Newton Tower, Sir William Newton Street, Port Louis, 11328, Mauritius
BRN: C07041427
FATCA-CRS INDIVIDUALSELF CERTIFICATION FORM
The purpose of this form is to gather information from you for TrustQore to comply with its obligations under the Foreign Account Tax Compliance Act (FATCA) and the Common Reporting Standard (CRS). TrustQore is bound by Tax Regulations1 to collect certain information about certain individuals, including their tax residency. In certain circumstances TrustQore may be obliged to share your information with the relevant tax authorities.You shall be required to complete and provide TrustQore with the information in this form where you are: a shareholder or of a company;a settlor, grantor, beneficiary with a vested right2, named discretionary beneficiary, protector, lender to a trust or any other person who exercises ultimate effective control over a trust.
Section 1 : Your Details:
Full Name
*
First Name
Last Name
Permanent residential address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth:
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Year
-
Month
Day
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City/Town and country of birth:
E-mail
example@example.com
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Section 2 : Tax Residency
Please indicate all countries in which you are resident for tax purposes and the associated Tax Reference Numbers (Tax Identification Number-TIN, Social Security Number-SSN, National Insurance Number-NIN, etc.) in the table below. The nature of the TRN to be provided will depend on your place of residence.
Countries in which you are a tax resident
Rows
Country / Countries of Tax ResidencyAddress
Tax Reference Number(s): US TIN, US SSN, UK NIN, etc.
1
2
3
4
5
6
7
If you are not certain in which country/ies you are tax resident, we suggest that you contact your tax advisor. Should any information you have provided in this form changes in the future, please ensure you promptly advise us of such changes. If a TIN is unavailable, please provide the appropriate reason A, B or C:
The country/jurisdiction where the Controlling Person is resident does not issue TINs to its residents .
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)
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) .
Are you (i) a U.S. citizen or (ii) hold a U.S. Green Card?
Yes
No
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Section 3 : Declaration
I declare that the information provided on this form is, to the best of my knowledge and belief, accurate and complete and I hereby consent to the release of my personal information to all relevant tax authorities as and when required.I undertake to notify TrustQore promptly in the event of any change of circumstances relating to the information in this form.
Print Name
Date
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Year
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Month
Day
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Signature
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