Westwinds Self-Certification

FATCA/CRS Self-Certification - Individual
We are obliged under the Isle of Man Income Tax Act 1970, Regulations, Guidance Notes made pursuant to that Law and Treaties and Intergovernmental Agreements entered into by the Isle of Man in relation to the automatic exchange of information for tax matters (collectively ’AEOI‘), to collect certain information about each account holder’s tax status.

Please complete all sections below and provide any additional information that is requested. Please note that we may be obliged to share this information with relevant tax authorities. Terms referenced in this form shall have the same meaning as applicable under the relevant Isle of Man Regulations, Guidance Notes or Agreements.

If any of the information below regarding your tax residence or AEOI classification changes in the future, please ensure you advise us of these changes promptly. If you have any questions about how to complete this form, please refer to the OECDs CRS Commentaries, the OECD AEOI Portal, the Isle of Man’s FATCA and/or CRS guidance or contact your tax advisor.
Section 1 - Account Holder Information
Name

PrefixFirst/Given NameMiddle NameLast/Family Name
Date of Birth

DayMonthYear
Date
Place of Birth
Jurisdiction
Email Address

Confirmation Emailexample@example.com
Phone Number

Country CodeArea CodePhone Number
Addresses
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Jurisdiction
Is your Residential Address the same as your Mailing Address?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Jurisdiction
Section 2 - Declaration of Tax Residence
Please select how many jurisdictions you are tax resident in
Jurisdiction of Tax Residence
Tax Identification Number (TIN)
If no TIN is available, please enter "N/A" and provide a functional equivalent or an explanation if no functional equivalent is available in the textbox below
If a TIN is not available please provide a functional equivalent (such as your social security, national insurance, personal identification or a resident registration number). If no TIN or functional equivalent is available for any of the jurisdictions listed, please advise the reason why (such as the jurisdiction does not issue such numbers) below
Further information on the issuance rules for TINs and their format can be found on the OECDs AEOI Portal: https://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/
Jurisdiction of Tax Residence 2
Tax Identification Number (TIN) 2
If no TIN is available, please enter "N/A" and provide a functional equivalent or an explanation if no functional equivalent is available in the textbox below
If a TIN is not available please provide a functional equivalent (such as your social security, national insurance, personal identification or a resident registration number). If no TIN or functional equivalent is available for any of the jurisdictions listed, please advise the reason why (such as the jurisdiction does not issue such numbers) below
Further information on the issuance rules for TINs and their format can be found on the OECDs AEOI Portal: https://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/
Jurisdiction of Tax Residence 3
Tax Identification Number (TIN) 3
If no TIN is available, please enter "N/A" and provide a functional equivalent or an explanation if no functional equivalent is available in the textbox below
If a TIN is not available please provide a functional equivalent (such as your social security, national insurance, personal identification or a resident registration number). If no TIN or functional equivalent is available for any of the jurisdictions listed, please advise the reason why (such as the jurisdiction does not issue such numbers) below
Further information on the issuance rules for TINs and their format can be found on the OECDs AEOI Portal: https://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/
Jurisdiction of Tax Residence 4
Tax Identification Number (TIN) 4
If no TIN is available, please enter "N/A" and provide a functional equivalent or an explanation if no functional equivalent is available in the textbox below
If a TIN is not available please provide a functional equivalent (such as your social security, national insurance, personal identification or a resident registration number). If no TIN or functional equivalent is available for any of the jurisdictions listed, please advise the reason why (such as the jurisdiction does not issue such numbers) below
Further information on the issuance rules for TINs and their format can be found on the OECDs AEOI Portal: https://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/
Section 3 - Declaration of US Citizenship or Residence for Tax Purposes
Please tick and complete as appropriate
US TIN
Section 4 - Declaration and Undertakings
I declare that the information provided in this form is, to the best of my knowledge and belief, accurate and complete.

I undertake to advise the recipient promptly and provide an updated Self-Declaration form within 30 days where any change in circumstances occurs which causes any of the information contained in this form to be inaccurate or incomplete.

Where legally obliged to do so, I hereby consent to the recipient sharing this information with the relevant tax information authorities.

Fraud Notice

If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies to prevent fraud and money laundering.

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FATCA/CRS Self-Certification - Individual

Section 1 - Account Holder Information

Addresses

Section 2 - Declaration of Tax Residence

Section 3 - Declaration of US Citizenship or Residence for Tax Purposes

Section 4 - Declaration and Undertakings