FATCA & CRS Form

1. Company details
Company name*
Company registration number (if applicable)
Country of registration*
Registration address*

Address line 1

Address line 2

Town / city

PostcodeCountry
Is the registration address the same as the mailing address?

Yes
Mailing address (if different from registration address)*

Address line 1

Address line 2

Town / city

PostcodeCountry

2. CRS

	Country of tax residency	TIN or equivalent	Reason IF no TIN provided*	Explanation for not providing a TIN for the respective tax residency
1
2
3
4

*Reason IF or no TIN provided:
- Reason A - The country/jurisdiction where the Account Holder is resident 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 box below if you have selected this reason).
- Reason C - 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.
Please read the guidance document for instructions and definitions, which is available on the following link - https://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/CRS_ENTITIES_Self-Cert_Form.pdf

3. FATCA
Is the entity a Financial Institution? (example: Bank, Investment Services, Payment Services)*

NoYes

3a . Financial Institutions
A. Investment Entity (example: Bank, Custodial Institution or Specified Insurance Company)B. Investment Entity (example: Fund)
i. An Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institutionii. Other Investment Entity
Please provide the Global Intermediary Identification Number (GIIN)*
Please indicate the name of any Controlling Person(s).*

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname

3b. Non-financial Entity (NFE)
What type of company?

A. Active (example: a regular private company, start-up). The company is engaged in a trading activity and is deriving more than 50% of its income from this activity and more than 50% of its assets are used to generate trading income. (MOST COMMON)B. Active Traded Company (example: a Corporation, the stock of which is regularly traded on an established securities market or a Corporation which is a related Entity of such a corporation.)C. Other Active (example: Non-Profit)D. Passive (example: Holding Company)
Please provide the established security market on which it is regularly traded.
If applicable, provide the name of related Entity which is a regularly traded corporation.
Please indicate the name of any Controlling Person(s).

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname
Please indicate the name of any Controlling Person(s).

First nameSurname

United States of America Tax Liability (“FATCA”)
Please complete the following by ticking one of the following boxes as applicable. If the Entity has connections with the US by having one or more to the below indicate or has US controlling persons, complete either W-8BEN-E or W-9 form. Kindly seek tax advice in case of difficulty.
Does the company have a link to the USA?*

No, I hereby declare that the Entity is classified as non-US Person and therefore non-US tax resident. (MOST COMMON)Yes, I hereby declare that the Entity is classified as Passive NFFE with one or more US citizens/residents as Controlling Person(s).Yes, I hereby declare that the Entity is classified as a US person and therefore US tax resident and has one or more of the following US indicia:
US Place of IncorporationUS Residence/Mailing AddressUS telephone number
If the Entity is classified as a US Person, has connections with the US by having one or more of the below indicia or is a Passive NFFE with US controlling persons, complete one of the below forms as applicable:
- W-8BEN-E - Certificate of Status of Beneficial Owner for United States Tax Withholding and Reporting (Entities) - https://www.irs.gov/pub/irs-pdf/fw8bene.pdf)
- W-9 - Request for Taxpayer Identification Number and Certification (Individuals) - https://www.irs.gov/pub/irs-pdf/fw9.pdf

4. Controlling person - Self-certification

Please enter the details of the controlling person of the company*

	Country of tax residency	TIN or equivalent	Reason IF no TIN provided	Explanation for not providing a TIN for the respective tax residency	Type of controlling person
1
2
3
4

Maltese Regulations based on the OECD Common Reporting Standard (“CRS”) require Moneybase Limited, Calamatta Cuschieri Investment Services Limited and Calamatta Cuschieri Investment Management Limited to collect and report certain information about an account holder’s tax residency. If the account holder’s tax residence is located outside Malta, we may be legally obliged to pass on the information in this form and other financial information with respect to your financial accounts to the Malta Tax and Customs Authority (MTCA) and they may exchange this information with tax authorities of another jurisdiction or jurisdictions pursuant to intergovernmental agreements to exchange financial account information.

The CRS self-certification will remain valid unless there is a change in circumstances relating to information, such as the account holder’s tax status or other mandatory field information, that makes this form incorrect or incomplete. In that case you must notify us and provide an updated self-certification.

As a financial institution, we are not allowed to give tax advice. Your tax adviser may be able to assist you in answering specific questions on this form. Your domestic tax authority can provide guidance regarding how to determine your tax status.

You can also find out more, including a list of jurisdictions that have signed agreements to automatically exchange information, along with details about the information being requested, on the OECD automatic exchange of information portal (http://www.oecd.org/tax/automatic-exchange/).

5. Declaration
I declare that the information provided in this form is, to the best of my/our knowledge and belief, accurate and complete.

I understand and acknowledge that, unless informed of any changes in circumstances, Moneybase Limited, Calamatta Cuschieri Investment Services Limited and Calamatta Cuschieri Investment Management Limited will assume the information contained in this form is correct for following financial years.

I undertake to advise Moneybase Limited, Calamatta Cuschieri Investment Services Limited and Calamatta Cuschieri Investment Management Limited within 30 days of any change in circumstances which causes the information contained herein to become incorrect and to provide an updated CRS self-certification.

I acknowledge that the information contained in this form, including information regarding the Account Holder and the account, including the account balance information, account number and payments made to the account, may be reported 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.
Full name*

First nameLast name
Position / Capacity*
Signature*

Clear
Should be Empty:

1. Company details

2. CRS

3. FATCA

3a . Financial Institutions

3b. Non-financial Entity (NFE)

United States of America Tax Liability (“FATCA”)

4. Controlling person - Self-certification

5. Declaration