FATCA-CRS Declaration & Supplementary KYC Information
Declaration Form for Individuals
(Please seek appropriate advice from your tax professional on your tax residency, related FATCA & CRS guidance)
Folio No* PAN / PEKRN* (* Mandatory Fields)
Name*
Address Type* Residential Nationality* Indian US Others (please specify)
[for KYC Registered Office
address] Business
Place of Birth* Country of Birth*
Gross Annual Below 1 Lakh 1-5 Lacs Occupation Business Professional
Income Details 5-10 Lacs 10-25 Lacs Details* [Please Public Sector Private Sector
in INR* 25 Lacs - 1 Cr > 1 Crore tick any one (√)] Government Service
Agriculturist Housewife
Net Worth in Student Retired
INR. In Lacs & ____________ dd-mmm-yyyy Forex Dealer
Date [Optional] Others [Please specify] ______
Politically Yes Related to PEP Any other
Exposed Person Not Applicable information
[PEP]* [if applicable] [Please specify]
Are you a tax resident (i.e. are you assessed for Tax) in any other country other than India?* Yes No
If ‘Yes’, please fill for all countries (other than India) in which you are a Resident for tax purpose i.e. where you are a
Citizen/ Resident / Green Card Holder / Tax Resident in the respective countries
S. Country of Tax Tax Identification Identification Type If TIN is not available, please tick
No. Residency Number (TIN) or [TIN or other, the reason A, B or C
Functional Equivalent please specify] [as defined below]
1 Reason A B C
2 Reason A B C
Reason A The country where the Account Holder is liable to pay tax does not issue TIN to its residents.
Reason B No TIN required [Select this reason only if the authorities of the respective country of tax residence do not required the
TIN to be collected]
Reason C Others – Please specify the reasons __________________________________________
Declaration:
I acknowledge and confirm that the information provided above is true and correct to the best of my knowledge and belief. In case any of
the above specified information is found to be false or untrue or misleading or misrepresenting, I/ am aware that I may liable for it. I hereby
authorize you [PPFAS/Fund/AMC] to disclose, share,rely, remit in any form, mode or manner, all / any of the information provided by me,
including all changes, updates to such information as and when provided by me to / any of the Mutual Fund, its Sponsor, Asset
Management Company, trustees, their employees / RTAs ('the Authorized Parties') or any Indian or foreign governmental or statutory or
judicial authorities / agencies including but not limited to the Financial Intelligence Unit-India (FIU-IND), the tax / revenue authorities in
India or outside India wherever it is legally required and other investigation agencies without any obligation of advising me of the same.
Further, I authorize to share the given information to other SEBI Registered Intermediaries/or any regulated intermediaries registered with
SEBI / RBI / IRDA / PFRDA to facilitate single submission / update & for other relevant purposes. I also undertake to keep you informed in
writing about any changes / modification to the above information in future within 30 days and also undertake to provide any other
additional information as may be required at your / Fund’s end or by domestic or overseas regulators/ tax authorities. I/We authorize
Fund/AMC/RTA to provide relevant information to upstream payors to enable withholding to occur and pay out any s ums from my account
or close or suspend my account(s) without any obligation of advising me of the same. I also confirm that I have read and understood the
FATCA & CRS Terms and Conditions given below and hereby accept the same
Date: Sign Here
Place:
=============================================================================================
Acknowledgement
We [PPFAS, on behalf of participating Mutual Funds] acknowledge the receipt of FATCA/CRS declaration form duly filled
and signed from Mr. / Ms. / M/s. _____________________________________PAN________________ on dd-mmm-yyyy
Date: Signature with Name, Emp. ID & Seal
