601, Brigade International Financial Center, GIFT SEZ, GIFT CITY, Gandhinagar, Gujarat
FATCA Information Sheet and Undertaking
This form is to be submitted for each individual/Authorized signatory/Beneficial Owner/Director Separately
Name of the individual/Authorized Signatory/Beneficial Owner
/Director
Customer ID / account number
Name of the account
U.S.Indica Fill Details in the Column U S Person
1 Citizenship Yes No
2 Place of Birth Yes No
3 Address Yes No
4 Telephone Number Yes No
5 Standing Instructions to transfer funds to or Yes No
from an account maintained in the United states
6 A Power of Attorney signatory authority granted Yes No
to a person with a U.S. address
7 U.S. “in-care-of” or “hold mail” Address Yes No
8 US Permanent Resident Card (Green Card) Holder Yes No
a. If answer any of the above is ‘YES’, the individual is classified as ‘U S PERSON’
b. Please attach documents in support of above position
c. If answer any of the above is ‘YES’, please attach the applicable form – ‘W-88EN’ or ‘W-9’ or
Applicable Form (available in IRS website)
d. If answer any of the above is ‘YES’, please US Tax ID #:
provide us the US Tax Identification Number
Declaration
I hereby declare that I have understood FATCA and submit this declaration in compliance of FATCA
requirement. I also declare and confirm that the information provided above is true, accurate and
complete and the same is as per applicable laws/guidelines. I hereby authorize Punjab National Bank or
any of its affiliates (including branches) to share my information with domestic and overseas tax
authorities to establish my tax liability in any jurisdiction, or as the case may be. I agree that the Bank
may withhold from my account(s) such amounts as may be required according to applicable laws,
regulations and directives. Any change in status at any time will be promptly notified to the Bank.
Name:
Place:
Date: Signature
For Office Use only:As declared by the captioned party, the, Yes No
FATCA applicability:
