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FATCA Status Declaration Form SIBL

The document is a FATCA Status Declaration Form for individuals at Social Islami Bank Limited, requiring personal information and responses to questions regarding U.S. citizenship and residency. It includes consent for the bank to share information with tax authorities and to withhold amounts as necessary. The form must be signed and dated by the account holder and bank officials for processing.

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polashhassan1990
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93 views1 page

FATCA Status Declaration Form SIBL

The document is a FATCA Status Declaration Form for individuals at Social Islami Bank Limited, requiring personal information and responses to questions regarding U.S. citizenship and residency. It includes consent for the bank to share information with tax authorities and to withhold amounts as necessary. The form must be signed and dated by the account holder and bank officials for processing.

Uploaded by

polashhassan1990
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Social Islami Bank Limited

FATCA STATUS DECLARATION FORM (INDIVIDUAL)


Account Name :
Account Number :
Country of Birth :
Country of Residence :

Please tick Yes or No for each of the following questions: Yes No


1. Are you a US Citizen?
□ □
2. Do you hold U.S. Green Card or is a lawful resident of the US? □ □
3. Do you have a U.S. address (including P.O. Box) or U.S. phone number or □ □
U.S. e-mail address?
4. Have you granted Power of Attorney to someone who has a U.S. □ □
address or U.S. phone number or U.S. e-mail address?
5. Have you stayed in U.S. for 183 days during 3-year period including □ □
present year?
6. Do you receive payments sourced from USA? That is Interest, Dividend,
Rent, Payment for services (salaries), and any other Fixed Determinable □ □
Annual Periodical [FDAP] income.

I/we hereby acknowledge that the statement given above is true, accurate and complete. In any
event if this statement is identified as false, I hereby consent SIBL to treat the account as per the
directions of FATCA.
I/we hereby consent for SIBL or any of its affiliates (including branches) to share my/our information
with domestic or overseas regulators or tax authorities where necessary to establish my tax liability
in any jurisdiction (if required).
Where required by domestic or overseas regulators or tax authorities, I/we consent and agree that
the bank may withhold and pay out from my account(s) such amounts as may be required according
to applicable laws, regulations, agreements with regulators or authorities and directives.
I/we agree and undertake to notify SIBL within 30 calendar days if there is a change in any
information which I/we have provided to the bank.

Signature (with date) Signature (with date) Signature (with date)


FOR BANK USE ONLY
Account Name :
Account Number :
Customer ID :

□ AOF checked, supporting documents received and preserved with AOF


□ Signature (s) admitted/verified
□ Updated in CBS

Account Opening Officer (signature and seal) BAMLCO/Authorized Officer (signature and seal)

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