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Annexure

Self-certification by the Account holder in respect of Other Indicia being resident of


any country or territory outside India other than the United States of America (the
U.S.) for tax purpose/ current residence or mailing address in any country or territory
outside India other than U.S. / Post Box No. in any country or territory outside India
other than the U.S. / one or more telephone numbers in any country or territory
outside India other than the U.S. (and no telephone number in India) / standing
instructions (with respect to financial accounts other than depository accounts) to
transfer funds to an account maintained in any country or territory outside India other
than the U.S.
To

The Branch Manager


State Bank of India,
……………………………..
……………………………..

Dear Sir,

I, the undersigned hereby declare and certify as under:


I/We am/are a resident for tax purposes in India only and not a resident of any
country/territory (ies) outside India for tax purposes.

AND
I/We enclose copies of the following ((Strike off whichever is not applicable)

i) a certificate of residence issued by an authorized government body (including a


government agency or a municipality) of the country or territory of which I/we am/are
a resident for tax purposes;
OR
(ii) valid identification indicating my/our name issued by an authorized government body
(including a government agency or a municipality) which is used for identification
purposes for being resident of the jurisdiction for tax purposes.

OR
I/We confirm that the Other Indicia found to have been associated with my/our account
consequent to due diligence procedure undertaken by the Bank is correct and I/we further
confirm that I/we am/are a tax resident of the following country(ies) or territory(ies) outside
India other than U.S. and therefore my/our account is an Other Reportable Account.
I/We give below other information (To be provided mandatorily if other indicia is
confirmed by the account holder for the purpose of reporting to CBDT. If other indicia
is not confirmed by the account holder, the information below is optional. ) as required
for reporting purpose and/or updation of records:

1. Place of Birth
2. Country of Birth
3. Date of Birth
4. Country(ies) of Tax Tax identification number (TIN) or functional equivalent (if
residence outside issued by jurisdiction)
India
i)
ii)
iii)
iv)
v)
5. Address Address:
City/Town
Postal Code (Pin Code):
State:
Country:
6. Permanent Account
Number (PAN)
7. Father’s Name
8. Spouse’s Name
9. Aadhaar Number
10. Identification Type Identification Number (Number mentioned in the
(Document identification document)
submitted)
A - Passport
B - Election ID Card
C - PAN Card
D - ID Card
E - Driving License
G - UIDAI Letter
H - NREGA job card
Z – Others (please
specify)
(Tick as applicable)
11. Occupation Type i) S – Service
ii) B – Business
iii) O – Others (please specify)
(Tick as applicable)
12. Nationality
13. Address Type i) 1 - Residential Or Business
ii) 2 – Residential
iii) 3 – Business
iv) 4 – Registered Office
v) 5 – Unspecified
(Tick as applicable)
14. Mobile/Telephone
Number
15 Other Contact
Number
16 Details of Other (i) CIF:
Accounts held with (ii) Account Number(s):
State Bank of India (iii) Name of Branch where account(s) held:
under any other CIF, (iv) Whether Single or Joint:
if any (v) Name of Joint holder(s):

Declaration and undertaking :

a) I/ We hereby certify that I / we have declared my/our status as per the rules applicable
under section 285BA of the Income Tax Act, 1961 as notified by Central Board of Direct
Taxes (CBDT) vide Notification No. S.O. 2155(E) dated 7 August 2015 and RBI Circular
Ref No. DBR.AML.BC.No.36/14.01.001/2015-16 dated 28 August 2015 in this regard.
b) I / We certify that the information provided by me/us above as applicable to me/us and
signed by me/us as well as in the documentary evidence provided by me/us are, to the
best of my/our knowledge and belief, true, correct and complete and that I/we have not
withheld any material information that may affect the assessment/categorization of my
account as an Other Reportable Account or otherwise.
c) I / We undertake the responsibility to declare and disclose within 30 days from the date
of change, any changes that may take place in the information provided above, as well
as in the documentary evidence provided by me/us or if any certification becomes
incorrect and to provide fresh and valid self- certification along with documentary
evidence.
d) I / We also agree that my/our failure to disclose any material fact known to me/us, now or
in future, may invalidate me from transacting in the account and State Bank of India
would be within its right to put restrictions in the operations of my/our account or close it
or report to any regulator and/or any authority designated by the Government of India
(GOI) /RBI for the purpose or take any other action as may be deemed appropriate by
State Bank of India, under the guidelines issued by CBDT/RBI from time to time, if the
deficiency is not remedied by me/us within the stipulated period.
e) I/We also agree to furnish and intimate to State Bank of India any other particulars that
are called upon me / us to provide on account of any change in law either in India or
abroad in the subject matter herein.
f) I/We shall indemnify State Bank of India for any loss that may arise to State Bank of
India on account of providing incorrect or incomplete information.

Place:………………………….

Date:…………………………..
Signature of the Account holder

……………………………………
(Name of the Account holder)

Signature of the Account holder

……………………………..
(Name of the Account holder)

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