SELF-CERTIFICATION FORM
- LEGAL PERSONS–
Branch/Agency ______CUSTOMER CODE ______
A. CUSTOMER IDENTIFICATION DATA FOR FATCA AND CRS PURPOSES
Entity’s name / Resident
Non-resident
Address: / CUI/TIN/NIF
Correspondence address: / Trade Registry No./ Registration No.
If you are resident in participanting jurisdiction and you cannot provide the NIF, please specify:
Thecountry where I am fiscally resident is not issuing NIF/TIN.
The account owner cannot obtain NIF/TIN – please provide the reason.
Please tick the status of the account owner:
- FINANCIAL INSTITUTION – INVESTMENT ENTITY
- Investment entity located in a non-participating jurisdiction
- Another type of investment entity
- FINANCIAL INSTITUTION–Depository Institution, Custodial Institution, Specified Insurance Company
- ACTIVE NON-FINANCIAL ENTITY (Active NFFE)
- PASSIVE NON-FINANCIAL ENTITY (Passive NFFE)
- In case you have ticked one of the 5 boxes above and the entity is established/ registered/ fiscally resident in USA, please proceed as per point 1below.
- In case you have ticked I (A/B) or II, then please provide the GIIN (Global Intermediary Identification Number), obtained for FATCA purposes (if exists) and provide the forms W-8BEN-E.
- In case you have ticked III or IV and the entity is registered in CRS jurisdiction, then proceed as point 2below.
- In case you have ticked I (A) or IV, please fill in the points 3 and 4below and provide the information requested under point 5.
1. The account owner is an entity set-up/ registered/ tax resident in USA / Yes / Please, provide W-9 form and sign the statement included in the present form
No
2. Fiscal residency of the entity: / Country of fiscal residency 1: / NIF related to country of fiscal residency 1:
Country of fiscal residency 2: / NIF related to country of fiscal residency 2:
In case the residency country differs from the country of company registration, please provide the fiscal residency certificate from the declared fiscal residency country.
I hereby declare that I do not have a Tax Residence in other Countries apart from those ones declared above.
3. The account owner is a “passive” non-US entity with a major holder/ real beneficiary from USA / Yes / Please, provide W-9 form for the US person and sign the statement included in the present form.
No
4. The account owner is a „passive” entity with beneficial owner/ controlling person from aCRS state / Yes / No
Did you give power of attorney or signature rights to a person with address in USA or in a CRS state? / Yes,address in SUA / If you are not a US Entity Please, provide W-8BEN-E form and sign the statement included in the present form.
Yes,address in CRS state / CRS state:
No
Phone number / In case you hold telephone numbers from USA please provide them together with the information below: / N/A
Please provide W-9 form and sign the statement included in the present form
If you are not a US person, please provide W-8BEN-E form and sign the statement included in the present form.
Country Code_____ / Phone no.
Country Code_____ / Phone no.
In case you hold telephone numbers in other countries, except USA and Romania, please provide them together with the information below: / N/A
Country Code_____ / Phone no.
Country Code_____ / Phone no.
5. Details on beneficial owners/ controlling persons of the entity*
Type of person: / beneficial owner controlling person
Surname, first name:
Residency country:
Birth date/ place:
Address of residency:
NIF/TIN:
Type of person: / beneficial owner controlling person
Surname, first name:
Residency country:
Birth date/ place:
Address of residency:
NIF/TIN:
Type of person: / beneficial owner controlling person
Surname, first name:
Residency country:
Birth date/ place:
Address of residency:
NIF/TIN:
Type of person: / beneficial owner controlling person
Surname, first name:
Residency country:
Birth date/ place:
Address of residency:
NIF/TIN:
Note:
* the information will be filled only for the passive entities with beneficial owners/ controlling persons, residents in CRS states or in USA.
For the purpose of this form the following terms mean:
Self-certification – has the meaning of statement on own responsibility;
USA – United States of America;
US Person – US Citizen (including when holding one or more citizenships) or resident in USA for tax purposes;
US Entity – legal entity which is organized according to USA laws or is resident in USA or has a tax statute in USA or a tax identification number in USA (TIN);
Non-US Passive Entity – non-US legal entity in which over 50% of the gross income derives from passive investments such as dividends, rents or shares;
Major holder from USA – if a US person (individual or legal entity) holds directly or indirectly over 25% from a non-US entity’s shares, which gives a majority U.S. ownership;
FATCA – (US FOREIGN ACCOUNT TAX COMPLIANCE ACT) The Law regarding the tax compliance applicable to foreign accounts.
CRS – “Common Reporting Standard” – represents the standard issued by OECD for the automatic exchange of information on the financial accounts of the customers private individuals and legal entities with the fiscal residency in one of the countries adhering to this standard.
Participating jurisdiction (CRS State) - a) any member state except Romania; b) any other jurisdiction: (i) to which Romania has an agreement in force based on which the respective jurisdiction will provide the information mentioned by the Law 207/2015 under Section I; and (ii) that is identified on a list published by Romania and notified to the European Commission; c) any other jurisdiction: (i) to which the Union has an agreement into force based on which the respective jurisdiction will provide the information mentioned by Law 207/2015 under Section I; and (ii) that is identified on a list published by the European Commission
Entity – a legal person or a legal arrangement, a company, a partnership, a fiduciary contract or a foundation;
Active non-financial entity (Active NFFE) – an Active non-financial entity by reason of income and assets: less than 50% of the gross income of the entity for the previous year or another appropriate reporting period is passive income and less than 50% of the assets owned by the NFFE during the previous year or in another appropriate reporting period are active that produce or are owned for producing passive income; Publicly traded entity or entity affiliated to a publicly traded entity; start-up company (<24 months from the incorporation date); entity that is liquidating or emerging from bankrupcy; Non-profit organization, as they are defined by the Ministry of Public Finances Order no. 1939/18.08.2016;
Passive entity (Passive NFFE) – entities of which gross income originate for more than 50% from passive income (example: interests, dividends, commissions) or that have more than 50% of their own assets invested into assets that generate passive income;
Investment entity includes two types of activities:
a)an entity that primarily conducts as main business one or more of the following activities or operations for or on behalf of a customer (trading in money market instruments; foreign exchange; exchange, interest rate and index instruments; transferable securities; or commodity futures trading; individual and collective portfolio management; or that is investing, manages financial assets or money on behalf of other persons) or,
b)an entity the gross income of which is primarily deriving from investing, reinvesting or trading in financial assets where the entity is managed by another entity that is a depository institution, a custodial institution, a specified insurance company, or an investment entity as provided under letter a).
Controlling person/s – the private individuals who exercise control over an entity, the term being equivalent with the ones of „beneficial owner”, as per the legislation on prevention of money laundering/ financing of terrorism.
In case of a trust, this term mean the settlor/s, the trustee/s, the protector/s (if any), the beneficiary/ies or class/es of beneficiaries, and any other private individual exercising ultimate effective control over the trust, and in the case of legal arrangement other than the trust, this term means the persons in equivalent or similar positions;
NIF – fiscal identification number (or its functional equivlent if there is no fiscal identification number).
Note: for more details on the terms above, please read the legal provisions in force, i.e. Law 233/2015, that has ratified the Intergovernmental Agreement (IGA) signed between Romania and the USA on 28.05.2015, Law 207/2015 regarding the Fiscal Code and the Public Finances Ministry Order no. 1939/18.08.2016.
TERMS AND CONDITIONS
We inform you that Marfin Bank cannot give tax advice. If you have questions about determining the fiscal residency, please contact your tax advisor. The accounts owner is responsible of ensuring that the information provided is complete and accurate and to facilitate to the Marfin Bank any additional information or documents if and when requested.
The terms and conditions specified below complement and are part of the Framework Agreement – “General Business Conditions” agreed and signed by the Client (Account Holder) at account opening with Marfin Bank (Romania) SA (Bank). These regulate the conditions for applying the FATCA & CRS requirements at the level of the Bank.
Thus, in accordance with the Law no. 233/2015, that has ratified the Intergovernmental Agreement (IGA) signed between Romania and the USA on 28.05.2015, Law 207/2015 regulating the exchange of information regarding financial accounts, for tax purposes, between Romania and the EU Member states (as per the Directive 2011/16/EU – DAC2) and between Romania and other Jurisdictions adopting CRS (Common Reporting Standard) and the Public Finances Ministry Order no. 1939/18.08.2016:
1. Reporting obligations
1.1 The Bank is required to identify and report to the Romanian Tax Authority (and this to the US tax authority IRS/the Competent Authority of Participating Jurisdiction) the Clients resident for tax purposes in the US or in any Jurisdictions adopting CRS/DAC 2 that hold financial assets in Romania and that configure as account holders of specific accounts with the Financial Institution (e.g. current accounts, bankbooks, custody accounts, prepaid cards, repurchase agreements, derivatives, certificates of deposit);
1.2. The Bank is not required to report certain entities, already classified as US Persons or as resident for tax purposes in a Jurisdiction adopting CRS/DAC2, such as:
- listed companies;
- companies controlled by a listed company;
- banks and Financial Institutions;
- governments, governments of US territories, any political subdivision or wholly owned agency or instrumentality of any one or more of the foregoing;
1.4 The Bank is required to report the controlling persons, if resident for tax purposes in one or more Jurisdictions adopting CRS/DAC2, of so-called "Passive Entities" and "Passive Investment Entity".
1.5 In the event that the Client declares not to be a resident for tax purposes in the US or in any Jurisdictions adopting CRS/DAC 2 but any Indicia indicating the Client is a resident for tax purposes of a Reportable Jurisdiction arise from documents and information owned by the Bank, the Client is required to provide additional information and/or documents that the Bank may require to verify the declaration provided by the Client.
1.6By reporting to the Tax Authority, the Bank is required to disclose the information defined under Art. 2, paragraph 2 of the signed IGA (tax residents in US) and in the Annex 1, Section I of the Law 207/2015 (for tax residents in Jurisdictions adopting CRS/DAC2).
The Client acknowledges that he/she can exercise the right specified within the Law 677/2001 for protection of individuals regarding the processing of personal data and free movement of such data, in particular of the following rights: right to be informed, right to access data, right of intervention on the data, right of opposition, right to not be subject to an individual decision, right to go to Court.
2. Notifying the Bank regarding the changing of personal data
The Client will immediately inform the Bank in writing regarding any change in the Client’s personal data and information as well as changes regarding its organization form, object of activity, shareholders, beneficiary owners, empowered persons, directors.
3. The right to withhold or to close the account
Any sum that may be payable by us the Bank to you the Customer shall be subject to all applicable lawsAny sum that may be payable by the Bank to you the Client shall be subject to all applicable laws, including any withholding tax requirement.
The Client declares that he/she was informed, understood and accepted the fact that if refuses to provide the above mentioned declaration and/or the required information and/or documents, the Bank might be required to (i) not open the account, or close the existing accounts; and/or (ii) report the Client as a US Person or as resident for tax purposes in any Jurisdictions adopting CRS/DAC 2 if any Indicia indicating the Client is a resident for tax purposes of a Reportable Jurisdiction occur; and/or (iii) sell any US securities or financial assets, with the application of the US withholding tax where required.
DECLARATION ON OWN RESPONSIBILITY
The undersigned Client, through authorized representative, confirm that the information included in the present form are real and complete as well as assures the authenticity of any related documents provided to the Bank, authorising Marfin Bank (Romania) S.A. to undertake any verifications in respect to these data.
I undertake to communicate to the Bank any change of Tax Residence or of any other information contained in this document within 30 days (including the Tax ID, if available in the Country of Tax residence), and to provide any integrative information that may be requested.
I also declare that Marfin Bank (Romania) S.A. is exempted from any interest, penalties and any other charges that may be applied by the U.S. and/or the Romanian tax authorities and/or any foreign Competent Authorities as a consequence of untrue or incomplete information and documentation provided by the Client to the Bank, or as a consequence of the Client's failure to comply with any of the above mentioned commitments.
I also understand that the information contained in this Self-Certification and the attached integrative documentation, if any, may be shared with third parties in order to comply with FATCA and CRS/DAC 2 requirements.
Surname, first name
Signature
Date
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