FATCA & CRS Form

FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA) AND
COMMON REPORTING STANDARD (CRS) SELF CERTIFICATION FORM

Tax authorities require Primary Securities Ltd to collect and report certain information about an investor’s tax residency status.
If you are unable to complete this form please seek appropriate advice relating to the tax information required (as set out in the Automatic Exchange of Information Guidance published by the Australian Taxation office www.ato.gov.au).

FATCA/CRS Self Certification

  • FATCA/CRS Self Certification Form

    This form must be completed as part of the registration process. * Regulated super funds (self managed superannuation funds, APRA regulated super funds, government super funds or pooled superannuation trusts) are not required to complete this Form). Individual/Joint Applicants complete Sections 1 & 5. Entities complete sections 2,3,4 & 5.
  • 1. INDIVIDUALS/JOINT APPLICANTS

    Individual/Joint Applicants complete Sections 1 & 5
  • Are any of the applicants a tax resident of any other country outside of Australia?
  • Full NameDate of BirthTown of BirthCountry of BirthCurrent Residential Address (Not PO Box or C/-) 
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  • Is the individual a US citizen or resident of the US for tax purposes?
  • Jurisdiction of Tax Residence (country)Tax Identification Number (TIN) or EquivalentReason code if no TIN provided 
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    Reason A – the jurisdiction of the individual’s tax residence does not issue TINs to its residents. Reason B – the individual is otherwise unable to obtain a TIN or equivalent number. (Further information required below) Reason C – NO TIN is required (only select this reason if the domestic law of the relevant jurisdiction does not require the TIN to be disclosed)
  • Individuals and Joint Individual Applicants please continue to Section 5.
  • 2. ENTITIES

    Entities complete sections 2,3& 4
  • Is the applicant an Australian Retirement Fund (including an Australian Self Managed Superannuation) where the registered security holder is NOT a Financial Institution?
  • US applicants only – is the entity a Specified US Person for US tax purposes?
  • Jurisdiction of Tax Residence (country)Tax Identification Number (TIN) or EquivalentReason code if no TIN provided 
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    Reason A – the jurisdiction of the individual’s tax residence does not issue TINs to its residents. Reason B – the individual is otherwise unable to obtain a TIN or equivalent number. (Further information required below) Reason C – NO TIN is required (only select this reason if the domestic law of the relevant jurisdiction does not require the TIN to be disclosed)
  • Go to section 3 if the applicant is a Financial Institution or Section 4 if the applicant is not a Financial Institution
  • 3. FINANCIAL INSTITUTIONS

  • Is the applicant a Financial Institution for the purposes of FATCA?
  • (exempt beneficial owner, deemed compliant FFI, non participating FFI, or excepted Financial Institution)
  • Sponsoring Entity’s nameGlobal Intermediary Identification Number (GIIN) 
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  • Trustee’s nameGlobal Intermediary Identification Number (GIIN) 
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  • Specify the type of Financial Institution below (reporting financial institution/non reporting financial institution).
  • Are you an investment entity resident in a non participating jurisdiction for CRS purposes and managed by another Financial Institution
  • 4. CONTROLLING PERSONS

    If the applicant is: a. for FATCA purposes a Passive NFFE; or b. for CRS purposes a Passive NFE or an investment entity managed by a financial institution with a tax residence in a non CRS jurisdiction.
  • Please provide the information requested below on any of the applicant’s controlling persons if the controlling person is a tax resident of any country outside of Australia. A controlling person is:
    • any natural person that exercises control over a corporation, including directors or beneficial owners who ultimately own 25% or more of the share capital.
    • In respect of a trust, any natural person including the trustee, protector, beneficiary settlor or any other natural person exercising ultimate effective control over the trust.
    Individuals and Joint Individual Applicants please continue to Section 5.
    NameDate of BirthTown of BirthCountry of BirthResidential AddressJurisdiction of tax residence (country)Tax identification number of equivalentReason code if no TIN provided (see below) 
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  • Reason A – the jurisdiction of the individual’s tax residence does not issue TINs to its residents. Reason B – the individual is otherwise unable to obtain a TIN or equivalent number. (Further information required below) Reason C – NO TIN is required (only select this reason if the domestic law of the relevant jurisdiction does not require the TIN to be disclosed)
  • 5. Declaration and Signature

    By signing this self certification form you declare and agree: 1. that the information provided is true and correct. 2. that the information provided may be disclosed to the Australian Tax Office or any other government bodies, including bodies located overseas, to enable it to be reported and used in compliance with any FATCA or CRS regulations. 3. I/we will promptly notify Primary Securities with any changes to the information provided by me/us and provide any further information reasonably required by Primary to comply with any obligation under the FATCA or CRS regulations within 30 days of such change in circumstances.