Please complete the following table indicating:

i. where the Controlling Person is a tax resident;

ii. The Controlling Person’s TIN for each country indicated.

(iii) If the Controlling Person is a tax resident in a country that is a Reportable jurisdiction(s) then please also complete Part 3 “Type of Controlling Person”.

If the Controlling Person is tax resident in more than three countries please use a separate sheet. If a TIN is unavailable please provide the appropriate reason A, B or C:

Reason A
The country where the controlling person is liable to pay tax does not issue TINs to its residents

Reason B
The controlling person is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)

Reason C
No TIN is required. (Note. Only select this reason if the authorities of the country of tax residence entered below do not require the TIN to be disclosed)

I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder’s relationship with NBF setting out how NBF may use and share the information supplied by me.

I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable Account(s) may be provided to the tax authorities of the country in which this account(s) is/ are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident pursuant to intergovernmental agreements to exchange financial account information.

I certify that I am the Controlling Person or am authorized to sign for the Controlling Person of all the account(s) held by the entity Account Holder to which this form relates and where I am not the Controlling Person.

I certify that where I have provided information regarding any other person (such as a Controlling Person or other Reportable Person to which this form relates) that I will, within 30 days of signing this form, notify those persons that I have provided such information to NBF and that such information may be provided to the tax authorities of the country in which the account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the person may be tax resident pursuant to intergovernmental agreements to exchange financial account information.

I undertake to advise NBF within 30 days of any change in circumstances which affects the tax residency status of the individual identified in Part 1 of this form or causes the information contained herein to become incorrect, and to provide NBF with a suitably updated self-certification and Declaration within 90 days of such change in circumstances.

I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.