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DBS Self-Certification Form for Non-US Entities
U.S. Foreign Account Tax Compliance Act (“FATCA”)
Please complete this Self-Certification Form carefully. Kindly consult your tax, legal and/or other professional advisers if you have any question
on or in relation to FATCA, any of the US IRS Forms1 (including which US IRS Form to complete and submit) or this Self-Certification Form.
Your Name
Registered address
1. Are YOU incorporated, established, constituted or organised in the
United States of America?
Yes. Please complete and submit US IRS Form W9 instead.
No. Please proceed to Question 2.
2. Which of the following statements best describes YOU?
FATCA Status
Please select only 1 of the following.
Financial Institution
You are a financial institution2, and
A
• You are a Participating FFI or Registered deemed-compliant FFI, and
• Your GIIN (Global Intermediary Identification Number) is
Participating FFI
B
• You are a Non-Participating FFI
Non-Participating FFI
C
• You are none of the above.
• Please complete and submit the appropriate US IRS Form W-8
Non-Financial Institution
You are not a financial institution2, and
D
Public Sector Entity
• You are any of the following:
Central Banks
Government Agencies
Statutory Boards
Entities owned by Statutory Boards
Public Sector entities
Foreign Embassies or Trade Representative Offices
International Organizations
Exempt Beneficial
Owners
E
Charity/ Non-profit Organisation
• You are a Charity/ Non-profit organisation established and maintained exclusively for:
Religious, charitable, scientific, artistic, cultural or educational purposes, or
Professional organisation, business league, chamber of commerce, labour organisation, agricultural
or horticultural organisation, civil league or an organisation operated exclusively for promotion of
social welfare
• The Charity/ Non-profit organisation fulfills all the following conditions:
Exempt from income tax in its jurisdiction of residence;
Has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
Its formation documents or the local law do not permit the distribution of any income or assets
to or for the benefit of a private person or non-charity entity except for payment as reasonable
compensation for services or distribution in accordance with the charity’s charitable activities; and
Its formation documents or the local law require all of the charity’s assets to be distributed to a
government entity or other non-profit organisation upon the charity’s dissolution or liquidation.
Non-Profit
Organisation
DBS Bank Ltd Co. Reg. No: 196800306E
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DBS Self-Certification Form for Non-US Entities
U.S. Foreign Account Tax Compliance Act (“FATCA”)
2. Which of the following statements best describes YOU? (CONTINUED)
Please select only 1 of the following.
FATCA Status
F
Publicly Listed Company and its Related Entity
• Your stock is regularly traded on one or more established securities markets3, or
• You are an affiliate (in other words, a member) of an entity the stock of which is regularly traded on
an established securities market
Publicly traded NFFE
or NFFE affiliate of
a publicly traded
corporation
G
Treasury / Financing Centre of Corporate Groups
• You engage in financing and hedging transactions with, or for, Related Entities that are not
Financial Institutions, and
• The group of such Related Entities is primarily engaged in a business other than that of a
Financial Institution, and
• You do not provide financing or hedging services to any entity that is not a Related Entity
Non-Profit
Organisation
H
Start-up Company
• You are just starting and is not yet in operations, and has no prior operating history
• You are investing capital into assets with the intention to operate a business other than that of
a Financial Institution
• The date of your incorporation is not more than 24 months prior to the date of this
self-certification form
Excepted
Nonfinancial
Start-Up Company
I
Active Business
• Your primary line of business is
• You derive at least 50% of your gross income (for the previous calendar year) from these business
activities and not from passive income4 such as investments, dividends, interests, rents or royalties,
and
• At least 50% of the weighted average percentage of assets held by you (tested quarterly, using
fair market value or book value of assets as reflected in your balance sheet) produce or are held to
produce income for these business activities
Active NFFE
J
Passive Investments
• You derive more than 50% of your gross income (for the previous calendar year) from passive
income4 such as investments, dividends, interests, rents or royalties, and
You do not have substantial US Owners who own at least 25% of your entity.
You have substantial US Owners who own at least 25% of your entity. Please fill up Question 3 below.
Passive NFFE
K
• You are none of the above.
• Please complete and submit the appropriate US IRS Form W-8
3. Substantial US Owners (only for Passive NFFE)
If you selected J in Question 2, please provide details of substantial US Owners who own at least 25% of your entity.
Name
DBS Bank Ltd Co. Reg. No: 196800306E
Address
US Tax ID (SSN/EIN)
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DBS Self-Certification Form for Non-US Entities
U.S. Foreign Account Tax Compliance Act (“FATCA”)
Members of the DBS Group do not, and cannot, provide any tax advice. Accordingly, any US tax matters set out in this Self-Certification Form
is not intended or written to be used, and cannot be used, in connection with the promotion, marketing or recommendation by any person
for any of the matters set out in this Self-Certification Form or for the purpose of avoiding U.S. tax-related penalties.
For the purpose of this Self-Certification Form, “DBS Group” means DBS Group Holdings Ltd and its subsidiaries, direct or indirect.
Agreement and sign-off
By signing below, you hereby:
1. undertake to promptly:
(a) notify your Relationship Manager or any DBS branch if there is any change in any of the information provided above, in any event by no
later than the date falling 30 days from the date of change; and
(b) provide to your Relationship Manager or any DBS branch such other information, documents or other evidence which may be required
in connection with such change in any of the information provided above; and
2. represent, warrant and certify to each member of DBS Group that, as at the date of this Self-Certification Form:
(a) all information provided in this Self-Certification Form is true, complete and accurate in all respects; and
(b) the persons named and signing below are duly authorised to complete and sign this Self-Certification Form for and on your behalf and
to submit this Self-Certification Form.
Name:
Name:
Date:
Date:
Signature:
Signature:
Name:
Name:
Date:
Date:
Signature:
Signature:
1
‘US IRS Forms’ refers to the US Internal Revenue Service (IRS) Forms W-9, W-8BEN-E, W-8IMY, W-8EXP and W-8ECI that are available from
the US IRS website. You are advised to always obtain your own legal and tax advice when filling up US IRS Forms.
2
‘Financial Institution’ refers to any entity that:
(a) Accepts deposits in the ordinary course of a banking or similar business; or
(b) Holds, as a substantial portion of its business, financial assets for the account of others; or
(c) Is an investment entity; or
(d) Is an insurance company (or a holding company that is a member of an expanded affiliated group that includes an insurance company),
and the insurance company (or holding company) issues, or is obligated to make payments with respect to, a cash value insurance or
annuity contract; or
(e) Is an entity that is a holding company or treasury centre.
3
An ‘established securities market’ generally refers to a Securities exchange that; (i) is officially recognized, sanctioned, or supervised by a
governmental authority of the foreign country in which the market is located; and (ii) has an annual value of shares traded on the exchange
(or a predecessor exchange) exceeding $1 billion during each of the three calendar years immediately preceding the year in which the
determination is being made.
4
‘Passive income’ refers generally to the portion of gross income that consists of: dividends (including substitute dividend payments); interest;
income equivalent to interest; rents and royalties (other than those derived in the active conduct of a trade or business conducted, at least
in part, by employees); annuities; net gains from the sale of property that gives rise to passive income; net gains from certain transaction
in commodities; net foreign currency gains; net income from notional principal contracts; amounts received under cash value insurance
contracts; and amounts received by an insurance company in connection with its reserves for insurance and annuity contracts. DBS Bank Ltd Co. Reg. No: 196800306E
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