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    1.FATCACRS Self-Certification - (Individual) Applicant (L&C Approved) PDF

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    Pulkesh Pulak
    This document is a FATCA/CRS self-certification form for an individual customer of Tata AIA Life Insurance Company. It collects information such as the customer's name, identification details, country of birth, tax residency status, and Tax Identification Number if the customer resides outside of India for tax purposes. The customer must declare this information and agrees to update it if any details change in the future. They also acknowledge the company's right to investigate the information and share it as required by law.

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    1.FATCACRS Self-Certification - (Individual) Applicant (L&C Approved) PDF

    Uploaded by

    Pulkesh Pulak
    679 views1 page
    This document is a FATCA/CRS self-certification form for an individual customer of Tata AIA Life Insurance Company. It collects information such as the customer's name, identification details, country of birth, tax residency status, and Tax Identification Number if the customer resides outside of India for tax purposes. The customer must declare this information and agrees to update it if any details change in the future. They also acknowledge the company's right to investigate the information and share it as required by law.

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    1.FATCACRS Self-certification - [Individual] Applicant (l&C approved).pdf

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    This document is a FATCA/CRS self-certification form for an individual customer of Tata AIA Life Insurance Company. It collects information such as the customer's name, identification details, country of birth, tax residency status, and Tax Identification Number if the customer resides outside of India for tax purposes. The customer must declare this information and agrees to update it if any details change in the future. They also acknowledge the company's right to investigate the information and share it as required by law.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    679 views1 page

    1.FATCACRS Self-Certification - (Individual) Applicant (L&C Approved) PDF

    Uploaded by

    Pulkesh Pulak
    This document is a FATCA/CRS self-certification form for an individual customer of Tata AIA Life Insurance Company. It collects information such as the customer's name, identification details, country of birth, tax residency status, and Tax Identification Number if the customer resides outside of India for tax purposes. The customer must declare this information and agrees to update it if any details change in the future. They also acknowledge the company's right to investigate the information and share it as required by law.

    Copyright:

    © All Rights Reserved
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    of 1

    U19801

    TATA AIA LIFE INSURANCE COMPANY LIMITED


    (Incorporated in India)
    FATCA / CRS Self - Certification - Individual

    Proposer’s Name: Proposal/Application Number:


    Father’s Name:
    Place of Birth: Country of Birth:
    Occupation Type: Service / Business / Professional/ Others / Not Categorized
    Identification Type: (Document submitted as proof of the identity of the Individual)
    A- Passport B- Election ID Card C- PAN Card D- ID Card E- Driving License G-UIDAI Letter H- NREGA Job card
    Z- Others X- Not Categorized
    Identification Number:
    (Number mentioned in the identification document as above. This information is mandatory if PAN or Aadhar number is not submitted)
    Residence for Tax Purposes in Jurisdiction(s) outside India: YES / NO (If “YES’ then mandatorily to fill the balance details and sign. If “NO” then sign)
    For the purposes of taxation, I am a resident in the following countries and my Tax Identification Number (TIN)/functional equivalent in each country is set out below
    or I have indicated that a TIN/functional equivalent is unavailable (kindly fill details of all countries of tax residence if more than one):

    Country/Countries of Address in the jurisdiction Tax Identification Number (TIN)/ TIN/ Functional Equivalent Validity of documentary
    Tax Residency for Tax Residence Functional Equivalent Number* Number Issuing Country evidence provided

    *Documentary evidence to be provided for TIN / Functional Equivalent


    Declaration and Undertakings
    I/We, certifies that:
    a) It shall be my / our responsibilities to educate myself / ourself and to comply at all times with all relevant laws relating to reporting under section 285BA of the Act read
    with the Rules 114F to 114H of the Income Tax Rules, 1962 thereunder and the information provided in the Form is in accordance with the aforesaid rules,
    b) The information provided by me/us in the Form, its supporting Annexures as well as in the documentary evidence are, to the best of 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 the account as a Reportable account
    or otherwise,
    c) I/We permit/authorise the Company to collect, store, communicate and process information relating to the policy / account and all transactions therein, by the
    Company and any of its affiliates wherever situated including sharing, transfer and disclosure between them or with any entity or entities, and to the authorities in
    and/or outside India of any confidential information for compliance with any law or regulation whether domestic or foreign,
    d) 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 in the Form, its supporting Annexures as well as in the documentary evidence provided by us or if any certification becomes incorrect and to
    provide fresh self-certification along with documentary evidence,
    e) I / We also agree that in case of our failure to disclose any material fact known to us, now or in future, the Company may report to any regulator and/or any authority
    designated by the Government of India (GOI) /RBI/IRDA for the purpose or take any other action as may be deemed appropriate by the Company if the deficiency is not
    remedied by us within the stipulated period.
    f ) I / We hereby accept and acknowledge that the Company shall have the right and authority to carry out investigations from the information available in public domain
    for confirming the information provided by me / us to the Company.
    g) I/We also agree to furnish such information and/or documents as the Company may require from time to time on account of any change in law either in India or abroad
    in the subject matter herein.
    h) I/We shall indemnify the Company for any loss that may arise to the Company on account of providing incorrect or incomplete information.

    Date: D D M M Y Y Y Y Signature (s)


    Place: Name:

    Instructions
    1. All the above information should be mandatorily provided.
    2. In case PAN is not available father’s name is mandatory.
    3. All the Addresses provided in Proposal and the above annexure should contain City/Town, State, Postal Code and Country
    4. Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India
    • Jurisdiction(s) of Tax Residence: Since US taxes the global income of its citizen, every US citizen of whatever nationality, is also a resident for tax purpose in USA.
    • Tax Identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if the said jurisdiction has issued a high integrity
    number with an equivalent level of identification (a “Functional equivalent”), the same may be reported. Examples of that type of number for individual include, a
    social security/insurance number, citizen/personal identification/services code/number and resident registration number)

    Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No. 110 ! CIN: U66010MH2000PLC128403).
    Registered & Corporate Office Address: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
    For more Information, contact your advisor or call on our Helpline No 1-860-266-9966 (local charges apply) or SMS “Service” to 58888 or
    e-mail us at [email protected] or visit our website www.tataaia.com • L&C/Misc/2016/Jul/328

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