Name: CUSTOMER DECLARATION - ENTITY

ID: DMS-201805-Branch Items-FATCA Reference Material-101178

Version: 1.2.0.0 Effective Date:02-14-2019 12:00:00

CUSTOMER DECLARATION
Entity
Date: _______________________
IDENTIFICATION INFORMATION OF ENTITY
CIF#:
Customer Name:

Identification: VAT#: Co. Reg#: BIR#:

Legal Address: Mailing Address (if different from Legal):

Date of Incorporation: Power of Attorney (if applicable):

Country of Incorporation or Organization:

Contact#: (Bus): (Fax):

Is Entity resident for tax purposes of any country other than that listed above? Yes No

If Yes, please list each country and applicable Tax Identification number, and indicate whether Entity has any
Branch(es) of Operation in the countries listed.
Tax ID Number. If unavailable,
Country Branch of Operation
please state reason A,B,C
(with explanation where necessary)

Reason A- The country/ jurisdiction where Account Holder is liable to pay tax does not issue Tax ID to its residents.
Reason B- The Account Holder is otherwise unable to obtain a Tax ID or equivalent number (Include explanation above)
Reason C- No Tax ID is required (note: only select this reason if the authorities of the country of residence for tax purposes
do not require the Tax ID to be disclosed).

CLASSIFICATION OF ENTITY
Financial Institutions (FI): Please select the appropriate classification below:
Reporting Financial Institution1 – (Please provide GIIN1) GIIN# _________________
Participating Financial Institution 1 GIIN# _________________
Sponsored Financial Institution 1 GIIN# _________________
Please provide your GIIN. If you do not have one, please Sponsor Name: ________________________
provide your Sponsor’s name and your Sponsor’s GIIN. Sponsor GIIN# ________________________

If unable to provide a GIIN, please select the reason why your organization does not have a GIIN:
 It is a FI in a Model 1 IGA country and has not yet obtained a GIIN
 It is a Non-Reporting Financial Institution under a Model 1 or Model 2 IGA1
 It is a FI that intends to apply for a GIIN but has not yet applied or has not yet received it
 It is an Exempt Beneficial Owner1
 It is a Certified Deemed Compliant Financial Institution1
 It is a Registered Non-Profit Organisation1
 It is an Owner-documented FFI1
 It is a Territory Financial Institution1
 It is a Non-Participating Foreign Financial Institution1
All Other Entities: Please select the appropriate classification below:
 Active NFE1
 Passive NFE1
 Direct Reporting NFE1 Provide GIIN# (if applicable): _____________________
 Excepted NFE1
FORM NO FCDE Rev January 2019 Page 1 of 3
Name: CUSTOMER DECLARATION - ENTITY
ID: DMS-201805-Branch Items-FATCA Reference Material-101178
Version: 1.2.0.0 Effective Date:02-14-2019 12:00:00

Qualified Intermediary1: QI# ___________________

Please provide your QI Number in addition to selecting the appropriate classification above.
1 Definitions provided on next page.

SUMMARY OF CONTROLLING PERSONS THAT ARE REPORTABLE

Note: Please use ‘Customer Declaration Entity - Additional Information’ form to include any additional reportable persons not included
below.
% Tax ID Type Date of
Full Name Ownership Country of Birth Nationality
and Number Birth

INCOME EARNINGS EXEMPTION

Declared: Yes No Is Entity considered an ‘Exempt Beneficial Owner’
under a statutory authority or tax treaty with
If Yes, does Entity derive more than 50% of its gross
respect to specified types of income?
earnings from passive income, AND, is more than 50% of
the Entity’s weighted average percentage of assets held Yes No
for the production of passive income?
Note: Passive income includes interest, dividends, rent and royalties, Supporting documents provided
annuities, and gains from the sale of passive assets

Yes No

DECLARATION
The Entity, , does hereby solemnly and sincerely declare as follows:

1. The Entity hereby certifies/confirms that the information provided above is to the best of my/our knowledge, true,
correct and complete.
2. The Entity will notify First Citizens immediately in the event of any change to either this Form or to the Entity’s tax status
and will provide First Citizens with updated information within 30 days of such change.
3. The Entity will notify First Citizens immediately in the event of any change to the Entity’s Beneficial Owner(s) and/or their
tax status and will provide First Citizens with updated information within 30 days of such change.
4. The Entity will comply with all tax and exchange control reporting requirements imposed by any applicable jurisdiction
relating to the Entity’s accounts maintained with First Citizens. Please note that you may be required, under certain
circumstances, to provide additional information/ documents confirming the Entity’s tax status before an account is opened.
5. The Entity authorizes First Citizens to provide a copy of this Form and information regarding income paid, credited or for
the benefit of any of the Entity’s accounts to: (i) the United States Internal Revenue Service and any tax authority or party
authorized on behalf of such authority; (ii) any person that has control, receipt or custody of income of which the Entity
is the owner; or (iii) any party that can disburse or make payments of income of which the Entity is the owner.

Affix Company Stamp or Seal here

Signature of Chairman/ Director: __________________________________ (If applicable, as prescribed by the
Company’s By-Laws)

Signature of Secretary: __________________________________________

CSR Signature: __________________________________________________ Date: ______________________

Authorized Signature: ____________________________________________ Date: ______________________

FORM NO FCDE Rev January 2019 Page 2 of 3

Name: CUSTOMER DECLARATION - ENTITY
ID: DMS-201805-Branch Items-FATCA Reference Material-101178
Version: 1.2.0.0 Effective Date:02-14-2019 12:00:00

Entity Classification Definitions

(a) Reporting Financial Institution: a financial institution (FI) under Model 1 or Model 2 IGA that is in effect. This also includes foreign branches of USFI
that are treated as a reporting FI under the terms of a Model 1 IGA.
(b) Participating Financial Institution: a financial institution that has agreed to enter into a foreign financial institution agreement; a reporting financial
institution under a Model 2 IGA; a foreign branch of a USFI that has a Qualified Intermediary Agreement in effect.
(c) Sponsored Financial Institution: an investment entity, financial institution (controlled by a foreign entity) or a direct reporting non-financial entity
that has another entity that will perform the due diligence, withholding and reporting obligations on its behalf.
(d) Non-Reporting Financial Institution: An entity that is established in a jurisdiction that has in effect a Model 1 or 2 IGA and that is treated as a non-
reporting FI in Annex II of the applicable Model 1 or 2 IGA or that is otherwise treated as a deemed-compliant FI or an exempt beneficial owner.
(e) Exempt Beneficial Owner: a government, a political subdivision of a foreign government, a wholly owned agency or instrumentality of any one or
more of same; an international organization or a wholly owned agency or instrumentality thereof; a central bank of issue; a g overnment of a U.S.
Territory; a treaty-qualified retirement fund; a broad participation retirement fund; a narrow participation retirement fund; an investment vehicle
used exclusively for retirement funds; a pension fund of an exempt beneficial owner; an entity wholly owned by an exempt beneficial owner.
(f) Certified Deemed Compliant Financial Institution: an entity not required to register with the IRS as it has certified its deemed compliant status by
providing the relevant documentation to a withholding agent.
(g) Owner Documented FFI (Owner Documented Foreign Financial Institution): an investment entity that is not owned by or affiliated with an entity
that is a depository or custodial institution or a specified insurance company and does not maintain the financial accounts of any non-participating
financial institution and has or will provide all the information on its owners to a withholding agent.
(h) Territory Financial Institution: A US territory incorporated financial institution (other than an investment entity).
(i) Non-Participating Foreign Financial Institution: A financial institution that has not agreed to comply with the due diligence requirements of FATCA
and has not registered with the IRS to obtain a GIIN.
(j) Active NFE (Active Non-Financial Entity): A non-financial entity that derives less than 50% of its gross income from passive income (i.e. dividends,
interest, annuities, etc.).
(k) Passive NFE (Passive Non-Financial Entity): A non-financial entity that derives 50% or more of its gross income from passive income (i.e. dividends,
interest, annuities, etc.)
(l) Direct Reporting NFE (Direct Reporting Non-Financial Entity): a non-financial entity that has elected to report its US owners directly to the IRD
and was assigned a GIIN.
(m) Excepted NFE (Excepted Non-Financial Entity): any one of the following entities:
 A publicly traded entity  A related entity of a publicly traded entity
 An International Organisation  A Governmental Entity or Central Bank
 A holding company that is a part of a non-financial group  An active business
 A financial company of a non-financial group  A liquidating company
 A charity or non-profit organisation  A start-up company

(n) Qualified Intermediary: A person described in Treas. Reg. §1.1441-1(e)(5)(ii) that has entered into a qualified intermediary agreement with the
IRS.

If the country in which your organization is resident has signed an Intergovernmental Agreement (‘IGA’) with the United States or any other foreign
government, please refer to the equivalent definitions in the relevant IGA.

FORM NO FCDE Rev January 2019 Page 3 of 3