Client Information Record Jan2023

CLIENT INFORMATION RECORD (Individual)
All information requested in this form is required to be provided in full for client acceptance.
The information declared must be true and correct.
Documents to verify information will be requested.
SECTION A : PERSONAL PARTICULARS
Full Name 姓名
ID card or Passport No.

身份証或護照號碼
Nationality 國藉
Date of Birth 出生日期
Residential Address 住址
Contact No. 聯絡電話
Email address 電郵地址
SECTION B : OCCUPATION / BUSINESS DETAILS
Occupation 職業 Director 董事/ Owner 股東 / position 職位 : __________________________________
Industry 行業
Company Name 公司名稱
Company Address 公司地址
Yes 是 / No 否
PEP* 政治人物 (Client/ family
Grantor / family member / associate 委託人 / 家人 / 朋友
member/ associate) 自己/家人/朋友
Formerly/ Currently 過去 / 現任
SECTION C : SOURCE OF WEALTH
Salary/ company dividend from work 薪金/ 公司利潤
Sources of wealth Income from Investment 投資收入

財富來源 Accumlative Saving 累積的儲蓄
Others : ___________________________
Current Year 今年 :
Total Annual Income
總收入 Last Year 去年 :
SECTION D : Self-Certification for Tax Residency - FATCA

YE S 是/ No 否 (We do not accept US citizenship, residency or nationality in US
United States of America (US)
我們不接受美國公民,住民或國藉)
Remarks 註 : * PEP - Politically Exposed Person means you are ccurrently or was formerly entrusted with a prominent public function
in any country.
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Unit 2738, Level 27, Wing On Centre, 111 Connaught Road Central , Hong Kong
Tel: 3622 1583 Whatsapp: 9142 5449 We chat: PacificFiduciary email:[email protected]
CLIENT INFORMATION RECORD (Individual)
SECTION D : Self-Certification for Tax Residency - CRS

Please complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where the grantor is a
resident for tax purposes and (b) the Grantor’s TIN for each jurisdiction indicated. Indicate all (not restricted to 3) jurisdictions of
residence.
請提供以下資料，列明 (a) 委託人的居留司法管轄區，亦即委託的程務管轄區 (香港包括在內) 及 (b)
該居留司法管轄區發給委託人的稅務編號。列出的有 (不限於 3個) 居留司法管轄區。
Explain why the Grantor

is unable to obtain a TIN
Taxpayer Identification
Jurisdiction of Residence Enter Reason A, B or C if n TIN is available if Reason B is selected.
Number
居留司法管轄區如沒有提供稅務編號，請填寫理由 A, B or C 如選擇理由B,
稅務編號
請解釋為何未能獲得稅
務編號
If TIN is unavailable, provide the appropriate reason A, B or C

如沒有提供稅務編號，必需填寫合適理由 :
Reason A : The jurisdiction where the Grantor is a resident for tax purposes does not issue TINs to its residents
理由A : 委託人的居留司法管轄區，並沒有向其居民發出稅務編號
Reason B : The Grantor is unable to obtain a TIN. Explain why the Grantor is unable to obtain a TIN if the Grantor has
selected this reason
理由 B 委托人不能取得稅務編號。如選取這一理由，解釋委託人不能取得稅務編號的原因
Reason C : TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not
require the TIN to be disclosed.
理由 C : 無需提供稅務編號。居留司法管轄區的主管機關不需要委託人披露稅務編號
Declarations and Signature
I/We acknowledge and agree that (a) the information contained in this form is collected and may be kept by Pacific Fiduciary for
the purpose of automatic exchange of financial account information, and (b) such information and information regarding me/us
and any reportable account(s) may be reported by Pacific Fiduciary to the Inland Revenue Department of the Government of the
Hong Kong Special Administrative Region and exchanged with the ta authorities of another jurisdiction or jurisdictions in which
I/we may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided
under the Inland Revenue Ordinance (Cap.112). 本人知識及同意，柏域信誠可根據<稅務條例>
（第112章），有關交換財務帳戶資料的法律條文（a) 收集本表格所在資料並可儲存作自動交流財務轉賬資料用途及 (b)
把本人資料及任何需申報帳戶的資料向香港特別行政區政府稅務局申報從而把資料轉交到本人的居留司法管轄區的財務
當局
I/We undertake to advise Pacific Fiduciary of any change in circumstances which affects the tax residency status of the individual
identified in Section A of this form or causes the information contained herein to become incorrect, and to provide Pacific
Fiduciary with a suitably updated self-certification form within 30 days of such change in circumstances.
本人承諾於情況有所改變以致影響本表格第一部份所述的個人稅務居民身份或引致此申請表所在的資料不正確本人會通
知柏域信誠並會在情況發生改變後30日內向柏域信誠提交一份以適當更改的自我表格證明
I/We declare that the information given and statements made in this form are, to the best of my knowledge, and belief, true,
correct and complete. 本人聲明就本人所知所信本表格內所填報的所有資料和姓名均屬真實正確及完備。
Signature of Grantor
委託人簽署
Name of Grantor
委託人姓名
Date 日期
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Personal Financial Details 財務狀況
Income Monthly Income (USD) Financial Outgoings Monthly Outgoings (USD)
收入每月收入 (美元) 財政開支每月支出 ( 美元)
Income (include salary bonus
and commission, investment
Family expenses
income, dividend from shares
… etc)
收入 (包括家庭支出
Rental Income Mortgage repayment/ Rent
租金收入按揭供款/ 租金
Other income Other expense
其他收入其他支出
Monthly total income Monthly total outgoings
每月總入每月總支出
Liquied ASSET USD Liabilities USD

流動資產美元債務美元
Cash and deposit in bank Debts/ Loan
現金/ 銀行存款欠債/貸款額
Other liquid asset (e.g. Stocks/

Securities/ bonds … etc ) Mortgage Loan
其他流動資金物業按揭貸款
(如股票/證/券債券單位信託
… 等)
Total Liquid Assets Total Liabilities
流動總資產總債務
Fixed Assets (e.g. Real Estates) USD

固定資產 (如房地產) 美元
Customer Declaration客户声明：
I understand this information is for financial needs analysis. I confirm that any answers and statements given are complete, true
and correct to the best of my knowledge.
我了解此信息用于财务需求分析。我确认，就我所知，给出的任何答案和陈述都是完整，真实和正确的。
_____________________________________________
Grantor Signature 委託人簽署
____________________________________________
Proposed Grantor Name 委託人姓名
_____________________________________________
Date 日期
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Client Information Record Jan2023

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CLIENT INFORMATION RECORD (Individual)

SECTION A : PERSONAL PARTICULARS

ID card or Passport No.

Date of Birth 出生日期

Contact No. 聯絡電話

Email address 電郵地址

SECTION B : OCCUPATION / BUSINESS DETAILS

Occupation 職業 Director 董事/ Owner 股東 / position 職位 : __________________________________

Company Name 公司名稱

Company Address 公司地址

Sources of wealth Income from Investment 投資收入

SECTION D : Self-Certification for Tax Residency - FATCA

SECTION D : Self-Certification for Tax Residency - CRS

Explain why the Grantor

If TIN is unavailable, provide the appropriate reason A, B or C

Liquied ASSET USD Liabilities USD

Other liquid asset (e.g. Stocks/

Fixed Assets (e.g. Real Estates) USD

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