MCG15365_(0517) Please turn over to complete your application Existing account number Title Surname Given names Date of birth DD / MM / YYYY Gender M F Mother’s maiden name Nationality Current Residential Address Permanent Temporary Unit no. Street no. Street Suburb/Town State Postcode Country Postal Address (if different from above) Unit no. Street no. Street Suburb/Town State Postcode Country Do you or an immediate family member hold a Public Office Position? No Yes (Please specify position e.g. Politician/Diplomat) By signing this form you confirm that you have, or you will, inform any member of your family referred to above of the information about him or her provided by you to Citibank in this application form. 3. YOUR PERSONAL DETAILS - APPLICANT 1 1. APPLICATION TYPE 2. ACCOUNT TYPE (please select the product(s) you wish to apply for) Existing account number Title Surname Given names Date of birth DD / MM / YYYY Gender M F Mother’s maiden name Nationality Current Residential Address Permanent Temporary Unit no. Street no. Street Suburb/Town State Postcode Country Postal Address (if different from above) Unit no. Street no. Street Suburb/Town State Postcode Country Do you or an immediate family member hold a Public Office Position? No Yes (Please specify position e.g. Politician/Diplomat) By signing this form you confirm that you have, or you will, inform any member of your family referred to above of the information about him or her provided by you to Citibank in this application form. 7. YOUR PERSONAL DETAILS - APPLICANT 2 Home ( ) Work ( ) Fax ( ) Mobile Email 4. CONTACT DETAILS Home ( ) Work ( ) Fax ( ) Mobile Email 8. CONTACT DETAILS Not Employed Student Retired Self-Employed Employed Occupation Employer 5. EMPLOYMENT INFORMATION Not Employed Student Retired Self-Employed Employed Occupation Employer 9. EMPLOYMENT INFORMATION TFN collection is authorised under taxation law. It is not an offence if you do not quote your TFN or claim an exemption, but if you do not Citibank will deduct Withholding Tax at the top marginal rate. If claiming exemption please indicate below: I receive an Age, Service, Veterans or Disability Support Pension I receive a Supporting Parent, Widows, Wife’s, Carer’s Pension or Rehabilitation Allowance If you are a Non-Resident of Australia for taxation purposes, provide country details below: If you are a resident of Australia and would like to quote your TFN please provide below: — — 6. TAX FILE NUMBER (TFN) / EXEMPTION NOTIFICATION TFN collection is authorised under taxation law. It is not an offence if you do not quote your TFN or claim an exemption, but if you do not Citibank will deduct Withholding Tax at the top marginal rate. If claiming exemption please indicate below: I receive an Age, Service, Veterans or Disability Support Pension I receive a Supporting Parent, Widows, Wife’s, Carer’s Pension or Rehabilitation Allowance If you are a Non-Resident of Australia for taxation purposes, provide country details below: If you are a resident of Australia and would like to quote your TFN please provide below: — — 10. TAX FILE NUMBER (TFN) / EXEMPTION NOTIFICATION Page 1 of 4 Citibank Application Form Transaction and Savings Account (Personal) Citigroup Pty Limited ABN 88 004 325 080 AFSL No. 238098 Australian credit licence 238098 Citibank Ultimate Saver Citibank Plus Cash Investment Account Online Cash Management Account Money Market at Call Account Citibank Term Deposit Cash Management Account Citi Online Saver Account Individual Joint
Transcript
MCG15365_(0517)Please turn over to complete your application
Existing account number
Title Surname
Given names
Date of birth DD / MM / YYYY
Gender M F
Mother’s maiden name
Nationality
Current Residential Address Permanent Temporary
Unit no. Street no. Street
Suburb/Town State Postcode
Country
Postal Address (if different from above)
Unit no. Street no. Street
Suburb/Town State Postcode
Country
Do you or an immediate family member hold a Public Office Position?
No Yes (Please specify position e.g. Politician/Diplomat)
By signing this form you confirm that you have, or you will, inform any member of your family referred to above of the information about him or her provided by you to Citibank in this application form.
3. YOUR PERSONAL DETAILS - APPLICANT 1
1. APPLICATION TYPE 2. ACCOUNT TYPE (please select the product(s) you wish to apply for)
Existing account number
Title Surname
Given names
Date of birth DD / MM / YYYY
Gender M
F
Mother’s maiden name
Nationality
Current Residential Address Permanent Temporary
Unit no. Street no. Street
Suburb/Town State Postcode
Country
Postal Address (if different from above)
Unit no. Street no. Street
Suburb/Town State Postcode
Country
Do you or an immediate family member hold a Public Office Position?
No Yes (Please specify position e.g. Politician/Diplomat)
By signing this form you confirm that you have, or you will, inform any member of your family referred to above of the information about him or her provided by you to Citibank in this application form.
7. YOUR PERSONAL DETAILS - APPLICANT 2
Home ( ) Work ( )
Fax ( ) Mobile
Email
4. CONTACT DETAILS
Home ( ) Work ( )
Fax ( ) Mobile
Email
8. CONTACT DETAILS
Not Employed Student Retired Self-Employed Employed
Occupation
Employer
5. EMPLOYMENT INFORMATION
Not Employed Student Retired Self-Employed Employed
Occupation
Employer
9. EMPLOYMENT INFORMATION
TFN collection is authorised under taxation law. It is not an offence if you do not quote your TFN or claim an exemption, but if you do not Citibank will deduct Withholding Tax at the top marginal rate.
If claiming exemption please indicate below:
I receive an Age, Service, Veterans or Disability Support Pension
I receive a Supporting Parent, Widows, Wife’s, Carer’s Pension or Rehabilitation Allowance
If you are a Non-Resident of Australia for taxation purposes, provide country details below:
If you are a resident of Australia and would like to quote your TFN please provide below:
— —
6. TAX FILE NUMBER (TFN) / EXEMPTION NOTIFICATION
TFN collection is authorised under taxation law. It is not an offence if you do not quote your TFN or claim an exemption, but if you do not Citibank will deduct Withholding Tax at the top marginal rate.
If claiming exemption please indicate below:
I receive an Age, Service, Veterans or Disability Support Pension
I receive a Supporting Parent, Widows, Wife’s, Carer’s Pension or Rehabilitation Allowance
If you are a Non-Resident of Australia for taxation purposes, provide country details below:
If you are a resident of Australia and would like to quote your TFN please provide below:
— —
10. TAX FILE NUMBER (TFN) / EXEMPTION NOTIFICATION
Page 1 of 4
Citibank Application FormTransaction and Savings Account (Personal) Citigroup Pty Limited
ABN 88 004 325 080AFSL No. 238098
Australian credit licence 238098
Citibank Ultimate Saver Citibank Plus
Cash Investment Account
Online Cash Management Account
Money Market at Call Account
Citibank Term Deposit
Cash Management Account
Citi Online Saver Account
Individual
Joint
11. U.S. TAXATION DECLARATION FOR U.S. PERSONS ONLY (U.S. Person defined below, if you are not a U.S. Person please proceed to section 12)
Page 2 of 4
Under the penalties of perjury I certify the following:
I am a US Person (Applicant 1) I am a US Person (Applicant 2)
1. The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person
Certification Instructions. You must cross out above item 2 if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to
report all interest dividends on your tax return.
Applicant 1 Taxpayer Identification Number/ US Social Security Number Applicant 2 Taxpayer Identification Number/ US Social Security Number
Definitions of a U.S. Person. For federal tax purposes, you are considered a U.S. Person if you are: An individual who is a U.S. Citizen or U.S. resident alien, a partnership, corporation, company, or association created or organised in the United States or under the laws of the United States, an estate (other than foreign estate) or, a domestic trust.
12. CITIBANK PLUS CUSTOMERS ONLY
How many Citibank Plus Linked Savings Accounts would you like? 0 1 2 3 (maximum)
Please complete this section if you would like each Account holder and each Additional Signatory to operate the Account (per the Authority to Operate) by written/telephone/facsimile instructions. The written/telephone/facsimile instruction authority provided below will apply to all future accounts opened unless otherwise requested.
Account title
Option 1 The Account holder authorises Citibank to act on written, telephone and facsimile instructions to transfer funds between all accounts held by the Account holder with Citibank provided they are in the same name and can be operated by the same signatories.
Option 2 The Account holder authorises Citibank to act on written or facsimile instructions to transfer funds to third parties nominated below (including by bank cheques, bank drafts and telegraphic transfers).
Account number (if applicable) Bank/Branch/BSB (account name if applicable) Nominated third parties (account name if applicable)
Please note: IF YOU DO NOT SELECT OPTION TWO ABOVE, PLEASE DRAW A DIAGONAL LINE THROUGH THE OPTION TWO TABLE TO DELETE THIS OPTION.
Option 3 The Account holder authorises Citibank to act on written or facsimile instructions to transfer funds to third parties generally (including by bank cheques, bank drafts and telegraphic transfers).
Citibank may require a tape recorded telephone call to be conducted to verify and confirm the request before the transaction can proceed.
15. SOURCE OF FUNDS
$ $
$
$
$
$
$
Initial Currency Initial Currency
Initial Currency
Initial Currency
Initial Currency
Initial Currency
Initial Currency
Source Source
Source
Source
Source
Source
Source
Citibank Ultimate Saver Account
Citibank Plus Account
Online Cash Management Account
Cash Management Account
Money Market At Call Account
Citibank Term Deposit Account
Cash Investment Account
If you have selected deposit or cheque book options, you will need to complete section 21 to ensure any written instructions can be actioned.
13. CHEQUE & DEPOSIT BOOK OPTIONS (Please indicate which options you would like)
Cash Investment Account Deposit book Yes No Cheque book Yes No
Citibank Ultimate Saver Deposit book Yes No
Online Cash Manager Account Deposit book Yes No
Citibank Plus Account Deposit book Yes No Cheque book Yes No
Cash Management Account Deposit book Yes No Cheque book Yes No
14. CITIBANK TERM DEPOSIT - OPTIONS
A. Please specify the term of your Citibank Term Deposit:
Term (maximum 60 months) Years Months or Special Maturity
dd /
mm /
yyyy
B. Please nominate one Notice and Interest payment period:
With 31 day notice to vary, withdraw or close Monthly (MITD)2 Maturity (MMTD) Annually (ANNY)2 Rate1 . %
or
Without 31 day notice to vary, withdraw or close Maturity (MATY) Quarterly (QITD)2 Rate1 . %
C. Please specify maturity instructions:
Reinvest my/our interest payment; or
Credit my/our interest payment(s) to Citibank at Call Account Number
1 The interest rate quoted above is only available if date of completion is the same as date of account opening. 2 Only available for terms one year and greater.
Page 3 of 4
17. PRIVACY CONSENTS AND NOTIFICATIONS
By applying for this product, you consent as follows:
In this section, ‘we/us’ means Citigroup Pty Limited (“Citi”) and our related companies that assist us to provide our services, and ‘you/your’ means all customers named in this application and other individuals (such as guarantors, directors or shareholders) connected with those customers.
Purposes for which we collect, use and disclose your personal information
1) We collect, use and disclose your personal information:
• to assess this application and future applications;
• to provide and manage your products, accounts and services and to manage your relationship and arrangements with us;
• to comply with applicable laws both in Australia and overseas (for more details about relevant Australian laws please see our Privacy Policy); and
• for other purposes as listed in our Privacy Policy.
If you do not provide us with the information we may not be able to assess your application or provide or manage the products or services that you are (or if you are not the applicant, that the applicant is) seeking.
2) We usually collect your personal information directly from you. However, we may need to collect personal information about you from third parties, for example, where we need information from a third party to assist us to process your application (such as to verify information you have provided or to assess your circumstances) or to locate or communicate with you.
3) Where you have provided information about another individual, you must make them aware of that fact and the contents of this Privacy Consent and Notification, and have obtained their consent to make this disclosure to us.
Disclosures of your personal information
4) We may disclose to, and obtain personal information about you from:
• Our affiliates and sales agents and organisations that carry out functions on our behalf including card schemes, mailing houses,data processors, researchers and collection agents;
• reward providers including Airline partners and their service providers;
• any signatory to the product for which you are applying;
• any broker, financial, legal or other adviser acting in connection with your product or application;
• regulatory and tax authorities in Australia and overseas;
• any insurer relating to your product;
• organisations wishing to acquire an interest in any part of our business; and
• as further set out in our Privacy Policy.
Disclosures to overseas recipients
5) Some of the recipients to whom we disclose your personal information may be based overseas. It is not practicable to list every country in which such recipients are located but it is likely that such countries will include the United States of America, India, the Philippines, Malaysia, Hong Kong and Singapore. By consenting to us disclosing your personal information to overseas recipients, you agree that Australian Privacy Principle 8.1 shall not apply to the disclosure, meaning that Citi will not be obliged under the Privacy Act to ensure that an overseas recipient does not breach the Australian Privacy Principles and we will not be liable under the Privacy Act if the recipient does not act consistently with the Australian Privacy Principles. By completing this application you consent to such overseas disclosures.
Our Privacy Policy (including how to access and correct information and make a complaint)
6) You can view our Privacy Policy on our website citibank.com.au/privacy or obtain a copy by calling us. This policy includes information as to how you can access and/or seek correction of the personal information we hold about you. Our Privacy Policy also contains information as to how you can complain about a breach by us of the Privacy Act and how we will deal with such a complaint.
Your marketing communications preferences
7) By completing this application you agree that we, our affiliate companies and their partners may use your personal information to keep you informed about offers relating to this product and other products, services and offers which may be of interest to you. They may do this by phone, mail, email and SMS or other electronic messages. These consents operate indefinitely and shall remain in effect unless and until you notify us that you do not want to receive such communications. If you do not wish to receive these communications please notify us in writing or by calling us.
Note: If you have not told us that you do not wish to receive these communications by phone, you may be contacted even if you have registered your phone number on the national Do Not Call Register. Your telephone calls and conversations with a Citi representative may be recorded and monitored for quality, training and verification purposes.
18. CONDITIONS FOR WRITTEN/TELEPHONE/FACSIMILE INSTRUCTIONS
1. In these conditions: (a) “Authority” means the Written/Telephone/Facsimile Instructions
Authority provided on page 2 of this form together with these conditions (as amended by
the account holder from time to time); and (b) “Account” means the account/s described
on page 2 of this form. 2. The account holder has requested Citibank to accept certain
instructions by writing, telephone and facsimile in relation to the account as requested in
the Authority. The account holder understands that: (a) these methods of communication
involve greater risks (including, without limitation, the risk of fraud) than more commonly
accepted forms of communication; (b) Citibank will accept instructions received in
accordance with the Authority from each account holder and any persons authorised
to operate the account by way of an Authority To Operate. The account holder, fully
aware of the associated risks, requests and authorises Citibank to act upon facsimile and
telephone instructions given in accordance with this Authority. 3. The account holder shall
provide Citibank with: (a) a properly completed original Authority; (b) any other document
Citibank may request evidencing that this Authority has been properly authorised; and (c)
written notice upon termination of this Authority. 4. The account holder may, from time
to time, vary this Authority by delivering to Citibank an original signed variation in such
form as is acceptable to Citibank. Citibank is authorised to rely on each such variation.
Unless otherwise agreed in writing at that time, any such variation shall be effective no
earlier than the third Business Day after receipt by Citibank, and shall not affect Citibank’s
actions or omissions prior to such effective date. 5. The account holder agrees: (a) to
strictly limit information about the contents of this Authority to only those persons who
need to know in order to effectively operate the Account; (b) to use its best efforts to
ensure that such persons at all times treat the contents of this Authority with strict
confidentiality in order to maintain the security of the procedures hereby established;
(c) to immediately notify Citibank of any suspected breach or compromise of the security
of the procedures hereby established. 6. The account holder agrees that as long as
Citibank acts in accordance with this Authority: (a) Citibank shall have no further duty
to verify the content of any facsimile or telephone instructions or the identity of the
sender or confirmer of it; and (b) the account holder will be bound by any debit or credit
instruction, whether or not authorised by it, which is sent in its name and accepted by
Citibank. 7. Citibank shall have absolute discretion, for any reason whatsoever, to act or
not to act upon and/or to request verifications of any facsimile or telephone instructions
received in relation to the Account. Citibank shall attempt to notify the account
holder promptly should Citibank elect to defer acting in accordance with instructions.
8. The account holder will upon demand indemnify Citibank, its officers and employees,
its related bodies corporate and their officers and employees, for and hold them free and
harmless from and against: (a) any and all responsibility for, and any and all costs, claims,
losses or liabilities of any nature (direct or indirect) resulting from any act or omission
taken or not taken (as the case may be) in accordance with this Authority, including,
without limitation, any act or omission (or any delay) in response to instructions to Citibank
to transfer funds or purchase, sell or otherwise dispose of commodities or securities; and
(b) any and all costs and expenses associated with the terms described in 8 (a), including
Citibank’s legal fees and expenses EXCEPT THAT the account holder will have no liability in
respect of any such claims arising from Citibank’s bad faith or wilful misconduct, or where
Citibank has failed to act in accordance with this Authority. This paragraph 8 shall survive
the termination of this Authority or any part of it. 9. If any provisions of this Authority
is declared to be invalid or unenforceable, the remaining provisions shall nevertheless
remain in full force and effect.
19. ELECTRONIC STATEMENTS AND NOTICES
Electronic Statements and Notices - In this section, ‘you/your’ means the persons or persons
applying for the account (1) In this application to open a new account, you have been asked to
agree to Citibank providing you with statements, other notices and other information relating
to your account either: (a) by email; and/or (b) by making the statement, notice or information
available at Citibank’s website, provided: (i) Citibank alerts you by email to the availability of
this information; and (ii) Citibank provides you with the ability to readily retrieve and retain
this information. (2) If you agree to receive statements and other notices and information
relating to your account by email or other electronic form you will not receive a paper copy
of statements, notices or information relating to your account, unless you specifically request
it. If you do not agree to receive statements and other notices and information relating to
your account by email or other electronic form, Citibank reserves the right to reject your
application to open an account. (3) You may cancel your authorisation to receive statements,
notices or other information relating to your account by email at any time, or by contacting
Citiphone Banking. However if you do so, Citibank reserves the right to close your account.
(4) Citibank will send all statements and other notices and information to the most recent
email address that you have supplied to us. You must ensure that you notify Citibank of any
change in your email as soon as possible. You may do this online at www.citibank.com.au or
by contacting Citiphone Banking. (5) You can print and save a copy of any notice or other
document provided to you electronically. You are responsible for ensuring that you maintain
the appropriate software and hardware, including printer, to access, view, retrieve, print and
save a copy of such documents if you wish. To see and keep the information subject to this
agreement, you will need a web browser that meets Citibank’s site security requirements.
Refer to Citibank’s site for details. (6) You may request a paper copy of any statement, notice
or other information relating to your Facility or account provided to you by email or other
electronic form within 6 months from the date of receipt of a statement or of the electronic
communication. Citibank may charge you a reasonable fee for the cost of the paper copy.
Page 4 of 4
Branch ID. Agent ID.
GL Account Number for Source of Funds (if applicable) Serial or Deal No. (if applicable)
Applicant 1 GRBS Customer Occupation Code (obtain from CDD form) Citigold Customer Yes No
GEID (if applicable) Customer Relationship Number 1
Applicant 2 GRBS Customer Occupation Code (obtain from CDD form) Citigold Customer Yes No
GEID (if applicable) Customer Relationship Number 2
dd /
mm /
yyyy
dd /
mm /
yyyy
Application Maker (signature and stamp) Date Application Checker (signature and stamp) Date
BRANCH/OFFICE USE ONLY - MANDATORY RCAO Code
BRANCH/OFFICE USE ONLY - BUSINESS MATRIX - MANDATORY
Please select the relevant channel and account type
City at Work Application D2DQB7A1 A4EQA1A1 F4EQC1A1 B4EQA2A1
NRI Application A4RQA1A1
IPB Application A43QC1A1 F4CQC1A1
20. AUTHORISATION
In this section, ‘I‘, ‘my/our’ and ‘me/us’ means the person or persons applying for the account. I certify the particulars on this form to be true.
In the case of a Citibank Term Deposit, I/we acknowledge that I/we have been provided with a copy of the 31 day notice period fact sheet (where applicable) and the terms and
conditions for the product and agree to be bound by them.
For other product types, in the event that my/our application is approved, I/we acknowledge that I/we will be sent the terms and conditions for the product(s) for which I/
we have applied at or before the time the approval is communicated and I/we agree to be bound by those terms and conditions. I/We also understand that Citibank may close
my/our account if it’s not funded within 90 days of being opened. Citibank informed me that should I/we wish to view or be provided with the product terms and conditions prior
to this time, that depending upon my/our preference, Citibank would:
(a) Enable me/us to view the terms and conditions in paper or electronically in branch;
(b) Provide to me/us a paper copy of the terms and conditions, either in branch or by post or email them to me/us.
In the event that I/we do not currently have a Citibank Debit Card, if one is to be issued to me/us, I/we acknowledge that I/we will also be provided with the Non-Cash Payment
Facilities Terms & Conditions and I/we agree to be bound by those terms and conditions.
I have also read and agree to the above Privacy Preferences, Conditions for Written/Telephone/Facsimile Instructions Authority and the Electronic Statements and Notices
Terms and Conditions as they appear in sections 17, 18 and 19.
dd /
mm /
yyyy
dd
/ mm
/ yyyy
Individual Applicant 1 Signature Date Individual Applicant 2 Signature Date
First
Identity Verification Request
ApplicationReferenceNumber:
Title FamilyName
Name (noinitials)
Dateofbirth D D /M M / Y Y Y Y ContactNumber
Current Residential Address (PO Box is NOT accepted)
2. AlladdressesMUSTberesidential(notPOBox)andMUSTmatchtheaddressascompletedabove.3. All identification documents MUST be current and originals (photocopies or internet printouts are not acceptable forms of
Australia Post – Instructions1. ScanbarcodeintoEPOSandenterthe16digitApplicationReferenceNumber2. Verifytheapplicant’sidentityagainsttheacceptableidentificationdocumentsandrecorddetailsinIDWizard3. Attheendoftheverificationprocess,returnthisletterandthereceipttotheapplicant
Disclaimer and Privacy NoticeAustraliaPostisactingasanagentforCitibankandcollectsyourinformationtoidentifyyouinaccordancewithrequirementsunderAustralianlaw.YourdetailswillbeforwardedtoCitibankandmayalsobedisclosedtogovernmentagenciessuchasAUSTRAC.SubjecttocertainexceptionsyoumayrequestfromAustraliaPostaccesstoyourpersonalinformationthatitholds.Ifaccessisdenied,thelawsaysAustraliaPostmusttellyouwhy.
Page 1 of 1 MCG10645(09/13)
First
Identity Verification Request
ApplicationReferenceNumber:
Title FamilyName
Name (noinitials)
Dateofbirth D D /M M / Y Y Y Y ContactNumber
Current Residential Address (PO Box is NOT accepted)
2. AlladdressesMUSTberesidential(notPOBox)andMUSTmatchtheaddressascompletedabove.3. All identification documents MUST be current and originals (photocopies or internet printouts are not acceptable forms of
Australia Post – Instructions1. ScanbarcodeintoEPOSandenterthe16digitApplicationReferenceNumber2. Verifytheapplicant’sidentityagainsttheacceptableidentificationdocumentsandrecorddetailsinIDWizard3. Attheendoftheverificationprocess,returnthisletterandthereceipttotheapplicant
Disclaimer and Privacy NoticeAustraliaPostisactingasanagentforCitibankandcollectsyourinformationtoidentifyyouinaccordancewithrequirementsunderAustralianlaw.YourdetailswillbeforwardedtoCitibankandmayalsobedisclosedtogovernmentagenciessuchasAUSTRAC.SubjecttocertainexceptionsyoumayrequestfromAustraliaPostaccesstoyourpersonalinformationthatitholds.Ifaccessisdenied,thelawsaysAustraliaPostmusttellyouwhy.
Page 1 of 1 MCG10645(09/13)
The informa!on in this form is being collected as part of Ci!bank’s account opening procedures and to assist in complying with
Foreign Account Tax Compliance Act (FATCA) requirements. Each customer must complete a declara!on.
Sec on 1: Customer Details
Version 1.4 (07/14)
Ci!group Pty Limited ABN 88 004 325 080, AFSL No. 238098, Australian credit licence 238098
Page 1 of 1
Full Given Name(s) Surname
Date of Birth (dd/mm/yyyy)
/ /
Account Number / Applica!on Reference Number (if applicable)
1. In how many countries do you hold ci zenship / na onality?
List these below
Country 2
Country 3
Country 4
Country 5
2. In how many countries are you a tax resident?
Country 1
Country 2
Country 3
Country 4
Country 5
3. Country of Birth 4. Town / City of Birth
5. Do you have a current United States Green Card ? YES NO
Sec on 2: Declara on and Acknowledgement
I declare the above informa on to be true and complete.
Customer Signature
Date (dd/mm/yyyy)
/ /
When you have completed this declara on, mail to:
Sec on 3: Declara on Return
1 2 3 4 5 1 2 3 4 5
Country 1
List these below
Ci group Pty Ltd
Reply Paid 3483
Sydney, NSW 2001
Faxed or scanned copies cannot be accepted
6. Are you a United States ci zen or resident? YES NO
The informa!on in this form is being collected as part of Ci!bank’s account opening procedures and to assist in complying with
Foreign Account Tax Compliance Act (FATCA) requirements. Each customer must complete a declara!on.
Sec on 1: Customer Details
Version 1.4 (07/14)
Ci!group Pty Limited ABN 88 004 325 080, AFSL No. 238098, Australian credit licence 238098
Page 1 of 1
Full Given Name(s) Surname
Date of Birth (dd/mm/yyyy)
/ /
Account Number / Applica!on Reference Number (if applicable)
1. In how many countries do you hold ci zenship / na onality?
List these below
Country 2
Country 3
Country 4
Country 5
2. In how many countries are you a tax resident?
Country 1
Country 2
Country 3
Country 4
Country 5
3. Country of Birth 4. Town / City of Birth
5. Do you have a current United States Green Card ? YES NO
Sec on 2: Declara on and Acknowledgement
I declare the above informa on to be true and complete.
Customer Signature
Date (dd/mm/yyyy)
/ /
When you have completed this declara on, mail to:
Sec on 3: Declara on Return
1 2 3 4 5 1 2 3 4 5
Country 1
List these below
Ci group Pty Ltd
Reply Paid 3483
Sydney, NSW 2001
Faxed or scanned copies cannot be accepted
6. Are you a United States ci zen or resident? YES NO
1389908 20425 12/15 page 1 of 5
CRS Self-certification Form for Individuals
Please read these instructions carefully before completing the form.
Citi offices located in countries that have adopted the Common Reporting Standard (CRS) are required to collect and report certain information about an account holder’s tax residence status. Please note that Citi may be legally required to report certain
information provided in this form and other financial information with respect to your financial accounts to the tax authorities of
the country where your account is maintained. In turn, the local tax authorities may exchange the reported information with the
tax authorities in the country or countries in which you are a tax resident. Please complete this form only if the account holder
is an individual (including a sole proprietor or a decedent).
Definitions of an account holder and other terms are included in the Appendix.
Items that are marked with an asterisk (*) are required to be completed.
For joint or multiple account holders, use a separate form for each individual.
Please note that this self-certification form is for CRS purposes only. Its completion is not a substitute for the completion of any IRS Form W-9, Form W-8 or FATCA Self-certification that may otherwise be required for U.S. tax purposes.
If you are completing this form on behalf of someone else, please indicate the capacity (custodian, nominee, executor, under power of attorney, etc.) in which you are signing in Part 3. A parent or legal guardian should complete the form on behalf of an account holder who is a minor.
Do not use this form for an entity account holder. Trusts (but not sole proprietors or decedents) are considered entities for this purpose. Instead use the CRS Self-certification Form for Entities.
This Form will remain valid unless there is a change in circumstances that makes this Form incorrect or incomplete. In that case, you must notify Citi within 30 days of any such change and provide us with an updated CRS self-certification.
As a financial institution, Citi does not provide tax advice to its customers. If you have any questions about whether you are a tax resident in any particular country, please contact your tax advisor or visit the OECD AEOI portal for country-by-country information on tax residence at www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/.
Instructions
1389908 20425 12/15 page 2 of 5
CRS Self-certification Form for Individuals
Part 1 — Identification of Individual Account Holder
A. Name of Account Holder:
Family Name or Surname(s):* _____________________________________________________________________________________
Postal Code/ZIP code: ____________________________________________________________________________________________
D. Date of Birth*
Date of birth* (YYYY-MM-DD): _____________________________________________________________________________________
E. Place of Birth1
Town or City of Birth: ____________________________________________________________________________________________
Country of Birth: ________________________________________________________________________________________________
(Please complete Parts 1-3 in BLOCK CAPITALS)
1Complete section E (Place of birth) if required under the domestic law of the country where the account(s) is/are maintained.
1389908 20425 12/15 page 3 of 5
CRS Self-certification Form for Individuals
Please complete the following table indicating the Account Holder’s tax residence country or countries (i.e., where you are treated as a resident of the country for purposes of its income tax) and the Account Holder’s TIN (if any) for each country indicated. If the Account Holder 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 as indicated below:
Reason A – The country where the Account Holder is subject to income tax as a resident does not issue TINs.
Reason B – The Account Holder 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 because the tax residence jurisdiction that issued the TIN does not require a Financial Institution to collect and report the TIN.
Country of tax residence TIN
If no TIN available, enter
Reason A, B or C
1
2
3
Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.
1
2
3
Part 2 — Country of Tax Residence and Related
Taxpayer Identification Number (TIN) or Equivalent
1389908 20425 12/15 page 4 of 5
CRS Self-certification Form for Individuals
Part 3 — Declarations and Signature*
1. I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.
2 I acknowledge that the information provided on this Form regarding the Account Holder, as well as financial information (e.g., account balance or value, the amount of income or gross proceeds received) respecting the Financial Account(s) to which the Form is applied may be reported to the tax authorities of the country in which this/these account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be a tax resident pursuant to a legal agreement between the competent authorities of these countries on the automatic exchange of information on Financial Accounts under the Common Reporting Standard (CRS).
3. I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form relates.
4. If there is a change in circumstances that affects the tax residence status of the Account Holder or causes the information contained herein to become incorrect or incomplete, I understand that I am obligated to inform Citi of the change in circumstances within 30 days of its occurrence and to provide a suitably updated CRS self-certification.
Note: If you are not the Account Holder but are signing this form on behalf of the Account Holder, please indicate the capacity in which you are signing the form (e.g., power of attorney, executor or administrator, parent or guardian) and provide any required documentation of your authority.
Capacity: (* if applicable) _____________________________________________________________________________________________
1389908 20425 12/15 page 5 of 5
CRS Self-certification Form for Individuals
Note: The following selected definitions are provided to assist you with the completion of this form. If you have any questions about these definitions or require further detail, please contact your tax adviser.
“Account Holder” — The person listed or identified as the holder of a Financial Account. A person holding a Financial Account for the benefit of another person as an agent, a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated as the Account Holder. For example in the case of a parent/child relationship where the parent is acting as a legal guardian, the child is regarded as the Account Holder. With respect to a jointly held account, each joint holder is treated as an Account Holder. In the case of an estate, the decedent should be identified as the Account Holder.
“Controlling Person” — A natural person who exercise control over an entity. This definition corresponds to the term “beneficial owner” of an entity, as described in Recommendation 10 (and the Interpretative Note) of the Financial Action Task Force Recommendations (as adopted in February 2012). Where an entity Account Holder is treated as a Passive Non-Financial Entity (“NFE”), a Financial Institution must determine whether such Controlling Persons are Reportable Jurisdiction Persons. If you are a Controlling Person of a Passive NFE, you should complete a CRS self-certification for Controlling Persons instead of this Form.
”Entity” — A legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or foundation.
“Financial Account” — An account maintained by a Financial Institution and includes: Depository Accounts; Custodial Accounts; an equity or debt interest in certain Investment Entities; Cash Value Insurance Contracts; and Annuity Contracts.
“Participating Jurisdiction” — A jurisdiction (i) with which an agreement is in place pursuant to which it will provide the information set out in the Common Reporting Standard and required for the automatic exchange of financial account information, and (ii) which is identified in a published list.
“Reportable Jurisdiction” — A jurisdiction (i) with which an agreement is in place pursuant to which there is an obligation to provide financial account information set forth in the Common Reporting Standard, and (ii) which is identified in a published list.
“Reportable Jurisdiction Person” — An individual who is tax resident in a Reportable Jurisdiction under the laws of that jurisdiction.
“TIN” — The Taxpayer Identification Number or a functional equivalent in the absence of a TIN. A TIN is a unique combination of letters or numbers assigned by a jurisdiction to an individual or an Entity and used to identify the individual or Entity for the purposes of administering the tax laws of such jurisdiction.
Some jurisdictions do not issue a TIN. However, these jurisdictions often utilise some other high integrity number with an equivalent level of identification (a “functional equivalent”). Examples of that type of number include, for individuals, a social security/insurance number, citizen/personal identification/service code/number and resident registration number.
Appendix of Defined Terms
1389908 20425 12/15 page 1 of 5
CRS Self-certification Form for Individuals
Please read these instructions carefully before completing the form.
Citi offices located in countries that have adopted the Common Reporting Standard (CRS) are required to collect and report certain information about an account holder’s tax residence status. Please note that Citi may be legally required to report certain
information provided in this form and other financial information with respect to your financial accounts to the tax authorities of
the country where your account is maintained. In turn, the local tax authorities may exchange the reported information with the
tax authorities in the country or countries in which you are a tax resident. Please complete this form only if the account holder
is an individual (including a sole proprietor or a decedent).
Definitions of an account holder and other terms are included in the Appendix.
Items that are marked with an asterisk (*) are required to be completed.
For joint or multiple account holders, use a separate form for each individual.
Please note that this self-certification form is for CRS purposes only. Its completion is not a substitute for the completion of any IRS Form W-9, Form W-8 or FATCA Self-certification that may otherwise be required for U.S. tax purposes.
If you are completing this form on behalf of someone else, please indicate the capacity (custodian, nominee, executor, under power of attorney, etc.) in which you are signing in Part 3. A parent or legal guardian should complete the form on behalf of an account holder who is a minor.
Do not use this form for an entity account holder. Trusts (but not sole proprietors or decedents) are considered entities for this purpose. Instead use the CRS Self-certification Form for Entities.
This Form will remain valid unless there is a change in circumstances that makes this Form incorrect or incomplete. In that case, you must notify Citi within 30 days of any such change and provide us with an updated CRS self-certification.
As a financial institution, Citi does not provide tax advice to its customers. If you have any questions about whether you are a tax resident in any particular country, please contact your tax advisor or visit the OECD AEOI portal for country-by-country information on tax residence at www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/.
Instructions
1389908 20425 12/15 page 2 of 5
CRS Self-certification Form for Individuals
Part 1 — Identification of Individual Account Holder
A. Name of Account Holder:
Family Name or Surname(s):* _____________________________________________________________________________________
Postal Code/ZIP code: ____________________________________________________________________________________________
D. Date of Birth*
Date of birth* (YYYY-MM-DD): _____________________________________________________________________________________
E. Place of Birth1
Town or City of Birth: ____________________________________________________________________________________________
Country of Birth: ________________________________________________________________________________________________
(Please complete Parts 1-3 in BLOCK CAPITALS)
1Complete section E (Place of birth) if required under the domestic law of the country where the account(s) is/are maintained.
1389908 20425 12/15 page 3 of 5
CRS Self-certification Form for Individuals
Please complete the following table indicating the Account Holder’s tax residence country or countries (i.e., where you are treated as a resident of the country for purposes of its income tax) and the Account Holder’s TIN (if any) for each country indicated. If the Account Holder 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 as indicated below:
Reason A – The country where the Account Holder is subject to income tax as a resident does not issue TINs.
Reason B – The Account Holder 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 because the tax residence jurisdiction that issued the TIN does not require a Financial Institution to collect and report the TIN.
Country of tax residence TIN
If no TIN available, enter
Reason A, B or C
1
2
3
Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above.
1
2
3
Part 2 — Country of Tax Residence and Related
Taxpayer Identification Number (TIN) or Equivalent
1389908 20425 12/15 page 4 of 5
CRS Self-certification Form for Individuals
Part 3 — Declarations and Signature*
1. I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete.
2 I acknowledge that the information provided on this Form regarding the Account Holder, as well as financial information (e.g., account balance or value, the amount of income or gross proceeds received) respecting the Financial Account(s) to which the Form is applied may be reported to the tax authorities of the country in which this/these account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be a tax resident pursuant to a legal agreement between the competent authorities of these countries on the automatic exchange of information on Financial Accounts under the Common Reporting Standard (CRS).
3. I certify that I am the Account Holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form relates.
4. If there is a change in circumstances that affects the tax residence status of the Account Holder or causes the information contained herein to become incorrect or incomplete, I understand that I am obligated to inform Citi of the change in circumstances within 30 days of its occurrence and to provide a suitably updated CRS self-certification.
Note: If you are not the Account Holder but are signing this form on behalf of the Account Holder, please indicate the capacity in which you are signing the form (e.g., power of attorney, executor or administrator, parent or guardian) and provide any required documentation of your authority.
Capacity: (* if applicable) _____________________________________________________________________________________________
1389908 20425 12/15 page 5 of 5
CRS Self-certification Form for Individuals
Note: The following selected definitions are provided to assist you with the completion of this form. If you have any questions about these definitions or require further detail, please contact your tax adviser.
“Account Holder” — The person listed or identified as the holder of a Financial Account. A person holding a Financial Account for the benefit of another person as an agent, a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated as the Account Holder. For example in the case of a parent/child relationship where the parent is acting as a legal guardian, the child is regarded as the Account Holder. With respect to a jointly held account, each joint holder is treated as an Account Holder. In the case of an estate, the decedent should be identified as the Account Holder.
“Controlling Person” — A natural person who exercise control over an entity. This definition corresponds to the term “beneficial owner” of an entity, as described in Recommendation 10 (and the Interpretative Note) of the Financial Action Task Force Recommendations (as adopted in February 2012). Where an entity Account Holder is treated as a Passive Non-Financial Entity (“NFE”), a Financial Institution must determine whether such Controlling Persons are Reportable Jurisdiction Persons. If you are a Controlling Person of a Passive NFE, you should complete a CRS self-certification for Controlling Persons instead of this Form.
”Entity” — A legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or foundation.
“Financial Account” — An account maintained by a Financial Institution and includes: Depository Accounts; Custodial Accounts; an equity or debt interest in certain Investment Entities; Cash Value Insurance Contracts; and Annuity Contracts.
“Participating Jurisdiction” — A jurisdiction (i) with which an agreement is in place pursuant to which it will provide the information set out in the Common Reporting Standard and required for the automatic exchange of financial account information, and (ii) which is identified in a published list.
“Reportable Jurisdiction” — A jurisdiction (i) with which an agreement is in place pursuant to which there is an obligation to provide financial account information set forth in the Common Reporting Standard, and (ii) which is identified in a published list.
“Reportable Jurisdiction Person” — An individual who is tax resident in a Reportable Jurisdiction under the laws of that jurisdiction.
“TIN” — The Taxpayer Identification Number or a functional equivalent in the absence of a TIN. A TIN is a unique combination of letters or numbers assigned by a jurisdiction to an individual or an Entity and used to identify the individual or Entity for the purposes of administering the tax laws of such jurisdiction.
Some jurisdictions do not issue a TIN. However, these jurisdictions often utilise some other high integrity number with an equivalent level of identification (a “functional equivalent”). Examples of that type of number include, for individuals, a social security/insurance number, citizen/personal identification/service code/number and resident registration number.
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