SELF-CERTIFICATION FORM
- INDIVIDUALS – /
Branch /Agency ______CUSTOMER CODE ______
A. CUSTOMER IDENTIFICATION DATA FOR FATCA AND CRS PURPOSES
Name and surname / Resident
Non-resident
Address: / Birth date and place (town and country):
Correspondence address: / Telephone no.:
For the purpose of this form the following terms mean:
Self-certification – has the meaning of statement on own responsibility;
USA – United States of America;
US Person – US Citizen (including when holding one or more citizenships) or resident in USA for tax purposes;
FATCA – (US FOREIGN ACCOUNT TAX COMPLIANCE ACT) The Law regarding the tax compliance applicable to foreign accounts.
CRS – “Common Reporting Standard” – represents the standard issued by OECD for the automatic exchange of information on the financial accounts of the customers private individuals and legal entities with the fiscal residency in one of the countries adhering to this standard.
Participating jurisdiction (CRS State) - a) any member state except Romania; b) any other jurisdiction: (i) to which Romania has an agreement in force based on which the respective jurisdiction will provide the information mentioned by the Law 207/2015 under Section I; and (ii) that is identified on a list published by Romania and notified to the European Commission; c) any other jurisdiction: (i) to which the Union has an agreement into force based on which the respective jurisdiction will provide the information mentioned by Law 207/2015 under Section I; and (ii) that is identified on a list published by the European Commission
NIF – fiscal identification number (or its functional equivlent if there is no fiscal identification number).
Note: for more details on the terms above, please read the legal provisions in force, i.e. Law 233/2015, that has ratified the Intergovernmental Agreement (IGA) signed between Romania and the USA on 28.05.2015, Law 207/2015 regarding the Fiscal Code and the Public Finances Ministry Order no. 1939/18.08.2016.
Birth place in USA / Yes / If you are a US person, please provide W-9 form and sign the statement
included in the present form
If you are not a US person, please provide W- 8BEN form and justification documents issued by a competent authority regarding the non-US citizenship (e.g.: Passport, national identity card) AND a written explanation regarding the reasons for which you do not hold US citizenship anymore OR the reasons for which the account holder did not receive the US citizenship at birth.
No
USA Citizenship / Yes / If you are a US person, please provide W-9 form and sign the statement included in the present form
I held US citizenship until
...... / If you are not a US person, please provide W- 8BEN form and justification documents issued by a competent authority regarding the non-US citizenship (e.g.: Passport, national identity card) necessary to clarify the US indicia and to establish the account holder status as non-US foreign person AND a written explanation regarding the reasons for which you do not hold the US citizenship anymore.
No
Information on the domicile, residency, fiscal residency, mailing address or PO Box etc.)
Country of fiscal residency 1: / NIF related to country of fiscal residency 1:
Country of fiscal residency 2: / NIF related to country of fiscal residency 2:
I hereby declare that I do not have a Tax Residence in other Countries apart from those ones declared above.
Country of residence (foreign currency residence):
Country of domicile:
Country of mailing address:
Country of other address:
PO Box: / Country:
In case any of the countries specified above is US please choose one of the following options:
If you are a US person, please provide W-9 form and sign the statement included in the
present form
If you are not a US person, please provide W- 8BEN form and the residency certificate or justification documents issued by a competent authority regarding the non-US citizenship (e.g.: Passport, national identity card) necessary to clarify the US indicia and to establish the account holder status as non-US foreign person.
In case the residency country differs from the domicile country, please provide the fiscal residency certificate from the declared fiscal residency country.
If you are resident in participanting jurisdiction and you cannot provide the NIF, please specify:
The country where I am fiscally resident is not issuing NIF/TIN.
The account owner cannot obtain NIF/TIN – please provide the reason.
Phone number / In case you hold telephone numbers from USA please provide them together with the information below: / N/A
If you are a US person, please provide W-9 form and sign the statement included in the
present form
If you are not a US person, please provide W- 8BEN form or its substitute and the residency certificate or justification documents issued by a competent authority regarding the non-US citizenship (e.g.: Passport, national identity card) necessary to clarify the US indicia and to establish the account holder status as non-US foreign person.
Country Code_____ / Phone no.
Country Code_____ / Phone no.
In case you hold telephone numbers from other states, except USA and Romania, please provide them together with the information below: / N/A
Country Code_____ / Phone no.
Country Code_____ / Phone no.
Do you have a US Green Card? / Yes, number: _____ / No / N/A
Did you give power of attorney or signature rights to a person with address in USA or from a CRS state? / Yes, address in USA. / If you are a US person, please provide W-9 form and sign the statement included in the present form
If you are not a US person, please provide W- 8BEN form or its substitute and the residency certificate or justification documents issued by a competent authority regarding the non-US citizenship (e.g.: Passport, national identity card) necessary to clarify the US indicia and to establish the account holder status as non-US foreign person.
Yes, address in a CRS state. / CRS State:
No
TERMS AND CONDITIONS
We inform you that Marfin Bank cannot give tax advice. If you have questions about determining the fiscal residency, please contact your tax advisor. The accounts owner is responsible of ensuring that the information provided is complete and accurate and to facilitate to the Marfin Bank any additional information or documents if and when requested.
The terms and conditions specified below complement and are part of the Framework Agreement – “General Business Conditions” agreed and signed by the Client (Account Holder) at account opening with Marfin Bank (Romania) SA (Bank). These regulate the conditions for applying the FATCA & CRS requirements at the level of the Bank.
Thus, in accordance with the Law no. 233/2015, that has ratified the Intergovernmental Agreement (IGA) signed between Romania and the USA on 28.05.2015 as well as in accordance with the Law 207/2015 regulating the exchange of information regarding financial accounts, for tax purposes, between Romania and the EU Member states (as per the Directive 2011/16/EU – DAC2) and between Romania and other Jurisdictions adopting CRS (Common Reporting Standard):
1. Reporting obligations
1.1 The Bank is required to identify and report to the Romanian Tax Authority (and this to the US tax authority IRS/the Competent Authority of Participating Jurisdiction) the Clients resident for tax purposes in the US or in any Jurisdictions adopting CRS/DAC 2 that hold financial assets in Romania and that configure as account holders of specific accounts with the Financial Institution (e.g. current accounts, bankbooks, custody accounts, prepaid cards, repurchase agreements, derivatives, certificates of deposit);
1.2 The Client is required to provide her/his Country of tax residence and all the other information included in this Self-Certification;
1.3 In the event that the Client declares not to be a resident for tax purposes in the US or in any Jurisdictions adopting CRS/DAC 2 but any Indicia indicating the Client is a resident for tax purposes of a Reportable Jurisdiction arise from documents and information owned by the Bank, the Client is required to provide additional information and/or documents that the Bank may require to verify the declaration provided by the Client.
1.4 By reporting to the Tax Authority, the Bank is required to disclose the information defined under Art. 2, paragraph 2 of the signed IGA (tax residents in US) and in the Annex 1, Section I of the Law 207/2015 (for tax residents in Jurisdictions adopting CRS/DAC2).
The Client acknowledges that he/she can exercise the right specified within the Law 677/2001 for protection of individuals regarding the processing of personal data and free movement of such data, in particular of the following rights: right to be informed, right to access data, right of intervention on the data, right of opposition, right to not be subject to an individual decision, right to go to Court.
2. Notifying the Bank regarding the changing of personal data
The Client will immediately inform the Bank in writing regarding any change in the Client’s personal data and information, changing of the citizenship, residency, tax residency, address (residency, domicile, tax, correspondence etc.), phone and/or facsimile numbers, e-mail addresses.
3. The right to withhold or to close the account
Any sum that may be payable by us the Bank to you the Customer shall be subject to all applicable laws Any sum that may be payable by the Bank to you the Client shall be subject to all applicable laws, including any withholding tax requirement.
The Client declares that he/she was informed, understood and accepted the fact that if refuses to provide the above mentioned declaration and/or the required information and/or documents, the Bank might be required to (i) not open the account, or close the existing accounts; and/or (ii) report the Client as a US Person or as resident for tax purposes in any Jurisdictions adopting CRS/DAC 2 if any Indicia indicating the Client is a resident for tax purposes of a Reportable Jurisdiction occur; and/or (iii) sell any US securities or financial assets, with the application of the US withholding tax where required.
DECLARATION ON OWN RESPONSIBILITY
The undersigned Client, through authorized representative, confirm that the information included in the present form are real and complete as well as assures the authenticity of any related documents provided to the Bank, authorising Marfin Bank (Romania) S.A. to undertake any verifications in respect to these data.
I undertake to communicate to the Bank any change of Tax Residence or of any other information contained in this document within 30 days (including the Tax ID, if available in the Country of Tax residence), and to provide any integrative information that may be requested.
I also declare that Marfin Bank (Romania) S.A. is exempted from any interest, penalties and any other charges that may be applied by the U.S. and/or the Romanian tax authorities and/or any foreign Competent Authorities as a consequence of untrue or incomplete information and documentation provided by the Client to the Bank, or as a consequence of the Client's failure to comply with any of the above mentioned commitments.
I also understand that the information contained in this Self-Certification and the attached integrative documentation, if any, may be shared with third parties in order to comply with FATCA and CRS/DAC 2 requirements.
Surname, first name
Signature
Date

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