Customer Information Certificate –Registered Co-operative
Definition:a legal entity owned and controlled by the people for whom it was established and who benefit from using its services. Co-operatives may be set up for a very wide range of social and economic activities, such as retailing, agriculture, manufacturing, child care, housing, marketing, arts and crafts and taxi services. Co-operatives may be registered by a relevant State, Territory or overseas body.
Please note that this certificate may have been pre-populated with information that the Bank has previously collected from the customer. In completing this form you are responsible for completing any blank sections, checking the accuracy of any pre-populated section, informing us if any of the information is not correct and supplying the correct information in substitution.Bank use
only (initials)
1 / Full name of registered co-operative
2 / Does the co-operative have a business name/trading name, other than the co-operative name,under which it carries on its business?
(Note: this includes any business name, other than the co-operative name,registered with ASIC) / Yes (insert registered business/trading name)
No
3 / Does the co-operative have an ABN? / Yes (insert ABN)
No
4 / Is the co-operative a tax resident of any country outside of Australia? / Yes
No Go to 6
5 / Country(ies) outside of Australia in which the co-operative is a resident for tax purposes and country’s associated Tax Identification Number (TIN)*
*A TIN is an identifying number or equivalent used for tax purposes. If a ‘TIN’ is not available, please specify the reason against the appropriate country.
Note: If the co-operative has more than 3 countries in which it is a tax resident, please provide the details on a separate paper. /
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
6 / Co-operative’s registered office address (not a PO box)
7 / Full address of the co-operative’s principal place of business(not a PO box) / Same as co-operative’s registered office address above
8 / Identification number issued upon registration (i.e. Registration ID no.)
9 / Date of registration / / /
10 / State/Territory or country (if not Australia) of registration
11 / Full name (given name(s) including middle name(s) and family name) of the secretary or equivalent officer
Note: An initial, nickname, alias, shortened name or part of a name isNOT acceptable. / All given names:
Family name:
12 / Full name (given name(s) including middle name(s) and family name) of the treasurer or equivalent officer
Note: An initial, nickname, alias, shortened name or part of a name isNOT acceptable. / All given names:
Family name:
13 / Beneficial Owner – Chairman or Equivalent
Details ofthe chairman/president or equivalent officer
Note: the identity of all beneficial owners must be verified. This can be completed through the provision of certified copies of identification documents or via electronic verification. Electronic verification is only available to individuals with an Australian residential address and an Australian mobile number.
Foreign Tax Residency Information:
A Tax Identification Number (TIN) is an identifying number or equivalent used for tax purposes. If a ‘TIN’ is not available, please specify the reason against the appropriate country.
Note: If the chairman/president or equivalent officer has more than 3 countries in which they are a tax resident, please provide the details on a separate paper. / All given names:
Family name:
Other name(s) known by (if any):
Date of birth: / /
Permanent residential address, including country (not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is the chairman/president or equivalent officer a tax resident of any country outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which the chairman/president or equivalent officer isa resident for tax purposes and each country’s associated TIN.
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
14 / Beneficial Owner – Controller
Does the co-operative have any other INDIVIDUALS (NATURAL PERSONS), who ultimately control, through a capacity to make financial and operating decisions on behalf of, the co-operative? / Yes Go to 15
No Go to 16
15 / Provide the details of each INDIVIDUAL (NATURAL PERSON) who is a beneficial owner
Note: the identity of all beneficial owners must be verified. This can be completed through the provision of certified copies of identification documents or via electronic verification. Electronic verification is only available to individuals with an Australian residential address and an Australian mobile number.
Foreign Tax Residency Information:
A Tax Identification Number (TIN) is an identifying number or equivalent used for tax purposes. If a ‘TIN’ is not available, please specify the reason against the appropriate country.
Note: If the beneficial owner has more than 3 countries in which they are a tax resident, please provide the details on a separate paper. / Beneficial Owner 1
All given names:
Family name:
Other name(s) known by (if any):
Date of birth: / /
Permanent residential address, including country (not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 1 a tax resident of any country outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which beneficial owner 1 isa resident for tax purposes and each country’s associated TIN.
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
Beneficial Owner 2
All given names:
Family name:
Other name(s) known by (if any):
Date of birth: / /
Permanent residential address, including country (not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 2 a tax resident of any country outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which beneficial owner 2 isa resident for tax purposes and each country’s associated TIN.
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
Beneficial Owner 3
All given names:
Family name:
Other name(s) known by (if any):
Date of birth: / /
Permanent residential address, including country (not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner3 a tax resident of any country outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which beneficial owner 3 isa resident for tax purposes and each country’s associated TIN.
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
Beneficial Owner 4
All given names:
Family name:
Other name(s) known by (if any):
Date of birth: / /
Permanent residential address, including country (not a PO Box):
Email address for electronic verification purposes:
Is beneficial owner 4 a tax resident of any country outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which beneficial owner 4 isa resident for tax purposes and each country’s associated TIN.
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
- Country of tax residence:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
16 / Full name of person providing this certificate
17 / Capacity of person providing this certificate(select appropriate box) / Chairman/President or equivalent officer
Secretary or equivalent officer
Treasurer or equivalent officer
Financial Controller
Authorised Representative (e.g. solicitor, accountant)
18 / Certification
I hereby certify that:
1.I am authorised to complete this certificate on behalf of the Customer;
2.The details included in this certificate are true and correct as at the date of this certificate;
3.All documents in the possession or control of the Customer that verify the information in this certificate have been supplied to the Bank and all documents so supplied are true and correct as at the date of this certificate; and
4.I acknowledge that the Bank will rely on this certificate to determine whether to provide services to the Customer in compliance with the law.
19 / Signature of person providing this certificate /
20 / Date / / /
Privacy Statement: The personal information the Bank is collecting from you on this form will be used to satisfy the Bank's identification requirements under the Anti-Money Laundering & Counter-Terrorism Financing Act and Rules. If you do not provide all the information requested, the Bank may not be able to provide any product or service to the Customer. The Bank will use and disclose your personal information to other members of the Westpac Group, anyone the Bank engages to do something on its behalf, and other organisations that assist the Bank with its business which may include organisations located outside of Australia and to government agencies and regulators, in some cases offshore. Details are in the Bank’s privacy policy. The Bank's privacy policy, available at westpac.com.au or by calling 132 032 (or from overseas +61 2 9293 9270), contains information about how the Bank handles your personal information, how you can access the personal information the Bank holds about you and seek its correction, how you may complain about a breach of the Australian Privacy Principles and how the Bank will deal with your complaint.
You agree that where you have provided personal information about other individuals in this form you will tell those individuals that you have supplied their information to the Bank and make them aware of the contents of this Privacy Statement and that for each Beneficial Owner whose email address has been provided to the Bank you have made them aware of, and obtained their consent to, the Bank contacting them by email for the purpose of each Beneficial Owner electing to proceed with the Bank conducting online verification of their identity to satisfy the Bank’s identification requirements.
Westpac Group means Westpac Banking Corporation and its related bodies corporate.
Note: It is an offence under the Anti-Money Laundering & Counter-Terrorism-Financing Act 2006 to knowingly provide false or misleading information or knowingly produce a false or misleading document. Penalty: Imprisonment for 10 years.
The Bank’s Reporting Obligations: We are required to identify tax residents of a country(ies) other than Australia in order to meet account information reporting requirements under local and international laws.
If at any time after account opening, information in our possession suggests that you, the entity and/or any individual who holds ownership and/or control in the entity of 25% or more (Controlling Person/Beneficial Owner) may be a tax resident of a country(ies) other than Australia, you may be contacted to provide further information on your foreign tax status and/or the foreign tax status of the entity and/or any Controlling Person/Beneficial Owner. Failure to respond may lead to certain reporting requirements applying to the account.
By completing this application you certify that if at any time there is a change to the foreign tax status details for you, the entity and/or any controlling persons/beneficial owner, you will inform the bank. You also certify that if at any time there is a change of a controlling person/s/beneficial owner/s in your entity, you will inform the bank.
A controlling person/beneficial owner refers to the individual(s) that directly or indirectly owns a legal interest in the entity of 25% or more and/or exercises actual effective control over the entity, whether from an economic or other perspective such as through voting rights. In addition, in the case of a trust, a controlling person/beneficial owner includes the settlor(s), trustee(s), appointer(s), protector(s), beneficiary(ies) or classes of beneficiaries and in the case of an entity other than a trust, the term includes persons in equivalent or similar positions.
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