FATCA Self Certification for an Entity
Name of Business: / Customer Number:A. Specified U.S. person
For Corporation or Partnerships
Is the entity incorporated or organized in Canada? / yes→ go to section B / no →go to next question
Is the entity a specified U.S. person? / yes / no → go to section B
If “yes” provide U.S. TIN
For Trusts
Is the trust a specified U.S. person? / yes / no → go to section B
If “yes” provide U.S. TIN
B. Financial institution
Is the entity a financial institution? / yes / no →go to section C
If “yes”, indicate its status
Financial Institution with valid GIIN / Check if waiting for GIIN
Non-Participating Financial Institution (NPFI)
Other – provide status (e.g., deemed compliant financial institution)
C. Entity type/character
1. Check any that apply to the entity:
Active trade or business – Less than 50% of the entity’s gross income is passive income and less than 50% of its assets produce passive income
Registered charity, or a club, association or arrangement in Canada operated exclusively for cultural, athletic or educational purposes
Corporation with shares that regularly trade on an established securities market. Indicate Stock Market
Government or international organization (or agency thereof)
*If one of the above four apply to the entity, set the FATCA status to Active NFFE
2. If no category applies, indicate whether the entity is:
Active Non Financial Foreign Entity (NFFE) / Passive Non Financial Foreign Entity (NFFE)
3. If the entity is a passive NFFE, does any individual directly or indirectly owns/controls 25% or more of the entity?
yes no
If “yes”, provide the name, address and U.S. TIN of each individual who directly or indirectly owns/controls 25% or more of the entity and who is a U.S. person.
Name / Address / US TIN / % Control
I declare that the information provided on this form is, to the best of my knowledge and belief, correct and complete.
Name: / Title:
Signature: / Date:
Effective Date: