know your customer (kyc) application form (for non ... · partnership/trust and...

1. Name of Applicant (Please write complete name as per Certificate of Incorporation / Registration) :

______________________________________________________________________________________________________________

2. Constitution : Pvt. Ltd. Company Ltd. Company Partnership Ltd. Liability Partnership (LLP)

Trust & Foundation Incorporated Association or Body of Individuals Sole Proprietorship

Hindu Undivided Family (HUF) Society Liquidator Artificial Jurisdicial Person Others____________

3. PAN No.:

4. Place of Incorporation : __________________________ 5. Date of Incorporation : _________________

6. Country of Incorporation*:_____________________ 7. Registration No.:________________________________

8. Date of Commencement of Business : _________________

9. Country of Residence as per tax laws*: _______________________________________

10. TIN : ____________________________ TIN Issue Country*: ______________________

Know Your Customer (KYC) Application Form (For Non-Individuals Only)(Please fill in ENGLISH and in BLOCK LETTERS with black ink)

CIF No. A/c. No. KYC No.(If available)

D D M M Y Y Y Y

D D M M Y Y Y Y

11. Registered Address : Address Type : Business Residence Registered Office Unspecified Others ________

12. Correspondence / Mailing Address : Same as Registered Address

Address Type : Business Residence Registered Office Unspecified Others ___________

13. Address where entity is Residence outside India for tax purpose :

Same as Registered Address Same as Correspondence Address

Address Type : Business Residence Registered Office Unspecified Others ___________

Flat No :________________________________ Building Name : _____________________________________________

Street : _________________________________ Locality : ___________________________________________________

City :_____________________ Pincode :_____________State*:___________________ Country*: ___________________

Landline No. (Office): ______________________ Mobile No. : ___________________ Fax : _______________________

Landline No. (Res.): _______________________ Email ID : _________________________________________________

STD/ISD Country code No



Street : _________________________________ Locality : ___________________________________________________







Street : _________________________________ Locality : ___________________________________________________




(*Please refer to the enclosed annexure for state code & country code)



Sr. No.

Directors / Partners / Trustee /Member / Co-parceners etc.

1

2

3

4

5

6

AuthorisedSignatories

Yes / No

Residentialstatus

(Resident /Non Resident)

If Non-Resident

Country of Non- Resident

DIN/D-PIN (As per

MCAwebsite)

PEP orRelated to

1PEP (Yes/ No)

Particulars % of holding

16. Beneficial Owner Details: ¤(Private Ltd Company/Limited Company/Partnership/Limited Liability Partnership /

Trust and Foundation/Incorporated association or a body of individuals/Hindu Undivided Family/Others ____________)

I. Whether listed in a recognised stock exchange? Yes No

a) If listed in a recognised stock exchange, please provide the below information:

i. Name of the stock exchange: _________________ ii. Date of Listing : DD/MM/YYYY

iii. Ownership Structure/Pattern :

14. List of Directors / Trustee / Member / Co-parceners / Partners etc. :

15. Number of controlling person(s) resident outside India for tax purpose :

II. Out of the above I (b) :

a) If Owner(s) is/are listed in recognised Stock Exchange, please provide the below information:

i. Name of the stock exchange : ii. Date of Listing : DD/MM/YYYY

iii. Ownership Structure/Pattern :

b) If Owner(s) is/are not listed in recognised Stock Exchange, please provide the below information:

b) If not listed in a recognised stock exchange, please provide the below information : i. Ownership Structure/Pattern :

Particulars % of holding

Details of Shareholding / Capital / Profit / Interest :

¤ For the purpose of classifying Beneficial Owner: i. Controlling ownership interest" means ownership of or entitlement of more than 25% of Shares or capital or profits of the company. ii. Ownership of/entitlement for more than 15% of capital or profits or property or interest in the Partnership/Limited Liability Partnership/Trust and Foundation/Unincorporated association or a body of individuals/Hindu Undivided Family/Others ______________________

DECLARATION

I/we hereby confirm that the above-named person(s) hold or is entitled to more than 25% / 15% of shares capital or profits or property or interest in M/s.

I/we hereby agree, confirm and undertake to provide the KYC documents of the aforesaid Beneficial Owners(s) as thper Reserve Bank of India guidelines RBI/2012-13/385 (DBOD. AML.BC.NO. 21/14.01.001/2012-13) dated January 18 , 2013

Company Secretary† Authorised Signatory/Director†† Authorised Signatory/Director††

(To be signed by the Authorized Signatory of the Company whose account is being opened)(† In case of Company Secretary not available, obtain two directors signatures)(††In case of LLP / Partnership / Association of Persons / Body of Individuals / Trust/HUF to be signed by the Authorized Signatory)

Date Place

DDMMYYYY

17. Business : Agriculture Manufacture Trade Finance Bank Transport Service

Government Retail Wholesale Others

Nature of Business Details :

IEC Code, if applicable

18. Annual Turnover (In INR) : Upto 1 Crore 1-5 Crores 5-25 Crores 20-50 Crores

50-100 Crores Above 100 Crores

19. Additional Information :

(i) Business Size (ii) No. of Branches iii) No. of Employees

(iv) Physical Business (v) Main Geographies of Business :

(vi) Expected Account Activity in INR / Month

a) Cash b) Non Cash c) Wire Transfer

Financial Information :

a) Total Assets b) Total Liabilities c) Annual Sales

d) Net Profit

20. Existing Banking Relations :

I/we do not enjoy any credit facility with any other bank I/we enjoy credit facility with the following banks

Bank NameSr. No. Bank Address Type of Facility Amount

21. FATCA Details :

I. Please indicate the nature of your entity :

(a) US Entity : A Company Corporation, Association, Partnership, or Trust ("US Tax Obligor)

created/organised in the United States or under the laws of the United States of America.

(b) Non Us Entity (Indian or Foreign Entity) : A Company Corporation, Association, Partnership, or Trust

created organised outside the borders of the United States of America.

II. If you have selected I (a)-US Entity, please submit the W9 Form and Provide the Employer Identification

Number (EIN)

III. If you have selected I (b) - Non US Entity, then please further specify your FATCA status under the option of

(a) or (b) below:

(a) FI (Financial Institution) - Please choose the entity's applicable status:

Non Participating FI Participating FI India or Partner Jurisdiction FI

Registered Deemed Complain FI

Entity Wholly Owned by Exempt Beneficial Owners Certified Deemed Compliant FI

If the entity has a global Intermediary Identification Number ("GIIN") please indicate it here

If the entity does not have a GIIN, please submit a W8-Ben-E, if applicable

(b) NFFE (Non-Financial Foreign Entity) - Please choose the entity's applicable status :

Active NFFE Passive NFFE : with no US Controlling Person / Substantial US Owners (please submit the W8 BEN-E)

Passive NFFE : with US Controlling Person / Substantial US Owners (please submit the W 8 BEN-E

with US owners details)

IV. U.S Taxpayer Identification Number (SSN or ITIN ) : _________________________________________________

22. CRS Details :

Are you liable to pay taxes outside India ? Yes No

Entity Type :

1. Please indicate the type of your entity:

a. Financial Institution (Depository institution, custodial institution, specified insurance company and investment entity

in a CRS participating jurisdiction)

b. Financial Institution that is a professionally managed investment entity located in CRS non-participating jurisdiction.

c. Non-financial entity. Please further specify your entity status :

i. Active NFE - a corporation the stock of which is regulatory traded on an established securities market or a

corporation which is related entity of such a corporation.

ii. Active NFE - a government entity or central bank.

iii. Active NFE - an international organisation.

iv. Active NFE - Other than (i), (ii) and (iii)

v. Passive NFE

2. If you have selected 1(a) please complete Declarations section.

3. If you have selected 1(b) please complete Self certification for controlling person(s) section and Declaration section.

4. If you have selected 1(c) (i) or 1(c) (ii) or 1(c) (iii), please complete Declarations section.

5. If you have selected 1(c) (iv), please complete Tax Residency section and Declaration section.

6. If you have selected 1(c) (v), please complete Self certification for controlling person(s) section, Tax Residency section

and Declaration section.

Reason A - The country where the Account Holder / Controlling Person is tax resident does not issue TINs to its residents.

Reason B - the Account Holder / Controlling Person is otherwise unable to obtain a TIN or equivalent number (Please explain why the Account Holder / Controlling Person is unable to obtain a TIN in the table below if you have selected this reason).

Reason C - No TIN is required. (Note. Only select this reason if the authorities of the country of tax residence entered above do not allow the TIN to be disclosed to third parties).

Reason D - the Account Holder / Controlling Person has got no tax residence, therefore TIN is not applicable. In this case, please write "NONE" in the "Country of Tax Residency" Column.

If you indicated 'Reason B', please explain in the following boxes why the Account Holder is unable to obtain a TIN.

Reasons :

Country of Tax Residency Taxpayer Identification Number (TIN) TIN Issue CountryReasons for not providing TIN

(enter reason A, B, C or D)

1

2

3

Tax Residency :

Please list all jurisdictions in which you are treated as tax resident and provide the tax identification number for each one. If you are tax resident in more than three countries, please use a separate sheet.

(First Name) (Middle Name) (Surname)





23. Self certification for controlling person(s) :

(a) Details of controlling person (Individual) :

CIF No. (if available) : _____________________________ KYC No. (If available) : ___________________________________

Type of Control :

In case of Legal Person : Ownership Senior Managing Official Other means ______________________________

In case of Trust : Settler Trustee Protector Beneficiary Other _________________________________

In case of other arrangement : Settler Equivalent Trustee Equivalent Protector Equivalent

Beneficiary Equivalent Other Equivalent ____________________________

Name (as appearing in supporting identification document) Mr./Mrs./Ms. ___________

Gender : M F T - Transgender

Name : __________________________________________________________________________________________________

Maiden Name (if any) :_____________________________________________________________________________________

Spouse Name : ____________________________________________________________________________________________

Father Name : ____________________________________________________________________________________________

Mother Name : ___________________________________________________________________________________________

Marital Status : Married Unmarried Other _______________________

Residential Status : Resident Individual Non-Resident Indian Foreign National Person of Indian Origin

Date of Birth : __________________

Country of Birth*: _________________________________ Place of Birth : __________________________________________

Country of Residence*: (for tax purpose) __________________________ TIN : _______________________________________

TIN Issuing Country*: ________________________ Nationality : Indian Other (specify) ___________________

Category : General OBC SC NT Other _________________________

Passport No.: ________________________________

Date of Issue : __________________ Date of Expiry : __________________ Place of Issue : ___________________________

Valid Visa : Type of Visa :_______________________ Date of Issue : _________________ Date of Expiry : ________________

Place of Issue : ________________________________

KYC Documents Details :

PAN Card Election ID Driving License (Expiry Date _______________________) NREGA Job Card

Aadhar Card Others ___________________ ID Number ____________________________________

Occupation (please tick) :

Retired Bullion Housewife Student Service Politician Diplomat Money Service Business

Real Estate Jewellery / Diamond / Gems Precious Stones ___________________________

Self-employed _________Business _________Professional _________Others _________ (please specify)

Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB)

Other ______________________________________ (Please specify)

Designation : ____________________________________________________________________________________________

Address : Address Type : Owned Rental / Leased Ancestral / Family Company provide Other _____________


Street : _________________________________ Locality : ___________________________________________________




Please tick, if applicable : Politically Exposed Person (PEP) Related Politically Exposed Person

Reasons for not providing TIN : A B C D

(Please refer to Tax Residency Section for Reasons descriptions)

If you indicate reason "B", please explain




DD/MM/YYYY DD/MM/YYYY

DD/MM/YYYYDD/MM/YYYY

DD/MM/YYYY

DD/MM/YYYY

CIF No. (if available) : __________________________ KYC No. (If available) : ______________________________

Type Control (same as individual) :

In case of Legal Person : Ownership Senior Managing Official Other means ______________________

In case of Trust : Settler Trustee Protector Beneficiary Other __________________________

In case of other arrangement : Settler Equivalent Trustee Equivalent Protector Equivalent

Beneficiary Equivalent Other Equivalent ____________________________

Name (Please write complete name as per Certificate of Incorporation / Registration) :

______________________________________________________________________________________________________________

Constitution : Pvt. Ltd. Company Ltd. Company Partnership Ltd. Liability Partnership (LLP)

Trust & Foundation Incorporated Association or Body of Individuals Sole Proprietorship

Hindu Undivided Family (HUF) Society Liquidator Artificial Jurisdicial Person Others____________

PAN No.:

Place of Incorporation : __________________________ Date of Incorporation : _________________

Country of Incorporation*:_____________________ Registration No.:________________________________

Date of Commencement of Business : _________________

Country of Residence as per tax laws*: _______________________________________

TIN : ____________________________ TIN Issue Country*: ______________________

Registered Address : Address Type : Business Residence Registered Office Unspecified Others ________


Street : _________________________________ Locality : ___________________________________________________






(b) Details of Controlling Person (Non-Individual) :

Reasons for not providing TIN : A B C D

(Please refer to Tax Residency Section for Reasons descriptions)



DD/MM/YYYY

DD/MM/YYYY






24. Details of Related Person :

CIF No. (if available) : _____________________________

KYC No. (If available) : ___________________________________

Related Person Type : Director Promoter Karta Trustee Beneficiary

Authorised Signatory Court Appointed Official Other means ____________________

Name (as appearing in supporting identification document) Mr./Mrs./Ms. ___________

Gender : M F T - Transgender

Name : __________________________________________________________________________________________________

Maiden Name (if any) :_____________________________________________________________________________________

Spouse Name : ____________________________________________________________________________________________

Father Name : ____________________________________________________________________________________________

Mother Name : ___________________________________________________________________________________________

Marital Status : Married Unmarried Other _______________________

Residential Status : Resident Individual Non-Resident Indian Foreign National Person of Indian Origin

Date of Birth : _________________

Country of Birth*: _________________________________ Place of Birth : ________________________________________

Country of Residence*: (for tax purpose) __________________________ TIN : _____________________________________

TIN Issuing Country*: ________________________ Nationality : Indian Other (specify) ___________________

Category : General OBC SC NT Other _________________________

Passport No.: ________________________________

Date of Issue : __________________ Date of Expiry : __________________ Place of Issue : ____________________________

Valid Visa : Type of Visa :_______________________ Date of Issue : __________________ Date of Expiry : ________________

Place of Issue : ________________________________

KYC Documents Details :

PAN Card Election ID Driving License (Expiry Date _______________________) NREGA Job Card

Aadhar Card Others ___________________ ID Number ____________________________________

Occupation (please tick) :

Retired Bullion Housewife Student Service Politician Diplomat Money Service Business

Real Estate Jewellery / Diamond / Gems Precious Stones ___________________________

Self-employed _________Business _________Professional _________Others _________ (please specify)

Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB)

Other ______________________________________ (Please specify)

Designation : ____________________________________________________________________________________________

Address : Address Type : Owned Rental / Leased Ancestral / Family Company provide Other _____________


Street : _________________________________ Locality : ___________________________________________________




Please tick, if applicable : Politically Exposed Person (PEP) Related Politically Exposed Person

Reasons for not providing TIN : A B C D(Please refer to Tax Residency Section for Reasons descriptions)





PHOTOGRAPH

Please affixthe recent passport

size photograph andsign across it.

DD/MM/YYYY



DD/MM/YYYY

DECLARATION(i) I/we hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. In case any of the above

information is found to be false or untrue or misleading or misrepresenting, I/we am/are aware that I/we may be held liable for it. I/we confirm that the details submitted above are for updating the Bank's records and abide by Terms and Conditions as applicable from time to time. I/we agree and undertake to notify the Bank within 30 days if there is a change in any information which I/we have provided to the Bank.

(ii) FATCA / CRS Declaration : I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Accounts

Holder's relationship with ADCB setting out how ADCB may use and share the information supplied by me.

I acknowledge, and undertake to inform the Controlling Persons identified herein, that I have provided the above information to ADCB in order for ADCB to comply with its legal obligations on reporting and exchanging financial information, and that the information provided by me will be stored by ADCB until it is required for this purpose. I further acknowledge, and undertake to inform the Controlling Persons, that the information contained in this form and information in relation to the Account Holder and any Reportable Account may be reported to the local tax authority and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax resident.

I certify that I am authorized to sign for the Account Holder in respect of all the account(s) to which this form relates and have provided evidence of such authority.

The Account Holder shall notify ADCB within a reasonable time frame if there is a change of circumstances that affects the tax resident status of the Account Holder identified in this document or causes the information contained herein to become incorrect or incomplete (including any changes to the information on Controlling Persons identified in Self Certification for controlling person). In such circumstances the Account Holder agrees to provide an updated self-certification document.

I understand that the Bank is relying on the information provided herein for the purpose of determining the status of the applicant named above in compliance with FATCA / CRS. The Bank cannot offer any tax advice on CRS or FATCA or its impact on the applicant. I shall seek advice from any professional tax advisor for any tax related query.

I agree that as may be required by domestic regulators / tax authorities, the Bank may also be required to report reportable details to CBDT or close or suspend my account (as may be necessary).

(iii) I/We hereby consent to sharing KYC details/receiving information to/from Central KYC Registry, through SMS/Email on the above registered number/email address.

1 Politically Exposed Persons (PEP ) : PEPs are individuals who are or have been entrusted with prominent public functions in a foreign country. Examples of PEPs include, but not limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii) Senior government/judicial (iv) Senior executives of state -owned corporations (v) important political party officials (vi) Senior Indian Diplomatic personnel posted outside the country. The term PEP also include the families and close associates of the PEPs mentioned. Families: The families incluides close family members such as spouses, children, parents and siblings and may also include other blood relatives and relatives by marriage. Close associates: The term closely associated persons in the context of PEPs includes close business and personal advisors / consultants to the PEP as well as persons who obviously benefit significantly from being close to such a person.

Note : If the details cannot be captured in the above, the same should be provided on the letterhead of the entity, duly attested.

Authorised Signatory Name Signature Date Place

State Code & Country Code Annexure

Authorised Signatory Authorised Signatory Authorised Signatory

KYC Documents Checklist

KYC Application Form

FATCA Details: W8 BEN/ W9 (if applicable)

2

KYC documentation of Related Person :