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Controlling Person Tax Residency Self-Certification Form

PLEASE COMPLETE PARTS 1-3 IN BLOCK CAPITALS

Part 1 – Identification of Controlling Person

CRS-CP

A. Name of Controlling Person:
Family Name or Surname :
Title :
First Name :
Middle Name(s) :
B. Current Residence Address:
House/Apt/Suite No./ Street :
Town/City/ State/Province :
Country :
Postal Code :
C. Mailing Address:
(please complete if different from the address shown in Section B above)
House/Apt/Suite No.
Street/P. O. Box
:
Town/City/ State/Province :
Country :
Postal Code :
D. Date of Birth: (DD/MM/YYYY)
Date of Birth :
E. Place of Birth:
Town/City of Birth :
Country of Birth :
F. Please enter the legal name of the relevant Entity
    Account Holder(s) of which you are a Controlling Person
Legal Name of Entity 1 :
Legal Name of Entity 2 :
Legal Name of Entity 3 :