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Individual Tax Residency Self-Certification Form

PLEASE COMPLETE PARTS 1-3 IN BLOCK CAPITALS

Part 1 – Identification of Individual Account Holder

Form CRS-I

A. Name of Account Holder:
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 :