FATCA/CRS Self-Certification Declaration

Full Name

First NameLast Name

Date of Birth

Date

Residential Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Country of Citizenship

Country/Countries of Tax Residence (select all that apply)

Tax Identification Number (TIN) for each country of tax residence (if applicable)

If you do not have a TIN, please provide the reason

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you a U.S. Person for tax purposes?

Signature (please sign below to confirm your declaration)