UK Self-Certification Form - Entity

United Kingdom (UK) agreements with Crown Dependencies and Overseas Territories (CDOT) for the international exchange
of tax information.
Part 1

Identification of Account Holder

Name of Organisation

Country of Incorporation or Organisation

Permanent Residence Address

Country of Permanent Residence Address

Tax Residency (indicate all that apply)

Tax Identification Number (if applicable)

Part 2

Entity Classification

Please complete section A and/or B (as applicable) if your organisation is resident for tax purposes in Jersey, Guernsey, the
Isle of Man or Gibraltar before proceeding to section C.
All organisations are required to complete section C below.
A.Is the organisation a Specified Jersey/Guernsey/Isle of Man/Gibraltar Person (please tick only one box)?
Yes
No

B. If no, please confirm which of the following categories applies to the organisation (please tick one box, i to v):

i. Corporation the stock of which is regularly traded on one or more established securities markets or a member of
the same Expanded Affiliated Group (EAG) as such an entity.

ii. Depositary institution.

iii. Broker or dealer in securities, commodities, or derivative financial instruments that is regulated as such under
the laws of same the country in which you are tax resident (Jersey, Guernsey, Isle of Man or Gibraltar).
iv. Exempt beneficial owner (please refer to Note 1 on page 4).

v. Non-reporting financial institution (please refer to Note 2 on page 4).

C. All entities are required to complete this section.
Please confirm which of the following categories applies to the organisation under the Intergovernmental Agreements
(IGAs) between the UK and the Crown Dependencies and Gibraltar:
i. Financial Institution, please proceed to sign the Declaration.

ii. Active NFFE, please proceed to sign the Declaration.

iii. Passive NFFE and NONE of the Controlling Persons of the entity is a specified Jersey, Guernsey, Isle of Man
or Gibraltar Person. Please proceed to sign the Declaration.

iv. Passive NFFE and one or more of the Controlling Persons (please refer to Note 3 on page 4) of the entity is a
specified Jersey, Guernsey, Isle of Man or Gibraltar Person. Please proceed to complete Part 3 of this Form and
sign the Declaration.

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Part 3

Controlling Persons

Full Name

Residential Address

UK Self-Certification Form - Entity (10-2015)

Date
of Birth
(DD-MMYYYY)

Place
of Birth
(City, Town,
Country)

Country of Tax
Residence
(list all)

Tax Identification
Number (TIN) for
each Country of
Tax Residence
(as applicable)

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Declaration
1..I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct,
and complete; and
2..I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect or incomplete;
3..I authorise the recipient of this form to provide, directly or indirectly, to any relevant tax authority or any party authorised
to conduct an audit or other similar review of the recipient for tax purposes;
4..I acknowledge and agree that information contained on this form may be reported to any relevant tax authority;
5..This declaration is based on the attached definitions and certifications.

Sign Here

Signature of individual authorised to sign for beneficial owner

Print Name

Date (DD-MM-YYYY)

I certify that I have the capacity to sign for the entity identified in Part 1 of this form.

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Notes
Note 1: Exempt beneficial owner means the entities listed as Exempt Beneficial Owners in Annex III of the Agreement
between the Government of the UK and the Government of Jersey, Guernsey, Isle of Man or Gibraltar (as appropriate, in
which the entity is tax resident):
Governmental Entity

International Organisation

Broad Participation Retirement Fund

Narrow Participation Retirement Fund

Pension Fund of an Exempt Beneficial Owner

Investment Entity Wholly Owned by Exempt Beneficial Owners

Additional Entities (agreed between the UK Government and Jersey, Guernsey, Isle of Man or Gibraltar, as appropriate,
where the entity is tax resident)
Limited Capacity Exempt Beneficial Owners

Note 2: Non-reporting financial institution means any of the following, as defined in Annex III of the Agreement between
the Government of the UK and the Government of Jersey, Guernsey, Isle of Man or Gibraltar (as appropriate, in which the
entity is tax resident):

Small or limited scope financial institutions that qualify as Non-Reporting Financial Institutions (Local Credit Union;
Financial Institutions with only Low-Value Accounts; and Qualified Credit Card Issuers);

Investment Entities that Qualify as Non-Reporting Financial Institutions and Other Special Rules (Trustee-Documented
Trust; Sponsored Investment Entity; Sponsored, Closely-Held Investment Vehicle; Investment Advisors and Investment
Managers; Collective Investment Vehicle).

Note 3: Controlling Person means a natural person who exercises control over the entity or the shareholders of the entity
and should be interpreted in a manner consistent with the Recommendations of the Financial Action Task Force (these
Recommendations broadly equate to local Anti-Money Laundering (AML) requirements). For trusts and other similar legal
arrangements, this will include the settler, the trustee(s), the protector (if any), the beneficiaries, and any other natural
person exercising ultimate control over the trust.

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Glossary
We have provided a list of definitions of the various entity classifications under the Crown Dependencies and Overseas
Territories (CDOT) that are referred to in the self-certification.
In selecting the entitys CDOT classification, you should consider which of the following is most appropriate; please note that
we cannot advise you as to which classification is applicable to your organisation:
Active Non-Financial Foreign Entity (NFFE): Any NFFE that meets any of the following criteria:

i. Less than 50% of the NFFEs gross income for the preceding calendar year or other appropriate reporting period
is passive income and less than 50% of the assets held by the NFFE during the preceding calendar year or other
appropriate reporting period are assets that produce or are held for the production of passive income.
ii. The stock of the NFFE is regularly traded on an established securities market or the NFFE is a Related Entity of an
entity the stock of which is traded on an established securities market.

iii. The NFFE is a government, a political subdivision of such government or a public body performing a function of such
government or a political subdivision thereof, or an entity wholly owned by one of more of the foregoing.

iv. Substantially all of the activities of the NFFE consist of holding (in whole or in part) the outstanding stock of, or providing
financing and services to, one or more subsidiaries that engage in trades or businesses other than the business of
a Financial Institution, except that an NFFE shall not qualify for this status if the NFFE functions (or holds itself out)
as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund or any investment
vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets
for investment purposes.

v. The NFFE is not yet operating as a business and has no prior operating history, but is investing capital into assets with
the intention to operate a business other than that of a Financial Institution; provided, that the NFFE shall not qualify for
this exception after the date that is 24 months after the date of the initial organisation of the NFFE.
vi. The NFFE was not a Financial Institution in the past five years, and is in the process of liquidating its assets or is
reorganising with the intent to continue or recommence operations in a business other than that of a Financial Institution.

vii. The NFFE primarily engages in financing and hedging transactions with or for Related Entities that are not Financial
Institutions, and does not provide financing or hedging services to any entity that is not a Related Entity, provided that
the group of any such Related Entities is primarily engaged in a business other than that of a Financial Institution.
viii. The NFFE meets all of the following requirements:

a..It is established and operated in its jurisdiction of residence exclusively for religious, charitable, scientific, artistic,
cultural, athletic, or educational purposes; or it is established and operated in its jurisdiction of residence and it is a
professional organisation, business league, chamber of commerce, labour organisation, agricultural or horticultural
organisation, civic league or an organisation operated exclusively for the promotion of social welfare;

b..It is exempt from income tax in its country of residence;

c..It has no shareholders or members who have a proprietary or beneficial interest in its income or assets;

d..The applicable laws of the entitys country of residence or the entitys formation documents do not permit any income
or assets of the entity to be distributed to, or applied for the benefit of, a private person or non-charitable entity other
than pursuant to the conduct of the entitys charitable activities, or as payment of reasonable compensation for
services rendered, or as payment representing the fair market value of property which the entity has purchased; and
e..The applicable laws of the entitys country of residence or the entitys formation documents require that, upon
the entitys liquidation or dissolution, all of its assets be distributed to a governmental entity or other non-profit
organisation, or escheat to the government of the entitys country of residence or any political subdivision thereof.

Cash Value: The greater of the amount that the policy holder:

i. Is entitled to receive upon surrender or termination of the contract (determined without reduction for any surrender
charge or policy loan); and
ii. Can borrow under or with regard to the contract.

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Notwithstanding the foregoing, the term cash value does not include an amount payable under an Insurance Contract as:

i. A personal injury or sickness benefit or other benefit providing indemnification of an economic loss incurred upon the
occurrence of the event insured against;
ii. A refund to the policy holder of a previously-paid premium under an Insurance Contract (other than a life insurance
contract) due to policy cancellation or termination, decrease in risk exposure during the effective period of the Insurance
Contract, or arising from a redetermination of the premium due to correction of posting or other similar error; or

iii. A policy holder dividend based upon the underwriting experience of the contract or group involved.

Cash Value Insurance Contract: An Insurance Contract (other than an indemnity reinsurance contract between two
insurance companies) that has a cash value.
Controlling person: See Note 3 on page 4 of the UK Self-Certification Form - Entity.
Custodial Institution: Any entity that holds, as a substantial portion of its business, financial assets for the account of
others. An entity holds financial assets for the account of others as a substantial portion of its business if the entitys gross
income attributable to the holding of financial assets and related financial services equals or exceeds 20% of the entitys
gross income during the shorter of (i) the three-year period that ends on 31 December (or the final day of a non-calendar
year accounting period) prior to the year in which the determination is being made or (ii) the period during which the entity
has been in existence.
. An entity with no operating history as of the date of the determination is considered to hold financial assets for the account
of others as a substantial portion of its business if the entity expects to meet the gross income threshold based on its
anticipated functions, assets, and employees, with due consideration given to any purpose or functions for which the entity
is licensed or regulated (including those of any predecessor).
. Related financial services are any ancillary service directly related to the holding of assets by the institution on behalf of
others and includes the following:
custody, account maintenance and transfer fees;

execution and pricing commission and fees from securities transactions;

income earned from extending credit to customers;

income earned from contracts for differences and on the bid-ask spread of financial assets; and
fees for providing financial advice, clearance and settlement services.

Such institutions could include brokers, custodial banks, trust companies, clearing organisations and nominees. Insurance
brokers do not hold assets on behalf of clients and thus should not fall within the scope of this provision.

An execution only broker that simply executes trading instructions, or receives and transmit such instructions to another
executing broker will not hold assets for the account of others should not fall to be custodial institutions (although it is
possible that they could be an investment entity).
. Depositary Institution: Any entity that accepts deposits in the ordinary course of a banking or similar business. For the
purposes of UK FATCA HMRC will regard a person carrying out an activity in the UK that is regulated for the purposes of
the Financial Services and Markets Act by virtue of Article 5 of the Financial Services and Markets Act 2000 (Regulated
Activities) Order 2001 (accepting deposits) as Depositary Institution.
. Entities within this definition will include entities regulated in the UK as a savings or commercial bank, a credit union,
industrial and provident societies and building societies. In considering Article 5 HMRC will apply the relevant exclusions
contained therein for example, insurance brokers and solicitors would not be expected to fall within this definition.
However in considering whether an entity is conducting banking or similar business, it will be the actual activities that the
entity carries out that will be determinative.
. Entities that issue payment cards that can be pre-loaded with funds in excess of $50,000 to be spent at a later date,
such as a pre-paid credit card or e-money will also be considered to be Depository Institutions for the purposes of the

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Agreement, notwithstanding that these entities are exempt from the definition of a Depository provider for the purposes of
the provisions of the Electronic Money Issuers Regulations 2011.
. Entities that solely provide asset based finance services or that accept deposits solely from persons as collateral or
security pursuant to; a sale or lease of property; a loan secured by property; or a similar financing arrangement, between
such entity and the person making the deposit with the entity, will not be Depository Institutions. This might for instance
apply to a factoring or invoice discounting business.
. Entities that facilitate money transfers by instructing agents to transmit funds (but do not finance the transactions) will not
be considered to be engaged in banking or similar business as this is not seen as accepting deposits.
. Exempt Beneficial Owner: See Note 1 on page 4 of the UK Self-Certification Form - Entity.
. Financial Institution: A Custodial Institution, a Depositary Institution, an Investment Entity or a Specified Insurance
Company.
. Insurance Contract: Contract (other than an Annuity Contract) under which the issuer agrees to pay an amount upon the
occurrence of a specified contingency involving mortality, morbidity, accident, liability, or property risk.
. Investment Entity: Any entity that conducts as a business (or is managed by an entity that conducts as a business) one
or more of the following activities or operations for or on behalf of a customer:

i. Trading in money market instruments (cheques, bills, certificates of deposit, derivatives, etc.); foreign exchange;
interest rate and index instruments; transferable securities; or commodity futures trading;
ii. Individual and collective portfolio management; or

iii. Otherwise investing, administering, or managing funds or money on behalf of other persons.
This definition shall be interpreted in a manner consistent with similar language set forth in the definition of financial
institution in the Financial Action Task Force Recommendations.
The entity will be regarded as conducting these activities as a business if the entitys gross income attributable to such
activities is equal to or exceeds 50% of the entitys gross income during the shorter of:
The three-year period ending on 31 December of the year preceding the year in which the determination is made; or
The period during which the entity has been in existence.

. Non-Financial Foreign Entity (NFFE): Any Non-Resident Entity that is not treated as a Financial Institution under the UK
Agreement.
. Non-Jersey/Guernsey/Isle of Man/Gibraltar Entity: An entity that is not a person or entity who is resident in Jersey/
Guernsey/Isle of Man/Gibraltar for tax purposes.
Non-Reporting Financial Institution: See Note 2 on page 4 of the UK Self-Certification Form - Entity.
. Non-Resident Entity: An entity that is not tax resident in the other party for the purposes of the UK and Crown
Dependencies/Gibraltar Agreements.
. Passive Income: The portion of gross income that consists of:
i. Dividends, including substitute dividend amounts;
ii. Interest;

iii. Income equivalent to interest, including substitute interest and amounts received from or with respect to a pool of
insurance contracts if the amounts received depend in whole or part upon the performance of the pool;

iv. Rents and royalties, other than rents and royalties derived in the active conduct of a trade or business conducted, at
least in part, by employees of the NFFE;

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v. Annuities;

vi. The excess of gains over losses from the sale or exchange of property that gives rise to passive income derived in
items i to v;

vii. The excess of gains over losses from transactions (including futures, forwards, and similar transactions) in any
commodities, but not including:
a..Any commodity hedging transaction described in Section 954(c)(5)(A) of the US Internal Revenue Code, determined
by treating the entity as a controlled foreign corporation; or

b. .Active business gains or losses from the sale of commodities, but only if substantially all the foreign entitys
commodities are property described in paragraph (1), (2) or (8) of Section 1221(a) of the US Internal Revenue Code.

viii. The excess of foreign currency gains over foreign currency losses;

ix. Net income from notional principal contracts these are financial instruments that provide for the payment of amounts
by one party to another at specified intervals calculated by reference to a specified index upon a notional principal
amount in exchange for specified consideration or a promise to pay similar amounts (note that in the UK this would
normally be a swap);
x. Amounts received under cash value insurance contracts; or

xi.  Amounts earned by an insurance company in connection with its reserves for insurance and annuity contracts.
However, the following amounts are excluded from any calculation of Passive Income:

a..Any income from interest, dividends, rents or royalties that is received or accrued from a related person to the extent
such amount is properly allocable to income of such related person that is not passive income. For purposes of this
section, a person is a related person with respect to the NFFE if such person is:
An individual, corporation, partnership, trust, or estate which controls, or is controlled by, the NFFE; or

A corporation, partnership, trust, or estate which is controlled by the same person or persons which control the
NFFE.

b..In the case of an NFFE that regularly acts as a dealer in property described in item vi above of this section (referring
to the sale or exchange of property that gives rise to passive income), forward contracts, option contracts, or similar
financial instruments including notional principal contracts and all instruments referenced to commodities:
Any item of income or gain (other than any dividends or interest) from any transaction (including hedging
transactions and transactions involving physical settlement) entered into in the ordinary course of such dealers
trade or business as such a dealer; and

If such dealer is a dealer in securities, any income from any transaction entered into in the ordinary course of such
trade or business as a dealer in securities.
. Passive Non-Financial Foreign Entity (NFFE): Any NFFE that is not an Active NFFE.
Regularly Traded on an Established Securities Market: Her Majestys Revenue & Customs (HMRC) will treat the term
regularly traded on an established securities market, as having the meaning as per Section 1005(3) ITA 2007. However,
please see the restrictions to this treatment set out below.
HMRC publishes tables of named recognised stock exchanges (Table 1) and recognised stock exchanges under the
law of named jurisdictions (Table 2). Both of these tables state which markets on which securities would meet the HMRC
definition of listed for the purposes of HMRC legislation: http://www.hmrc.gov.uk/fid/rse-recognised-exchanges.htm#3.
Provided that the debt or equity interest meets the required conditions for regularly traded on an established securities
market there is no need to check annually if any transactions have been undertaken. This provides consistency with
existing HMRC treatment and recognised stock exchange includes the London Stock Exchange, AIM and PLUS.
The main markets of the London Stock Exchange and the PLUS Listed market meet the US Established Securities Market
definition in their own right as they are European Union (EU) Regulated Markets under Title III MiFID and are included in
the FSA list of Regulated Markets.
The AIM, PLUS Quoted and PLUS Traded Markets are not Regulated Markets under Title III MiFID. However, for the

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Glossary
purposes of this legislation HMRC view these as also meeting the requirement as they are all markets of exchanges that
have been designated as recognised investment exchanges by the FSA, they are recognised stock exchanges for the
purposes of the US/UK Double Tax Convention (Article 23 uses the term listed or admitting to dealings on a recognised
stock exchange) and they are within Section 1005 ITA 2007.
Restrictions applying to regularly traded on an established securities market
To prevent the risk that an entity could circumvent Foreign Account Tax Compliance Act (FATCA) reporting by seeking a
listing where there is no intention of the investment vehicle being widely available HMRC will in all cases treat as Financial
Accounts those equity or debt interests established with a purpose of avoiding reporting in accordance with the Agreement
including interests that nevertheless meet the underlying criteria for regularly traded on an established securities market.
Where there is an attempt to set up a particular interest or class of interest to avoid reporting under the Agreement then all
debt and equity interests will become reportable. This also should achieve the objectives of not requiring major financial
institutions to report on their interests but targets reporting at where it will be of most relevance.
In assessing whether a class of interest has been set up to avoid reporting HMRC will consider a number of factors, such
as, for example:
whether the Investment Entity is subject to regulation in the UK;

it complies with HMRC conditions in relation to the provision of certain tax reliefs for example, in regard to HMRC
approval for Investment Trust Companies and Venture Capital Trusts);

whether the vehicle complies with the Genuine Diversity of Ownership Condition (see for example regulation 9A of SI
2006/964) which targets certain tax benefits only to funds where there is an intention that it is held widely for the benefit
of a number of investors;
whether the investor has any right to redeem their holding at net asset value;

the degree to which the assets held in the underlying portfolio are exposed to investment or trading risk, (for example
most ITCs will be listed under Chapter 15 of the UK Listing Rules (closed-ended investment funds). These rules require
a company to have a published investment policy which demonstrates how they intend to manage their assets with a
view to spreading investment risk); and
whether the product is publically advertised through the issuance of a prospectus.

Please note the above is not an exhaustive list and where appropriate HMRC will consider each case on its
particular circumstances.
. Related Entity: An entity is a Related Entity of another entity if either entity controls the other entity, or the two entities
are under common control. For this purpose control includes direct or indirect ownership of more than 50% of the vote or
value in an entity. Notwithstanding the foregoing, either party may treat an entity as not a Related Entity if the two entities
are not members of the same affiliated group, as reference to Section 1471(e)(2) of the US Internal Revenue Code.
Specified Jersey Person, Specified Guernsey Person, Specified Isle of Man Person, Specified Gibraltar Person:
A person or entity who is resident in Jersey/Guernsey/Isle of Man/Gibraltar (as applicable) for tax purposes, and includes
a person or entity who is resident in both Jersey/Guernsey/Isle of Man/Gibraltar (as applicable) and the United Kingdom
(UK) under the respective domestic law of each Party, other than:
i.. A corporation the stock of which is regularly traded on one or more established securities markets;

ii. A corporation that is a Related Entity that is a member of the same affiliated group, as reference to Section 1471(e)(2)
of the United States (US) Internal Revenue Code, described in point i. above;

iii..A Depositary Financial Institution;

iv..A broker or dealer in securities, commodities, or derivative financial instruments including notional principal contracts,
futures, forwards and options that is registered under the laws of Jersey/Guernsey/Isle of Man/Gibraltar (as applicable);
or

v.. An exempt beneficial owner (see Note 1 on page 4).

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Glossary
. Specified Insurance Company: Any entity that is an insurance company (or holding company of an insurance company)
that issues, or is obligated to make payments with respect to, a Cash Value Insurance Contract or an Annuity Contract.
. Therefore, Insurance companies that only provide General Insurance or term Life Insurance should not be Financial
Institutions and neither will reinsurance companies that only provide indemnity reinsurance contracts.
. A Specified Insurance Company can include both Insurance Companies and the holding companies of insurance
companies. However, a holding company itself will only be a Specified Insurance Company if it issues or is obligated to
make payments with respect to Cash Value Insurance Contracts or Annuity Contracts.
. Insurance brokers are normally part of the payment chain and therefore should not be classified as a Specified Insurance
Company. This will not be the case where they are obligated to make payments under the terms of the Insurance or
Annuity Contract.

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