机构service

UWI-F041(01/2021)第1页,共7页致:中银集团人寿保险有限公司香港太古城英皇道1111号太古城中心第1期13楼To:BOCGroupLifeAssuranceCompanyLimited13/F,CityplazaOne,1111King'sRoad,TaikooShing,HongKong税务居民身份自我证明表格–实体/机构Self-CertificationFormforTaxResidency-Entity重要提示:ImportantNotes:1.
这是由账户持有人向中银集团人寿保险有限公司(下称「本公司」或「中银人寿」)提供的自我证明表格.
本公司可根据i)美国「海外账户税收合规法案」("FATCA")把账户持有人的资料提交予美国国税局;及/或ii)《2016年税务(修订)(第3号)条例》及其后的相关修订条例,把收集所得的资料交给香港政府税务局(「税务局」),税务局会将资料转交到另一税务管辖区的税务当局.
需提交的数据为账户持有人于本公司的保单记录及本表格收集所得的数据,当中包括账户持有人名称、地址、居留司法管辖区、实体成立为法团或设立所在地、税务编号及保单数据(包括保单号码及保单价值数据)等.
Thisisaself-certificationformprovidedbyanaccountholdertoBOCGroupLifeAssuranceCompanyLimited("theCompany"or"BOCLife").
Theaccountholder'sinformationmaybetransmittedbytheCompanytoi)theU.
S.
InternalRevenueServiceinaccordancewithUnitedStatesGovernment'sForeignAccountTaxComplianceAct("FATCA");and/orii)totheInlandRevenueDepartmentofHongKongGovernment("IRD")inaccordancewiththeInlandRevenue(Amendment)(No.
3)Ordinance2016andthesubsequentrelevantamendmentordinancefortransfertothetaxauthorityofanotherjurisdiction(s).
Transmitteddatawouldbeaccountholder'spolicyinformationrecordedintheCompanyandtheinformationcollectedfromthisform,whichincludesaccountholder'sname,address,jurisdictionofresidence,placeofincorporationororganization,taxpayeridentificationnumbers(TINs),andpolicyinformation(includingpolicynumberandpolicyaccountvalueinformation),etc.
2.
如您的税务居民身份有所改变,请于改变后30日内重新填写自我证明表格并交回本公司.
本公司将以您最新签署的自我证明表格为准.
此表格中所载数据只会在本公司完成相关内部处理及审核程序后方能生效.
Whenthereisanychangeofyourtaxresidency,pleasecompleteself-certificationformagainandsubmitthesametotheCompanywithin30daysuponyourchangeoftaxresidency.
Thelatestself-certificationformsignedbyyoushallprevail.
Theinformationoftheself-certificationformshallbeeffectiveonlyafterthecompletionofrelevantinternalprocessingandclearanceproceduresbytheCompany.
3.
自我证明表格内的数据只用作向美国国税局及/或税务局申报用途(如需要).
如账户持有人需要更新任何数据(如实体名称、商业登记号码、公司注册证明书号码、地址),请另行递交「客户重要数据更改申请表」予本公司.
Theinformationofthisself-certificationformisonlyusedforthepurposeofreportingtotheU.
S.
InternalRevenueServiceand/orIRD(ifrequired).
Pleasesubmitthe"ApplicationforKeyPersonalInformationChange"formtotheCompanyifthereisanyupdateofaccountholder'sinformation(e.
g.
name,businessregistrationnumber,certificateofIncorporationnumber,address).
4.
除不适用或特别注明外,必须填写这份表格所有部份.
如这份表格上的空位不够应用,请另纸填写.
Allpartsoftheformmustbecompleted(unlessnotapplicableorotherwisespecified).
Ifspaceprovidedisinsufficient,pleasecontinueonadditionalsheet(s).
5.
账户持有人可浏览美国国税局网页,了解FATCA的相关资料.
TheaccountholdermayvisittheU.
S.
InternalRevenueServicewebsiteforFATCArelatedinformation.
https://www.
treasury.
gov/resource-center/tax-policy/treaties/Pages/FATCA.
aspx有关「自动交换财务账户数据」的相关信息,可浏览税务局网页.
账户持有人亦可于经济合作与发展组织("OECD")专页,了解相关国家发布的税务居民身份规定,和可获接受的税务编号("TIN")格式.
ForinformationinrelationtoAutomaticExchangeofFinancialAccountInformation("AEOI"),pleasevisitIRDAEOIportal.
TheaccountholdermayalsovisittheOrganisationofEconomicCo-operationandDevelopment("OECD")AEOIwebsitefortaxresidencyrulesandacceptableTINissuedbytherelevantjurisdictions.
税务局「自动交换财务账户数据」专页/IRDAEOIPortal:http://www.
ird.
gov.
hk/eng/tax/dta_aeoi.
htmOECD「自动交换财务账户数据」网页/OECDAEOIWebsite:http://www.
oecd.
org/tax/automatic-exchange/6.
我们无法提供税务建议及/或居留司法管辖区的定义.
如账户持有人有任何税务相关或税务居民身份问题,请向专业法律及/或税务顾问寻求建议.
Weareunabletoprovidetaxadviceand/orthedefinitionforthejurisdictionofresidence.
Iftheaccountholderhasanyquestionsontaxmattersortaxresidency,pleaseseekadvicefromprofessionallegaland/ortaxadvisor(s).
UWI-F041(01/2021)第2頁,共7頁第一部份实体/机构账户持有人的身份识辨资料(每名实体/机构账户持有人须分别填写一份表格)Part1IdentificationofEntityAccountHolder(Completeaseparateformforeachentityaccountholder)保单号码(请填写全部或任何一张适用的保单号码):PolicyNumber(Pleasefillinthepolicynumberofalloranyapplicablepolicy(ies)):账户持有人身份:CapacityofAccountHolder:保单权益人PolicyOwner索偿人Claimant受益人Beneficiary其他(请列明)Others(Pleasespecify)(如果你是以授权人身分签署这份表格,须夹附由授权人或律师核实的授权书副本.
Ifyousignunderapowerofattorney,pleaseattachatruecopyofpowerofattorneycertifiedbythedonorofthepowerorbyasolicitor.
)实体/机构或分支机构的法定名称:LegalNameofEntityorBranch:(中文)(English)实体/机构成立为法团或设立所在的税务管辖区:JurisdictionofIncorporationorOrganisation:香港商业登记号码:HongKongBusinessRegistrationNumber:地址:Address:地址记录与本公司保单记录相同Address(es)is/arethesameastheone(s)inourcompany'spolicyrecord是Yes否,请于下方填写地址并连同『客户重要资料更改申请表』交回本公司.
No,pleasecompletethefollowingsectionandsubmittogetherwiththe"ApplicationofKeyPersonalInformationChangeForm"tous.
注册地址:IncorporationAddress:现时营业地址:CurrentBusinessAddress:通讯地址:CorrespondenceAddress:与现时营业地址相同(毋须填写右方资料)Sameascurrentbusinessaddress(Notrequiredtocompletedetailsontherightside)UWI-F041(01/2021)第3頁,共7頁第二部份美国外国账户税务合规法案分类Part2U.
S.
ForeignAccountTaxComplianceAct(FATCA)Classification请在适当的方格内加上""号并回答相关问题︰Pleasecheck""theapplicableboxandanswertherelevantquestions:美国机构U.
S.
Entity该机构在美国注册或是根据美国法例成立TheEntityisregisteredintheU.
S.
orestablishedunderlawsoftheU.
S.
贵公司是否豁免于FATCA申报IstheCompanyanexemptfromFATCAreporting是/Yes(W901)否/No(W900)请提供该机构之美国纳税人编号PleaseprovidetheEntity'sUSTaxpayerIdentificationNumber(TIN)非美国金融机构NonU.
S.
FinancialInstitution(FFI)该机构为美国以外地区成立之金融机构TheEntityisafinancialinstitutionregisteredorestablishedoutsidetheU.
S请提供该机构之全球中介人编号(W801)PleaseprovidetheEntity'sGlobalIntermediaryIdentificationNumber(GIIN)如未能提供全球中介人编号,请选择下列原因IftheEntitydoesnothaveaGIIN,pleaseselectthefollowingreason该机构已向美国国税局注册,但目前未收到全球中介人编号(W801/InputGIINlater)TheEntityhasbeenregisteredwiththeInternalRevenueServicebuttheGIINisnotyetreceived该机构为认证视为合规的非美国金融机构(W802)TheEntityisaCertifieddeemedcompliantFFI该机构为不参与的非美国金融机构(W803)TheEntityisaNon-participatingFFI该机构为记录拥有人的非美国金融机构(W804)(注1)TheEntityisanOwnerDocumentedFFI(Note1)该机构为豁免受益人(W806)TheEntityisanExemptBeneficialOwner其他(请列明)Other(Pleasespecify):非金融机构NonFinancialForeignEntities(NFFE)该机构为美国以外地区注册或成立之非金融机构TheEntityisanonU.
S.
entitythatisnotafinancialinstitutiona)该机构是否被动非美国机构(注2)TheEntityisaPassiveNFFE(Note2)是(请回答b)Yes(Pleaseanswerb)否(W806)Nob)该机构的控制人是否美国公民或美国居民如是,请于下列出该等人士的资料(注1,3)Anycontrollingperson(s)oftheentityisaU.
S.
citizenorresidentIfyes,pleaseprovidetheinformationofeachUScontrollingperson(s)below(Note1,3)是(W807)Yes否(W806)NoUWI-F041(01/2021)第4頁,共7頁编号No.
控制人英文姓名EnglishNameofControllingPerson(s)美国纳税人编号USTIN英文地址AddressinEnglish12345678910附录1Appendix1(注1)(Note1)个人资料披露同意书-美国合伙人ConsenttoDisclosePersonalInformation-USpartner(s)本人/我们同意贵公司可使用及披露本人/我们的个人资料(不论是在上述提供的或由贵公司于之前或将来获得的)(「个人资料」)作载于贵公司最新近的「资料政策通告」上的用途以遵守任何适用法律或规例及其任何须承担或获施加与本地或海外之法定、监管、政府、税务、执法或其他机构或金融服务提供商之自律监管或行业团体或组织之间的现有或将来之任何合约承诺或其他承诺(「承诺」).
本人/我们明白如不给予以上同意,可能会导致贵公司无法向机构提供服务.
I/WeconsenttotheCompanyusinganddisclosingmy/ourpersonaldata(whetherprovidedaboveorotherwiseobtainedbytheCompanypreviouslyorinthefuture)("PersonalData")forthepurpose(s)asshownintheCompany'slatest"DataPolicyNotice"withanyapplicablelaworregulationandanypresentorfuturecontractualorothercommitmentwithlocalorforeignlegal,regulatory,governmental,tax,lawenforcementorotherauthorities,orself-regulatoryorindustrybodiesorassociationsoffinancialservicesproviders("Commitment").
I/WeunderstandthatifI/wedonotgivetheaboveconsent,theCompanymaybepreventedfromprovidingtheEntitywithservices.
姓名(请以正楷填写):Name(PleasecompleteinBlockLetter):签署:Signature:日期(日/月/年):Date(DD/MM/YYYY):注1:如该机构为合伙商号,而当中任何合伙人为美国公民或居民,请该合伙人签署以上附录1之同意书.
Note1:IftheEntityisapartnershipandanyofthepartnersis/areU.
S.
citizenorresident,pleasearrangethatpartner(s)tosigntheConsentunderAppendix1.
注2:被动非美国机构指符合以下其中一项条件之机构:(a)根据该企业去年的财务报表,其50%以上的总收入是利息、股息、租金、外币兑换收益或年金等被动收入;或(b)根据该企业去年的财务报表,其50%以上的总资产是为产生被动收入而持有.
Note2:PassiveNFFEisanentitywhichsatisfiesoneofthebelowconditions:(a)Morethan50%oftheentity'sgrossincomefortheprecedingcalendaryearispassiveincomeincludinginterest,dividend,rentalincome,foreignexchangegain,annuity;or(b)Morethan50%oftheentity'sassetsheldduringtheprecedingcalendaryearareassetsthatproduceorareheldfortheproductionofpassiveincome.
注3:控制人指独资经营者、合伙人或任何有能力直接或间接控制该机构的自然人.
控制是指拥有超过10%该机构股票的投票权或价值.
就信托契约而言,控制人包括信托之授予人,受托人,监管人及受益人.
Note3:Controllingpersonreferstosoleproprietor,partneroranynaturalpersonthatdirectlyorindirectlycontrolstheEntity.
Controlreferstotheholdingofmorethan10%oftheEntity'sinterest.
Fortrustdeed,controllingpersonincludessettlor,trustee,protectorandbeneficiary.
UWI-F041(01/2021)第5頁,共7頁第三部份实体/机构类别Part3EntityType在其中一个适当的方格内加上号,并提供有关资料.
Tickoneoftheappropriateboxesandprovidetherelevantinformation.
财务机构FinancialInstitution托管机构、存款机构或指明保险公司CustodialInstitution,DepositoryInstitutionorSpecifiedInsuranceCompany投资实体/机构,但不包括由另一财务机构管理(例如:拥有酌情权管理投资实体/机构的资产)并位于非参与税务管辖区的投资实体/机构InvestmentEntity,exceptaninvestmententitythatismanagedbyanotherfinancialinstitution(e.
g.
withdiscretiontomanagetheentity'sassets)andlocatedinanon-participatingjurisdiction主动非财务实体/机构(如:有实质业务活动的非金融实体/机构)ActiveNFE(e.
g.
Non-FinancialInstitutionwithActiveBusiness)该非财务实体/机构的股票经常在_一个具规模证券市场)进行买卖NFEthestockofwhichisregularlytradedonwhichisanestablishedsecuritiesmarket_的有关连实体/机构,该有关连实体/机构的股票经常在一个具规模证券市场)进行买卖Relatedentityofthestockofwhichisregularlytradedonwhichisanestablishedsecuritiesmarket政府实体/机构、国际组织、中央银行或由前述的一个或多个实体/机构全权拥有的非财务实体/机构NFEisagovernmentalentity,aninternationalorganization,acentralbank,oranentitywhollyownedbyoneormoreoftheforegoingentities除上述之外的主动非财务实体/机构(请说明:ActiveNFEotherthantheabove(Pleasespecify:被动非财务实体/机构(如:非实质营运的非金融实体/机构)(注4)PassiveNFE(e.
g.
Non-FinancialInstitutionwithPassiveInvestment)(Note4)位于非参与税务管辖区并由另一财务机构管理的投资实体/机构Investmententitythatismanagedbyanotherfinancialinstitutionandlocatedinanon-participatingjurisdiction不属主动非财务实体/机构的非财务实体/机构NFEthatisnotanactiveNFE请填写所有控权人的姓名在列表内.
就法人实体/机构,如行使控制权的并非自然人,控权人会是该法人实体/机构的高级管理人员.
Indicatethenameofallcontrollingperson(s)oftheaccountholderinthetablebelow.
Ifnonaturalpersonexercisescontroloveranentitywhichisalegalperson,thecontrollingpersonwillbetheindividualholdingthepositionofseniormanagingofficial.
每名控权人须分别填写一份「税务居民身份自我证明表格–控权人」Eachcontrollingpersonshouldcompleteaseparate"Self-CertificationFormforTaxResidency–ControllingPerson"(1)(6)(2)(7)(3)(8)(4)(9)(5)(10)注4:有关「被动非财务实体」及控权人的释义,请参阅税务局的网页Note4:PleaserefertoIRD'swebsiteforthemeaningsoftermsandexpressionofPassiveNFEandcontrollingpersonhttp://www.
ird.
gov.
hk/chi/(中文)http://www.
ird.
gov.
hk/eng/(English)UWI-F041(01/2021)第6頁,共7頁第四部份居留司法管辖区及税务编号或具有等同功能的识辨编号(以下简称「税务编号」)Part4JurisdictionofResidenceandTaxpayerIdentificationNumberoritsFunctionalEquivalent("TIN")请提供以下资料,列明(a)账户持有人的居留司法管辖区,亦即账户持有人的税务管辖区(香港包括在内)及(b)该居留司法管辖区发给账户持有人的税务编号.
列出所有(不限于10个)居留司法管辖区.
Pleasecompletethefollowingtableindicating(a)thejurisdictionofresidence(includingHongKong)wheretheaccountholderisaresidentfortaxpurposesand(b)theaccountholder'sTINforeachjurisdictionindicated.
Indicateall(notrestrictedtoten)jurisdictionsofresidence.
如果账户持有人是香港税务居民,税务编号是其香港商业登记号码.
IftheaccountholderisataxresidentofHongKong,theTINistheHongKongBusinessRegistrationNumber.
如果账户持有人并非任何税务管辖区的税务居民(例如:它是财政透明实体),请填写实际管理机构所在的税务管辖区.
Iftheaccountholderisnotataxresidentinanyjurisdiction(e.
g.
fiscallytransparent),pleaseindicatethejurisdictioninwhichitsplaceofeffectivemanagementissituated.
如没有提供税务编号,必须填写合适的理由:理由A–账户持有人的居留司法管辖区并没有向其居民发出税务编号.
理由B–账户持有人不能取得税务编号.
如选取这一理由,解释账户持有人不能取得税务编号的原因.
理由C–账户持有人毋须提供税务编号.
居留司法管辖区的主管机关不需要账户持有人披露税务编号.
IfaTINisunavailable,providetheappropriatereasonA,BorC:ReasonA–ThejurisdictionwheretheaccountholderisaresidentfortaxpurposesdoesnotissueTINstoitsresidents.
ReasonB–TheaccountholderisunabletoobtainaTIN.
ExplainwhyitisunabletoobtainaTINifthisreasonisselected.
ReasonC–TINisnotrequired.
SelectthisreasononlyiftheauthoritiesofthejurisdictionofresidencedonotrequiretheTINtobedisclosed.
居留司法管辖区JurisdictionofResidence税务编号TIN如没有提供税务编号,勾选理由A、B或C(如已提供税务编号,无需填写此栏)TickReasonA,BorCifnoTINisavailable(PleaseskipthiscolumnifTINisavailable)如选取理由B,须解释账户持有人不能取得税务编号的原因ExplainwhyitisunabletoobtainaTINifReasonBisselected(1)ABC(2)ABC(3)ABC(4)ABC(5)ABC(6)ABC(7)ABC(8)ABC(9)ABC(10)ABCUWI-F041(01/2021)第7頁,共7頁第五部份声明及签署Part5DeclarationsandSignature我们声明就我们所知所信,本表格内所填报的所有资料和声明均属真实、正确和完备.
Wedeclarethattheinformationgivenandstatementsmadeinthisformare,tothebestofourknowledgeandbelief,true,correctandcomplete.
我们同意贵公司可使用及披露我们的资料(不论是在上述提供的或由贵公司于之前或将来获得的),以遵守任何适用法律或规例及其任何须承担或获施加与本地或海外之法定、监管、政府、税务、执法或其他机构或金融服务提供商之自律监管或行业团体或组织之间的现有或将来之任何合约承诺或其他承诺(「承诺」).
我们明白如不给予以上同意,可能会导致贵公司无法向我们提供服务.
WeconsenttotheCompanyusinganddisclosingourdata(whetherprovidedaboveorotherwiseobtainedbytheCompanypreviouslyorinthefuture)forcompliancewithanyapplicablelaworregulationandanypresentorfuturecontractualorothercommitmentwithlocalorforeignlegal,regulatory,governmental,tax,lawenforcementorotherauthorities,orself-regulatoryorindustrybodiesorassociationsoffinancialservicesproviders("Commitment").
WeunderstandthattheCompanymaybepreventedfromprovidinguswithserviceswithouttheaboveconsent.
我们进一步声明,就我们向贵公司提供的资料之相关人士(下称「该人士」),我们获该人士授权确认其同意贵公司可使用及披露其个人资料(不论是在上述提供的或由贵公司于之前或将来获得的)(「个人资料」)作载于贵公司最新近的私隐政策及个人资料收集声明上的用途以遵守其任何须承担或获施加与的承诺.
WefurtherdeclarethatwearedulyauthorizedbytheindividualsregardingwhomwehaveprovidedinformationtotheCompany(the"Individuals",eachan"Individual")toconfirmthateachIndividualconsentstotheCompanyusinganddisclosinghis/herpersonaldata(whetherprovidedaboveorotherwiseobtainedbytheCompanypreviouslyorinthefuture)("PersonalData")forthepurpose(s)asshownintheCompany'slatestPrivacyPolicyStatementandPersonalInformationCollectionStatementforcompliancewiththeCommitment.
我们知悉及同意,中银人寿可根据《税务条例》(香港法例第112章)有关交换财务账户资料的法律条文,(a)收集本表格所载资料并可备存作自动交换财务账户资料用途及(b)把该等资料和关于账户持有人及任何须申报账户的资料向香港特别行政区政府税务局申报,从而把资料转交到账户持有人的居留司法管辖区的税务当局.
Weacknowledgeandagreethat(a)theinformationcontainedinthisformiscollectedandmaybekeptbyBOCLifeforthepurposeofautomaticexchangeoffinancialaccountinformation,and(b)suchinformationandinformationregardingtheaccountholderandanyreportableaccount(s)maybereportedbyBOCLifetotheInlandRevenueDepartmentoftheGovernmentoftheHongKongSpecialAdministrativeRegionandexchangedwiththetaxauthoritiesofanotherjurisdictionorjurisdictionsinwhichtheaccountholdermayberesidentfortaxpurposes,pursuanttothelegalprovisionsforexchangeoffinancialaccountinformationprovidedundertheInlandRevenueOrdinance(Cap.
112,LawsofHongKong).
我们同意贵公司可按适用的法律、法规、指令和承诺在我们的保单中扣留相关所须的金额款项.
WeagreethattheCompanymaywithholdfromourpolicy(ies)suchamountsasmayberequiredaccordingtoapplicablelaws,regulations,directivesandCommitment.
我们承诺,如情况有所改变,以致影响本表格所述的实体/机构及/或个人的税务居民身份,或引致本表格所载的资料不正确,我们会通知中银人寿,并会在情况发生改变后30日内,向中银人寿提交一份已适当更新的自我证明表格.
WeundertaketoadviseBOCLifeofanychangeincircumstanceswhichaffectsthetaxresidencystatusoftheentityand/orindividualidentifiedinthisformorcausestheinformationcontainedhereintobecomeincorrect,andtoprovideBOCLifewithasuitablyupdatedself-certificationformwithin30daysofsuchchangeincircumstances.
我们证明,就与本表格相关的所有账户,我们获账户持有人授权签署本表格.
Wecertifythatweareauthorizedtosignfortheaccountholderofalltheaccount(s)towhichthisformrelates.
警告:根据《税务条例》第80(2E)条,如任何人在作出自我证明时,在明知一项陈述在要项上属具误导性、虚假或不正确,或罔顾一项陈述是否在要项上属具误导性、虚假或不正确下,作出该项陈述,即属犯罪.
一经定罪,可处第3级(即港币10,000)罚款.
WARNING:Itisanoffenceundersection80(2E)oftheInlandRevenueOrdinanceifanyperson,inmakingaself-certification,makesastatementthatismisleading,falseorincorrectinamaterialparticularANDknows,orisrecklessastowhether,thestatementismisleading,falseorincorrectinamaterialparticular.
Apersonwhocommitstheoffenceisliableonconvictiontoafineatlevel3(i.
e.
HKD10,000).
本人代表Forandonbehalfof实体/机构名称NameofEntity)签署:Signature:(签字式样须与本公司存案相符)(SignaturespecimenmustcorrespondtothatintheCompany'srecords)姓名:Name:签署日期(日/月/年):Date(DD/MM/YYYY):