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Account holder Tax Status Self-Certification Form 客戶稅務自我證明表格
This is a self-certification form provided by an account holder to a reporting financial institution for the purpose of automatic exchange of financial account information. The data collected may be transmitted by the reporting financial institution to the Inland Revenue Department for transfer to the tax authority of another jurisdiction.
這是由帳戶持有人向申報財務機構提供的自我證明表格，以作自動交換財務帳戶資料用途。申報財務機構可把收
集所得的資料交給稅務局，稅務局會將資料轉交到另一稅務管轄區的稅務當局。
An account holder should report all changes in his/her tax residency status to the reporting financial institution.
如帳戶持有人的稅務居民身分有所改變，應盡快將所有變更通知申報財務機構。
If you have any questions on your tax status, please consult your tax advisor or domestic tax authority. You are to notify us promptly and provide us with an updated tax status should there be any changes to your tax details.
若對於您的稅務狀況有任何疑問，請聯絡您的稅務顧問或當地稅務機關。若您的稅務狀況於日後出現任何變動，請立刻通知我們，並提供您最新的稅務狀況。
Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)
居留司法管轄區及稅務編號或具有等同功能的識辨編號（以下簡稱「稅務編號」）
Complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where the account holder is a resident for tax purposes and (b) the account holder’s TIN for each jurisdiction indicated. Indicate all (not restricted to five) jurisdictions of residence.
提供以下資料，列明（a）帳戶持有人的居留司法管轄區，亦即帳戶持有人的稅務管轄區（香港包括在內）及（b）該居 留司法管轄區發給帳戶持有人的稅務編號。列出所有（不限於 5個）居留司法管轄區。
If the account holder is a tax resident of Hong Kong, the TIN is the Hong Kong Identity Card Number. If a TIN is unavailable, provide the appropriate reason A, B or C:
如帳戶持有人是香港稅務居民，稅務編號是其香港身份證號碼。 如沒有提供稅務編號，必須填寫合適的理由：
Reason A – The jurisdiction where the account holder is a resident for tax purposes does not issue TINs to its residents.
理由 A - 帳戶持有人的居留司法管轄區並沒有向其居民發出稅務編號。
Reason B – The account holder is unable to obtain a TIN. Explain why the account holder is unable to obtain a TIN if you have selected this reason.
理由 B - 帳戶持有人不能取得稅務編號。如選取這一理由，解釋帳戶持有人不能取得稅務編號的原因。
Reason C – TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the
TIN to be disclosed.
理由 C–帳戶持有人毋須提供稅務編號。居留司法管轄區的主管機關不需要帳戶持有人披露稅務編號。
Declarations and Signature聲明及簽署
I acknowledge and agree that (a) the information contained in this form is collected and may be kept by the financial institution for the purpose of automatic exchange of financial account information, and (b) such information and information regarding the account holder and any reportable account(s) may be reported by the financial institution to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112).
本人知悉及同意，財務機構可根據《稅務條例》（第 112 章）有關交換財務帳戶資料的法律條文，（a）收集本表格所 載資料並可備存作自動交換財務帳戶資料用途及（b）把該等資料和關於帳戶持有人及任何須申報帳戶的資
料向香港特 別行政區政府稅務局申報，從而把資料轉交到帳戶持有人的居留司法管轄區的稅務當局。
I certify that I am the account holder of all the account(s) to which this form relates.
本人證明，就與本表格所有相關的帳戶，本人是帳戶持有人簽署本表格。
I undertake to advise SRSF of any change in circumstances which affects the tax residency status of the individual identified of this form or causes the information contained herein to become incorrect, and to provide SRSF with a suitably updated self-certification form within 30 days of such change in circumstances.
本人承諾，如情況有所改變，以致影響本表格所述的個人的稅務居民身分，或引致本表格所載的資料不正確，本 人
會通知中順，並會在情況發生改變後 30 日內，向中順提交一份已適當更新的自我證明表格。
WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a selfcertification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. $10,000). 警告: 根據《稅務條例》第 80(2E)條，如任何人在作出自我
證明時，在明知一項陳述在要項上屬具誤導性、虛假或不正 確，或罔顧一項陳述是否在要項上屬具誤導性、虛
假或不正確下，作出該項陳述，即屬犯罪。一經定罪，可處第 3 級 （即$10,000）罰款
