自我證明表格 – 個人
Self-Certification Form – Individual
(適用於自動交換財務賬戶資料 (Applicable to Automatic Exchange of Financial Account Information) )

客戶名稱Account Name:   ###name_0###  

本人知悉及同意，貴公司可根據《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税務居民國家的稅務當局。
I acknowledge and agree that (a) the information contained in this form is collected and may be kept by your company for the purpose of automatic exchange of financial account information, and (b) such information regarding the account holder and any reportable account(s) may be reported by your company to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another country or countries 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 certify that I am the account holder of all the account(s) to which this form relates.

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，本人會通知貴公司，並會在情況發生改變後30 日內，向貴公司提交一份已適當更新的自我證明表格。
I undertake to advise your company of any change in circumstances which affects the tax residency status of the individual identified in this form or causes the information contained herein to become incorrect, and to provide your company with a suitably updated self-certification form within 30 days of such change in circumstances.

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。
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)

税務居民國家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」）
Country of Tax Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)

請提供以下資料，列明（a）帳戶持有人的税務居民國家，（香港包括在內）及（b）該税務居民國家發給帳戶持有人的稅務編號。列出所有（不限於5個）税務居民國家。
Please complete the following table indicating (a) the country of tax residence (including Hong Kong) where the account holder is a resident for tax purposes and (b) the account holder’s TIN for each country indicated. Indicate all (not restricted to five) countries of tax residence.

如沒有提供稅務編號，必須填寫合適的理由 A, B or C：
If a TIN is unavailable, provide the appropriate reason A, B or C:

理由 A – 帳戶持有人的税務居民國家並沒有向其居民發出稅務編號。
Reason A – The country where the account holder is a resident for tax purposes does not issue TINs to its residents.

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 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C – 帳戶持有人毋須提供稅務編號。税務居民國家的主管機關不需要帳戶持有人披露稅務編號。
Reason C – TIN is not required. Select this reason only if the authorities of the country of tax residence do not require the TIN to be disclosed.

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。
If the account holder is a tax resident of Hong Kong, the TIN is the Hong Kong Identity Card Number.

如帳戶持有人是中國稅務居民，稅務編號是其中國身份證號碼。
If the account holder is a tax resident of China, the TIN is the China Identity Card Number.

重要提示Important Notes：

這是由帳戶持有人向貴公司提供的自我證明表格，以作自動交換財務帳戶資料用途。貴公司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居民國家的稅務當局。
This is a self-certification form provided by an account holder to your company for the purpose of automatic exchange of financial account information. The data collected may be transmitted by your company to the Inland Revenue Department for transfer to the tax authority of another country.

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貴公司。
An account holder should report all changes in his/her tax residency status to your company.

除不適用或特別註明外，必須填寫這份表格所有部分。如這份表格上的空位不夠應用，可另紙填寫。
All parts of the form must be completed (unless not applicable or otherwise specified). If space provided is insufficient, continue on additional sheet(s)

本人聲明就本人所知所信，本表格內所填報的所有資料和聲明均屬真實、正確和完備。
I declare that the information given and statements made in this form are, to the best of my knowledge and belief, true, correct and complete.

簽署 Signature

姓名 Name ###name_1###

日期 Date ###sign_date###