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Foreign Account Tax Compliance Act (FATCA) Form

This document is a FATCA form that must be filled out by any individual opening an account. It requires the individual to provide their name, country of birth, and answer whether they meet any of the following criteria: they are a U.S. citizen or national, U.S. resident, hold a U.S. green card, U.S. contact number, or U.S. address. By signing, the individual consents to the bank providing their personal information to regulatory authorities or the IRS as required by law. They also acknowledge the bank may close their account if required documents are not submitted on time.

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263 views1 page

Foreign Account Tax Compliance Act (FATCA) Form

This document is a FATCA form that must be filled out by any individual opening an account. It requires the individual to provide their name, country of birth, and answer whether they meet any of the following criteria: they are a U.S. citizen or national, U.S. resident, hold a U.S. green card, U.S. contact number, or U.S. address. By signing, the individual consents to the bank providing their personal information to regulatory authorities or the IRS as required by law. They also acknowledge the bank may close their account if required documents are not submitted on time.

Uploaded by

sajjad shaheen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Foreign Account Tax Compliance Act (FATCA) Form

− This form must be filled by an individual and submitted with Account Opening Form.
− Separate form must be filled for each individual i.e. each holder of an account in case of joint account,
Mandate holder or Beneficial Owner if ultimate beneficiary is other than the customer.

Name (as mentioned on the Account Opening Form) : ____________________________________________

Country of Birth : ____________________________________________


(If country of birth is United States, please provide documents as mentioned overleaf.)

Please tick Yes or No for each of the following questions:

Yes / No

1. Are you a U.S National / Citizen?

2. Are you a U.S. Resident?

3. Do you hold a U.S. Permanent Resident Card (Green Card)?

4. Do you hold a U.S. Contact Number?


(If yes, please provide on CIF)

5. Do you hold a U.S. Address?


(If yes, please provide on CIF)

I hereby confirm the information provided above is true, accurate and complete.

I hereby expressly and unconditionally allow United Bank Limited(“Bank”) to give the necessary
information as deemed fit to any regulatory authority allowed access to such information under Pakistan
statutes, rules, regulations or any other applicable law or to the US Treasury Internal Revenue Service of
the United States of America (or its representatives or agents), and do hereby consent, agree and confirm
that the Bank shall have the right to disclose my personal information with respect to any of my accounts
with the Bank directly or indirectly to the U.S Treasury Internal Revenue Service of the United States of
America (or its representatives or agents) when requested and as deemed necessary by the Bank, of
whatsoever nature.

I acknowledge and accept that the Bank reserves the right to close or suspend without prior notice, any
account for which required document/information is not submitted within stipulated time.

I undertake to notify the Bank within 30 days if there is a change in any information which I have provided
to the Bank.

Signature : ___________________________

Date : ___________________________

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