A sample Disclosure Certificate is set out below
[pic]
Customer Information Certificate – Domestic Proprietary Company
Definition: a company incorporated in Australia that is limited by share capital, whose membership is limited to
50 non-employee shareholders and that is prohibited from offering invitations to the public to subscribe to its shares or debentures.
|Please note that this certificate may have been pre-populated with information that the Bank has previously collected from |
|the customer. In completing this form you are responsible for completing any blank sections, checking the accuracy of any |
|pre-populated section, informing us if any of the information is not correct and supplying the correct information in substitution. |
| |Bank use |
| |only (initials) |
|1 |Is the company registered with ASIC as a proprietary company? | Yes ( Go to 2 | |
| | |No ( Complete the applicable Customer Information Certificate| |
|2 |Full name of company as registered with ASIC | | |
|3 |Does the company have a business name other than the company | Yes ( (insert registered business name) | |
| |name registered with ASIC? |No | |
|4 |ACN | | |
|5 |Does the company have an ABN? | Yes ( (insert ABN) | |
| | |No | |
|6 |Company’s office address as registered with ASIC (not a PO | | |
| |box) | | |
|7 |Company’s principal place of business address (not a PO box) | | |
| | |Same as company’s office address above as registered with ASIC | |
|8 |State or Territory as registered with ASIC | | |
|9 |Date registered with ASIC | / / | |
|10 |Is the company a tax resident of any country outside of | Yes | |
| |Australia? |No ( Go to 12 | |
|11 |Country(ies) outside of Australia in which the company is a |Country of tax residence: | |
| |resident for tax purposes and country’s associated Tax |TIN: | |
| |Identification Number (TIN)* |OR | |
| | |TIN not issued by this country | |
| |*A TIN is an identifying number or equivalent used for tax |TIN pending issue by country's tax authority | |
| |purposes. If a ‘TIN’ is not available, please specify the |Country of tax residence: | |
| |reason against the appropriate country. |TIN: | |
| | |OR | |
| |Note: If the company has more than 3 countries in which it is |TIN not issued by this country | |
| |a tax resident, please provide the details on a separate |TIN pending issue by country's tax authority | |
| |paper. |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
|12 |Full name (all given names including middle name(s) and family| | |
| |name) of each Director | | |
| |Note: An initial, nickname, alias, shortened name or part of a| | |
| |name is NOT acceptable. | | |
|13 |Is the company regulated, i.e. licensed and subject to | ASIC and holds an Australian Financial Services Licence (AFSL) | |
| |regulatory oversight, by? |ASIC and holds an Australian Credit Licence (ACL) | |
| |Note: A company is regulated by ASIC only if the company holds|Australian Prudential Regulation Authority (APRA) | |
| |an Australian Financial Services Licence (AFSL) and/or an |Private Health Insurance Administration Council (PHIAC) | |
| |Australian Credit Licence (ACL). |None of the above ( Go to 15 | |
|14 |Licence details (e.g. licence number) |Insert licence details ( | |
| | |Go to 19 | |
|15 |Beneficial Owner – Owner | Yes ( Go to 18 | |
| |Does the company have any INDIVIDUALS (NATURAL PERSONS), who |No ( Go to 16 | |
| |ultimately own directly or indirectly, through one or more | | |
| |shareholdings, 25 per cent or more of the issued capital of | | |
| |the company? | | |
| |Note: This includes INDIVIDUALS (NATURAL PERSONS) who are | | |
| |owners of an underlying company and who ultimately own 25 per | | |
| |cent or more of the issued capital of the company listed above| | |
| |at Q2. | | |
|16 |Beneficial Owner – Controller | Yes ( Go to 18 | |
| |Does the company have any INDIVIDUALS (NATURAL PERSONS), who |No ( Go to 17 | |
| |ultimately control, through a capacity to make financial and | | |
| |operating decisions on behalf of the company? | | |
|17 |Beneficial Owner – Other |Go to 18 | |
| |The company must have at least one ultimate beneficial owner. | | |
| |If you have answered “No” to Q15 and Q16 above, provide the | | |
| |details of any INDIVIDUALS (NATURAL PERSONS), who have 25 per | | |
| |cent or more voting rights (including a power of veto) or hold| | |
| |the position of senior managing official (or equivalent), e.g.| | |
| |CEO? | | |
|18 |Provide the details of each INDIVIDUAL (NATURAL PERSON) who is| | |
| |a beneficial owner |Beneficial Owner 1 | |
| | | | |
| |Note: the identity of all beneficial owners must be verified. |All given names: | |
| |This can be completed through the provision of certified |Family name: | |
| |copies of identification documents or via electronic |Other name(s) known by (if any): | |
| |verification. Electronic verification is only available to |Date of birth: / / | |
| |individuals with an Australian residential address and an |Permanent residential address, including country | |
| |Australian mobile number. |(not a PO Box): | |
| | | | |
| |Foreign Tax Residency Information: |Email address for electronic verification purposes: | |
| |A Tax Identification Number (TIN) is an identifying number or|Foreign Tax Residency Information: | |
| |equivalent used for tax purposes. If a ‘TIN’ is not |Is beneficial owner 1 a tax resident of any country outside of | |
| |available, please specify the reason against the appropriate |Australia? | |
| |country. |Yes | |
| | |No | |
| |Note: If the beneficial owner has more than 3 countries in |If yes, please indicate the country(ies) in which beneficial owner | |
| |which they are a tax resident, please provide the details on a|1 is a resident for tax purposes and each country’s associated TIN.| |
| |separate paper. |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Beneficial Owner 2 | |
| | | | |
| | |All given names: | |
| | |Family name: | |
| | |Other name(s) known by (if any): | |
| | |Date of birth: / / | |
| | |Permanent residential address, including country | |
| | |(not a PO Box): | |
| | | | |
| | |Email address for electronic verification purposes: | |
| | |Foreign Tax Residency Information: | |
| | |Is beneficial owner 2 a tax resident of any country outside of | |
| | |Australia? | |
| | |Yes | |
| | |No | |
| | |If yes, please indicate the country(ies) in which beneficial owner | |
| | |2 is a resident for tax purposes and each country’s associated TIN.| |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | | | |
| | | | |
| | | | |
| | |Beneficial Owner 3 | |
| | | | |
| | |All given names: | |
| | |Family name: | |
| | |Other name(s) known by (if any): | |
| | |Date of birth: / / | |
| | |Permanent residential address, including country | |
| | |(not a PO Box): | |
| | | | |
| | |Email address for electronic verification purposes: | |
| | |Foreign Tax Residency Information: | |
| | |Is beneficial owner 3 a tax resident of any country outside of | |
| | |Australia? | |
| | |Yes | |
| | |No | |
| | |If yes, please indicate the country(ies) in which beneficial owner | |
| | |3 is a resident for tax purposes and each country’s associated TIN.| |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Beneficial Owner 4 | |
| | | | |
| | |All given names: | |
| | |Family name: | |
| | |Other name(s) known by (if any): | |
| | |Date of birth: / / | |
| | |Permanent residential address, including country | |
| | |(not a PO Box): | |
| | | | |
| | |Email address for electronic verification purposes: | |
| | |Foreign Tax Residency Information: | |
| | |Is beneficial owner 4 a tax resident of any country outside of | |
| | |Australia? | |
| | |Yes | |
| | |No | |
| | |If yes, please indicate the country(ies) in which beneficial owner | |
| | |4 is a resident for tax purposes and each country’s associated TIN.| |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
| | |Country of tax residence: | |
| | |TIN: | |
| | |OR | |
| | |TIN not issued by this country | |
| | |TIN pending issue by country's tax authority | |
|19 |Full name of person providing this certificate | |
|20 |Capacity of person providing this certificate (select | Director |
| |appropriate box) |Secretary |
| | |Financial Controller |
| | |Authorised Representative (e.g. solicitor, accountant) |
|21 |Certification |
| |I hereby certify that: |
| |1. I am authorised to complete this certificate on behalf of the Customer; |
| |2. The details included in this certificate are true and correct as at the date of this certificate; |
| |3. All documents in the possession or control of the Customer that verify the information in this certificate have been supplied to the Bank and all |
| |documents so supplied are true and correct as at the date of this certificate; and |
| |4. I acknowledge that the Bank will rely on this certificate to determine whether to provide services to the Customer in compliance with the law. |
|22 |Signature of person providing this certificate |( |
|23 |Date | / / |
Privacy Statement: The personal information the Bank is collecting from you on this form will be used to satisfy the Bank's identification requirements under the Anti-Money Laundering & Counter-Terrorism Financing Act and Rules. If you do not provide all the information requested, the Bank may not be able to provide any product or service to the Customer. The Bank will use and disclose your personal information to other members of the Westpac Group, anyone the Bank engages to do something on its behalf, and other organisations that assist the Bank with its business which may include organisations located outside of Australia and to government agencies and regulators, in some cases offshore. Details are in the Bank’s privacy policy. The Bank's privacy policy, available at .au or by calling 132 032 (or from overseas +61 2 9293 9270), contains information about how the Bank handles your personal information, how you can access the personal information the Bank holds about you and seek its correction, how you may complain about a breach of the Australian Privacy Principles and how the Bank will deal with your complaint.
You agree that where you have provided personal information about other individuals in this form you will tell those individuals that you have supplied their information to the Bank and make them aware of the contents of this Privacy Statement and that for each Beneficial Owner whose email address has been provided to the Bank you have made them aware of, and obtained their consent to, the Bank contacting them by email for the purpose of each Beneficial Owner electing to proceed with the Bank conducting online verification of their identity to satisfy the Bank’s identification requirements.
Westpac Group means Westpac Banking Corporation and its related bodies corporate.
Note: It is an offence under the Anti-Money Laundering & Counter-Terrorism-Financing Act 2006 to knowingly provide false or misleading information or knowingly produce a false or misleading document. Penalty: Imprisonment for 10 years.
Our Reporting Obligations: We are required to identify tax residents of a country(ies) other than Australia in order to meet account information reporting requirements under local and international laws.
If at any time after account opening, information in our possession suggests that you, the entity and/or any individual who holds ownership and/or control in the entity of 25% or more (Controlling Person/Beneficial Owner) may be a tax resident of a country(ies) other than Australia, you may be contacted to provide further information on your foreign tax status and/or the foreign tax status of the entity and/or any Controlling Person/Beneficial Owner. Failure to respond may lead to certain reporting requirements applying to the account.
By completing this application you certify that if at any time there is a change to the foreign tax status details for you, the entity and/or any controlling persons/beneficial owner, you will inform the bank. You also certify that if at any time there is a change of a controlling person/s/beneficial owner/s in your entity, you will inform the bank.
A controlling person/beneficial owner refers to the individual(s) that directly or indirectly owns a legal interest in the entity of 25% or more and/or exercises actual effective control over the entity, whether from an economic or other perspective such as through voting rights. In addition, in the case of a trust, a controlling person/beneficial owner includes the settlor(s), trustee(s), appointer(s), protector(s), beneficiary(ies) or classes of beneficiaries and in the case of an entity other than a trust, the term includes persons in equivalent or similar positions.
-----------------------
Westpac Banking Corporation ABN 33 007 457 141
AFSL and Australian credit licence 233714
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.