Consent to release of information pursuant to FATCA - Wells Fargo

Consent Form 1

Consent to release of information pursuant to FATCA or to other regulatory bodies (Legal Entity)

To Wells Fargo Bank, N.A. [or other WF FFI entities] ("Wells Fargo"):

The undersigned entity acknowledges that Wells Fargo may be subject to the jurisdiction of various regulatory agencies in the United States and other countries outside the country where the undersigned maintains accounts or other relationships with Wells Fargo. In this regard, the undersigned consents to disclosure by Wells Fargo of information about the accounts and organization or ownership of the undersigned entity to any such regulatory bodies Wells Fargo deems necessary or appropriate. In particular, the undersigned entity agrees that the release of information as specifed by rules of the United States Internal Revenue Service (IRS) or other government agency as specifed in any relevant agreement between the United States Treasury Department or other agency and another country's government (Intergovernmental Agreement) addressing sharing of fnancial and other account information among countries, including for purposes of tax administration. Any such disclosures shall not be considered a breach of any duty of confdentiality owed to me by Wells Fargo (by law, contract, or otherwise).

__________________________________ Legal Entity Name

By: _________________________________

__________________________________ Name and title

__________________________________ Date

? 2016 Wells Fargo Bank, N.A. All rights reserved. Member FDIC. WCS-2415762

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