AIICO CRS Corporate Form – AIICO Capital Limited

Legal Name of Entity/Branch *

Country of Incorporation

Email *

Phone Number

start with the country code e.g 2348058905763

Address *

e.g. House/Apt/Suite Name, Number, Street, if any

State *

e.g. Town/City/Province/County/State

Country *

Postal Code

Company Type

Custodial Institution, Depository Institution or Specified Insurance Company
Investment Entity, except an investment entity that is managed by another financial institution (e.g. with discretion to manage the entity’s assets) and located in a non-participating jurisdiction

Invested Product(s) *

Guaranteed Income Note (GIN)
AIICO Money Market Fund (AMMF)
AIICO Balanced Fund (ABF)

Active NFE

NFE the stock of which is regularly traded is an established securities market
NFE is a governmental entity, an international organization, a central bank, or an entity wholly owned by one or more of the foregoing entities
Active NFE other than the above

Controlling Person 1 *

First

Last

Indicate the names of one of the controlling person of the account holder. If no natural person exercises control over an entity which is a legal person, the controlling person will be the individual holding the position of senior managing official. Complete Self Certification Form – Controlling Person for each controlling person.

Controlling Person 2

First

Last

Indicate the names of one of the controlling person of the account holder. If no natural person exercises control over an entity which is a legal person, the controlling person will be the individual holding the position of senior managing official. Complete Self Certification Form – Controlling Person for each controlling person.

Controlling Person 3

First

Last

Indicate the names of one of the controlling person of the account holder. If no natural person exercises control over an entity which is a legal person, the controlling person will be the individual holding the position of senior managing official. Complete Self Certification Form – Controlling Person for each controlling person.

Passive NFE

Investment entity that is managed by another financial institution and located in a non-participating jurisdiction
NFE that is not an active NFE

Country/Jurisdiction of Tax Residence *

TIN

Tax Identification Number

Reasons for No TIN

Reason A – The jurisdiction where the account holder is a resident for tax purposes does not issue TIN to its residents.
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.
TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the TIN to be disclosed.

Explain why the account holder is unable to obtain a TIN if you have selected Reason B

Declaration *

check the box *

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
FEDERAL INLAND REVENUE SERVICE and exchanged with the tax authorities of another jurisdiction or jurisdictions in which
the account holder may be resident for tax purposes.

I certify that I am the account holder / I am authorized to sign for the account holder of all the account(s) to which this
form relates.

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. I agree to AIICO Capital processing my Personal Data in line with its Privacy Policy.

WARNING:

It is an offence under section 10(3) of the Income Tax (CRS) Regulations, 2019 for any person, in making a SelfCertification, makes a false statement, false report or false declaration or gives any false information or omission in respect of any information required to be included on an Information Return under regulation 5 of these Regulations, the Service shall impose an administrative penalty of N5,000,000.00 and such person may also be liable to penalties as
prescribed in the Act.