AIICO CRS Individual Form – AIICO Capital Limited

Family Name or Surname(s) *

Title

First or Given Name *

Middle Name(s)

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 of Residence *

Date of Birth *

DD/MM/YYYY (e.g 25/01/1900)

Town or City of Birth *

Country of Birth *

Country/Jurisdiction of Tax Residence *

Invested Product(s) *

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

TIN

Tax Identification Number

Reason 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 Self Certification, 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.