自我證明表格—個人
Self-Certification Form — Individual
(適用於自動交換財務帳戶資料)
(Applicable to Automatic Exchange of Financial Account Information (“AEOI”))
客戶姓名客戶帳號
Name of Client: Client A/C Number:
第1部份個人帳戶持有人的身分識辨資料(對於聯名帳戶或多人聯名帳戶，每名個人帳戶持有人須分別填寫一份表格)
Part 1 Identification of Individual Account Holder (For joint or multiple account holders, complete a parate form for each individual account holder.)
(1)帳戶持有人的姓名Name of Account Holder
稱謂(例如：先生、太太、女士、小姐)
Title (e.g. Mr, Mrs, Ms, Miss)
姓氏* Last Name or Surname*
名字* First or Given Name*学校入党流程
中間名Middle Name(s)
(2)香港身份證或護照號碼地藏菩萨本愿经全文
Hong Kong Identity Card or Passport Number
(3)現時住址Current Residence Address
第1行(例如：室、樓層、大廈、街道、地區)
Line 1 (e.g. Suite, Floor, Building, Street, District)
凉茶配方
第2行(城市)* Line 2 (City)*
第3行(例如：省、州) Line 3 (e.g. Province, State)
國家* Country*
郵政編碼/郵遞區號碼Post Code/ZIP Code
(4)通訊地址(如通訊地址與現時住址不同，填寫此欄)Mailing Address (Complete if different to the current residence address)
第1行(例如：室、樓層、大廈、街道、地區)
Line 1 (e.g. Suite, Floor, Building, Street, District)
第2行(城市) Line 2 (City)
第3行(例如：省、州) Line 3 (e.g. Province, State)
國家Country
郵政編碼/郵遞區號碼Post Code/ZIP Code
(5)出生日期*及出生地(國家/城市)
Date of Birth* and Place of Birth (Country/City)
1
Self-Certification Form - Individual (revid on 18 May 2018)
2
Self-Certification Form - Individual (revid on 18 May 2018)
第2部份 居留司法管轄區及稅務編號或具有等同功能的識辨編號(以下簡稱「稅務編號」)* Part 2 Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent ("TIN") *
提供以下資料，列明(a)帳戶持有人的居留司法管轄區，亦即帳戶持有人的稅務管轄區(香港包括在內)及(b)該居留司法管轄區發給帳戶持有人的稅務編號。列出所有(不限於5個)居留司法管轄區。格雷格奥登
Complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where
the account holder is a resident for tax purpos and (b) the account holder's TIN for each jurisdiction indicated. Indicate all (not restricted to five) jurisdictions of residence. 如帳戶持有人是香港稅務居民，稅務編號是其香港身份證號碼。
If the account holder is a tax resident of Hong Kong, the TIN is the Hong Kong Identity Card Number.
如沒有提供稅務編號，必須填寫合適的理由：
If a TIN is unavailable, provide the appropriate reason A, B or C: 理由A — 帳戶持有人的居留司法管轄區並沒有向其居民發出稅務編號。
Reason A — The jurisdiction where the account holder is a resident for tax purpos does not issue TINs to its residents. 理由B — 帳戶持有人不能取得稅務編號。如選取這一理由，解釋帳戶持有人不能取得稅務編號的原因。
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 lected this reason. 理由C — 帳戶持有人毋須提供稅務編號。居留司法管轄區的主管機關不需要帳戶持有人披露稅務編號。
Reason C — TIN is not required. Select this reason only if the authorities of the jurisdiction of reside
nce do not require the TIN to be disclod.
系统测试工程师第3部份 聲明及簽署
Part 3
Declarations and Signature
本人知悉及同意，統一證券可根據《稅務條例》(第112章)有關交換財務帳戶資料的法律條文，(a)收集本表格所載資料並可備存作自動交換財務帳戶資料用途及(b)把該等資料和關於帳戶持有人及任何須申報帳戶的資料向香港特別行政區政府稅務局申報，從而把資料轉交到帳戶持有人的居留司法管轄區的稅務當局。
I acknowledge and agree that (a) the information contained in this form is collected and may be kept by PSHK for the purpo 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 PSHK to the Inland Revenue Department
of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purpos, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112).
工程管理实习日记本人證明，就與本表格所有相關的帳戶，本人是帳戶持有人 / 本人獲帳戶持有人授權簽署本表格#。
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.
本人承諾，如情況有所改變，以致影響本表格第1部份所述的個人的稅務居民身分，或引致本表格所
載的資料不正確，本人會通知統一證券，並會在情況發生改變後30日內，向統一證券提交一份已適當更新的自我證明表格。清明节的谚语
I undertake to advi PSHK of any change in circumstances which affects the tax residency status of the individual identified in Part 1 of this form or caus the information contained herein to become incorrect, and to provide PSHK with a suitably updated lf-certification form within 30 days of such change in circumstances.
本人聲明就本人所知所信，本表格內所填報的所有資料和聲明均屬真實、正確和完備。
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. 簽署Signature
姓名Name
身分Capacity
(如你不是第1部份所述的個人，說明你的身分。如果你是以授權人身分簽署這份表格，須夾附該授權書的核證副本。
Indicate the capacity if you are not the individual identified in
Part 1. If signing under a power of attorney, attach a certified
copy of the power of attorney.) 日期Date
# 刪去不適用者 # Delete as appropriate
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