請確認你已知曉聲明內容。 Please confirm that you are aware of the declarations. 填寫的資料不完整,請檢查。 最少填上一個居留司法管轄區 必須填上稅務編號 必須填上稅務編號或選擇沒有編號的理由 必須填上帳戶持有人不能取得稅務編號的原因 Please input the correct information. Please provide at least one jurisdiction of residence. TIN must be filled in. You must fill in the TIN or choose no reason for the number. Must fill in the reason why the account holder can not obtain the TIN.
   
 

Self-Certification Form – Individual
自我證明表格 – 個人

 
1. Name of Account Holder
帳戶持有人的姓名
  Title 稱謂   *
  Last Name or Surname 姓氏   *
  First or Given Name 名字   *
  Middle Name(s) 中間名  
  Account 賬戶
E.g.: 012345
  *
  Email 郵箱  
  Phone 手提電話   *
 
2. Identity Card or Passport Number
身份證或護照號碼
E.g.: HKID: A123456(7)
  *
 
3. Current Residence Address
現時住址
 
  Line 1 第一行
(i.e.: Suite室, Floor樓層, Building大廈, Street街道, District地區)
  *
  Line 2 第二行
(i.e.: City城市)
  *
  Line 3 第三行
(i.e.: Province省, State州)
 
  Country 國家   *
  Post Code/ZIP Code 郵政編號/郵遞區號碼  
 
4. Mailing Address (Complete if different to the current residence address)
通訊住址 (如通訊地址與現時營業地址不同,填寫此欄)
 
  Line 1 第一行
(i.e.: Suite室, Floor樓層, Building大廈, Street街道, District地區)
 
  Line 2 第二行
(i.e.: City城市)
 
  Line 3 第三行
(i.e.: Province省, State州)
 
  Country 國家  
  Post Code/ZIP Code 郵政編號/郵遞區號碼  
 
5. Date of Birth (dd/mm/yyyy)
出生日期 (日/月/年)
  *
 
6. Place of Birth
出生地點
  Town/City 鎮/城市  
  Province/State 省/州  
  Country 國家   *
 
7.  Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)
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」)

Complete the following table indicating (a) the jurisdiction of residence (including Hong Kong) where the account holder is a resident for tax purposes and (b) the account holder’s TIN for each jurisdiction indicated. Indicate all (not restricted to five) jurisdictions of residence.
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。

If the account holder is a tax resident of Hong Kong, the TIN is the Hong Kong identity Card Number.
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。


Jurisdiction of Residence
居留司法管轄區
TIN
稅務編號
Enter Reason A, B, C if no TIN is available
如沒有提供稅務編號,填寫理由A、B或C
Explain why the account holder is unable to obtain a TIN if your have selected Reason B
如選取理由B,解釋帳戶持有人不能取得稅務編號的原因
Reason A - The jurisdiction where the account holder is a resident for tax purposed does not issue TINs to its residents
理由A – 帳戶持有人的居留司法稅務管轄區並沒有向其居民發出稅務編號。

Reason B - The account holder is unable to obtain a TIN. Explan why the account holder is unable to obtain a TIN if you have selected this reason.
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 C - TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the TIN to be disclosed
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。
 

Declarations
聲明

I acknowledge and agree that (a) the information contained in this form is collected and may be kept by Celestial Securities Limited / Celestial Commodities Limited / CASH Trinity Bullion Limited / Celestial Finance Limited 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 Celestial Securities Limited / Celestial Commodities Limited / CASH Trinity Bullion Limited / Celestial Finance Limited 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 purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112).
本人知悉及同意,時富證劵有限公司 / 時富商品有限公司 / 時富三和金銀業有限公司 / 時富財務有限公司可根據《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 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 undertake to advise Celestial Securities Limited / Celestial Commodities Limited / CASH Trinity Bullion Limited / Celestial Finance Limited of any change in circumstances which affects the tax residency status of the individual identified in Part 1 of this form or causes the information contained herein to become incorrect, and to provide Celestial Securities Limited / Celestial Commodities Limited / CASH Trinity Bullion Limited / Celestial Finance Limited with a suitably updated self-certification form within 30 days of such change in circumstances.
本人承諾,如情況有所改變,以致影響本表格第1部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,本人會通知時富證劵有限公司 / 時富商品有限公司 / 時富三和金銀業有限公司/ 時富財務有限公司,並會在情況發生改變後30日內,向時富證劵有限公司 / 時富商品有限公司 / 時富三和金銀業有限公司 / 時富財務有限公司提交一份已適當更新的自我證明表格。
 

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.
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。
 

WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. $10,000).
警告: 根據《稅務條例》第80(2E)條,如任何人在作出自我證明時,在明知一項陳述在要項上屬具誤導性、虛假或不正確,或罔顧一項陳述是否在要項上屬具誤導性、虛假或不正確下,作出該項陳述,即屬犯罪。一經定罪,可處第3級(即$10,000)罰款。
 
 

* Mandatory field 必須填寫