Declarations and Signature. 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 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). 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 undertake to advise Excellent Success Investments 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 Excellent Success Investments Limited with a suitably updated self-certification form within 30 days of such change in circumstances. Signature Name Capacity Date (dd/mm/yyyy) (e.g. director or officer of a company, partner of a partnership, trustee of a trust etc.) # Delete as appropriate 致 ： 馬有成投資有限公司(“馬有成投資”) 香港灣仔軒尼詩道 139 號中國海外大廈 22 樓 帳 戶 名 稱 ： 帳 戶 號 碼 ： 重要提示： ⚫ 這是由帳戶持有人向申報財務機構提供的自我證明表格，以作自動交換財務帳戶資料用途。申報財務機構可把收集所得的資料交給稅務局，稅務局會將資料轉交到另一稅務管轄區的稅務當局。 ⚫ ⚫ 如帳戶持有人的稅務居民身分有所改變，應盡快將所有變更通知申報財務機構。 除不適用或特別註明外，必須填寫這份表格所有部分。如這份表格上的空位不夠應用，可另紙填寫。在欄/部標有星號 （*）的項目為申報財務機構須向稅務局申報的資料。 ⚫ （對於聯名帳戶或多人聯名帳戶，每名實體帳戶持有人須分別填寫一份表格）
Declarations and Signature. SUPPORTING DOCUMENTATION: Please attach to your Proof of Claim Form the documents that support your Proof of Claim Forms as further specified above. DO NOT SEND ORIGINAL DOCUMENTS. If such documentation is not available, please attach an explanation of why the documents are unavailable. VERIFICATION OF CLAIMS: All Proof of Claim Forms submitted are subject to verification by the Receiver and approval by the Court. It is important to provide complete and accurate information to facilitate this effort. Claimants may be asked to supply additional information to complete this process CONSENT TO JURISDICTION: If you submit a Proof of Claim Form in this case, you consent to the jurisdiction of the District Court for all purposes related to this claim and agree to be bound by its decisions, including, without limitation, a determination as to the validity and amount of any claims asserted against the Receivership Entities. In submitting a Proof of Claim Form, you agree to be bound by the actions of the District Court even if that means your claim is limited or denied. I (WE) DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT ALL OF THE FOREGOING INFORMATION SUPPLIED ON THIS PROOF OF CLAIM FORM BY THE UNDERSIGNED IS TRUE AND CORRECT. Executed this day of (Sign your name here) (Type or print your name here) (Capacity of person(s) signing, e.g., Beneficial Purchaser or Acquirer, Executor or Administrator)
1. Please sign the above declaration.
2. Remember to attach copies of supporting documentation, if available.
3. Keep a copy of your Proof of Claim and all supporting documentation for your records. 4. If you move, please send the Claims Agent your new address. 5. Contact the Claims Agent at (000) 000-0000 or (000) 000-0000 with any questions. Inquiries can also be sent via email to xxxx@xxxxxxxxxxxxxxxxxxxxxxx.xxx Submit your Proof of Claim Form and supporting documentation to the Receiver’s Claims Agent: (1) By email at xxxx@xxxxxxxxxxxxxxxxxxxxxxx.xxx; (2) by mail to Stanford Financial Claims, X.X. Xxx 000, Xxxxx Xxxxxx, XX 00000-0000;
Declarations and Signature. I acknowledge and agree that (a) the information contained in this form is collected and may be kept by FSSL/FSFL 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 FSSL/FSFL 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). I certify that I am authorized to sign for the Account Holder of all the Account and other account(s) to which this form relates. I undertake to advise FSSL/FSFL of any change in circumstances which affects the tax residency status of the Entity Account Holder or causes the information contained herein to become incorrect, and to provide FSSL/FSFL with a suitably updated self-certification form within 30 days of such change in circumstances. Signature Name Capacity Date (dd/mm/yyyy) (e.g. director or officer of a company, partner of a partnership, trustee of a trust etc.) 附表 5 (根據:《稅務條例》（第 112 章）法律條文)) 帳 戶 名 稱 : 帳 戶 號 碼 : （對於聯名帳戶或多人聯名帳戶，每名實體帳戶持有人須分別填寫一份表格）
(1) 實體或分支機構的法定名稱 *
(2) 實體成立為法團或設立所在的稅務管轄區
(3) 香港商業登記號碼 (4)現時營業地址
Declarations and Signature. 第 3 部聲明及簽署
Declarations and Signature. I acknowledge and agree that (i) the information contained in this form is collected and may be kept by FSSL/FSFL for the purpose of automatic exchange of financial account information, and (ii) such information and information regarding the controlling person and any reportable account(s) may be reported by FSSL/FSFL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with tax authorities of another jurisdiction or jurisdictions in which I 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) . I certify that I am the Controlling Person / I am authorized to sign for the controlling person # of all the Account(s) and other accounts (if any) held by the entity Account Holder(s) to which this form relates. I undertake to advise FSSL/FSFL of any change in circumstances which affects my tax residency status or causes the information contained herein to become incorrect, and to provide FSSL/FSFL with a suitably updated self-certification form within 30 days of such change in circumstances. # Delete as appropriate Signature Name Capacity (Indicate the capacity if you are not the Controlling Person. If signing under a power of attorney, attach a certified copy of the power of attorney.) Date (dd/mm/yyyy) 附表 6 (根據:《稅務條例》（第 112 章）法律條文)) 帳戶名稱: 帳戶號碼:
(1) 控權人的姓名姓氏 * 名 字 *
(2) 香港身份證或護照號碼
(3) 現時住址
(4) 通訊地址（如通訊地址與現時住址不同，填寫此欄）
(5) 出生日期 * （日/月/年）
(6) 出生地點 （可不填寫） 第 2 部 你作為控權人的實體帳户持有人 實體 實體帳户持有人的名稱
(1) (2) (3) 第 3 部 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」）* 理由 A – 控權人的居留司法稅務管轄區並沒有向其居民發出稅務編號。 理由 B – 控權人不能取得稅務編號。如選取這一理由，解釋控權人不能取得稅務編號的原因。
(2) (3)
Declarations and Signature. I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder's relationship with BH Mubasher Financial Services setting out how BH Mubasher may use and share the information supplied by me.
Declarations and Signature. The Account Holder understands that the information supplied by it is covered by the full provisions of the terms and conditions governing the Account Holder’s relationship with the Financial Institution setting out how the Financial Institution may use and share the information supplied by the Account Holder. The Account Holder acknowledges that the Financial Institution may disclose and transfer to the Financial Institution’s parent companies, and its and their respective branches, subsidiaries, affiliates, representative offices, or third party service providers located anywhere in the world (in or outside the country or jurisdiction in which the Account Holder resides, in which their relationship with the Financial Institution is maintained, in which the account or transaction is booked, in which information is collected and/or retained or in which the transaction is conducted) the information contained in this form and other information regarding the Account Holder, any Controlling Person and any Reportable Account(s) when considered necessary by the Financial Institution for its business purposes or in connection with, to comply with, or to facilitate compliance with, any law, regulation, court order or requirement (including under any code, guideline, standard, policy, circular or notice) of a governmental, regulatory, supervisory, law enforcement, prosecuting, tax or similar authority or industry body in any jurisdiction existing currently or in the future, or for the purposes of ongoing cooperation with such governmental, regulatory and/ or statutory authority, or to comply with any agreement or arrangement with such authority or between such authorities in any jurisdiction existing currently or in the future. The Account Holder consents to and instructs and authorizes the Financial Institution to make such disclosures and transfers and expressly waive any protection or right under data protection, confidentiality, or any other applicable law, to the extent necessary for such disclosures and transfers. The Account Holder acknowledges that the information contained in this form and information regarding the Account Holder may be reported to the tax authorities of the country/jurisdiction in which this account(s) is/are maintained and exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be tax resident pursuant to intergovernmental agreements to exchange financial account informati...
Declarations and Signature. I acknowledge and agree that (i) the information contained in this form is collected and may be kept by Granville Financial for the purpose of automatic exchange of financial account information, and (ii) such information and information regarding the controlling person and any reportable account(s) may be reported by Granville Financial to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with tax authorities of another jurisdiction or jurisdictions in which the controlling person 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) . I certify that I am the controlling person / I am authorized to sign for the controlling person # of all the account(s) held by the entity account holder(s) to which this form relates. I undertake to advise Granville Financial 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 Granville Financial with a suitably updated self-certification form within 30 days of such change in circumstances. Signature : Name : (Indicate the capacity if you are not the individual identified Capacity : in Part 1. If signing under a power of attorney, attach a Date (dd/mm/yyyy) : certified copy of the power of attorney.) # Delete as appropriate Form W-8BEN(Rev. July 2017) Department of the Treasury Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals) ▶ For use by individuals. Entities must use Form W-8BEN-E. ▶ Go to xxx.xxx.xxx/XxxxX0XXX for instructions and the latest information. ▶ Give this form to the withholding agent or payer. Do not send to the IRS. OMB No. 1545-1621 Do NOT use this form if: Instead, use Form: • You are NOT an individual W-8BEN-E • You are a U.S. citizen or other U.S. person, including a resident alien individual . . . . . . . . . . . . . . . . . . . W-9 • You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal services) W-8ECI
Declarations and Signature. I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder's relationship with BH Mubasher Financial Services setting out how BH Mubasher may use and share the information supplied by me. I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable Account(s) may be provided to the tax authorities of the country/jurisdiction in which this account(s) is/are maintained and exchange with tax authorities of another country/jurisdiction or counties/jurisdictions in which the account holder may be tax resident pursuant to intergovernmental agreements to exchange financial account information. I certify that I am the account holder (or am authorized to sign for the account holder) of all the account(s) to which this form relates. I undertake to advise BH Mubasher Financial Services within 10 days 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 or incomplete, and to provide BH Mubasher Financial Services with a suitably updated self-certification and declaration within up to 10 days of such change in circumstances. Date: خيراتلا Client Name: ليمعلا مسا Account No. (for company use) باسحلا مقر )ةكرشلا مادختسلا(
Declarations and Signature. [I] declare that all statements made in this self-certification form are, to the best of [my] knowledge and belief, correct and complete.
