Self-certification declaration

Valid for all Unity members

Important notes:

  • This is a self-certification form provided by an account holder to a reporting financial institution for the purpose of automatic exchange of financial account information. The data collected may be transmitted by the reporting financial institution to Inland Revenue for transfer to the tax authority of another jurisdiction. This form is intended to request information consistent with New Zealand Tax law.
  • An account holder should report all changes in his/her tax residency status to the reporting financial institution.
  • Unity does not provide tax advice. Please contact a specific tax adviser if you require guidance regarding how to determine your tax status.

Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)

Enter below the country of residence where you are a resident for tax purposes and your TIN for each jurisdiction indicated. Indicate all countries of residence.

If you are a tax resident of New Zealand only, you can skip the 'Jurisdiction of Residence' questions and just tick the "I am a tax resident of New Zealand only" box below.

What is a TIN? (Need help working out what your TIN is? It's a combination of letters or numbers issued by tax authorities or other agencies, and used to identify you for tax purposes in your country of tax residence. For what this may mean in your country search 'TIN' on oecd.org)

Or

Declaration

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 Inland Revenue and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to intergovernmental agreements to exchange financial account information. I certify that I am the account holder (or am authorised to sign for the Account Holder) of all the account(s) to which this form relates. I undertake to advise Unity 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 Unity with a suitably updated self-certification form within 90 days of such change in circumstances.

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.