Date:

To,
The Manager,
HDFC Bank Ltd.,
______________________, Branch

Subject Reasonable justification/ Curing documentation for tax residency for mismatch identified in FATCA-CRS
self-certification provided for customer ID______________

Dear Sir/Madam,

Further to FATCA-CRS self-certification form provided to the Bank on ____________, I provide the below details.
(a) I hereby declare that I am currently residing in ______________________________________ (country
name) and

I confirm that I am a tax resident of ______________________________________* as provided in FATCA-

CRS self-certification form and provide reason and additional documents (to be filled if country of
residence & country of tax residence are different) as mentioned in $Note1 below, along with this form
(*Please mention name of all countries where you are tax resident)

OR

(b) My tax residence has changed with effective from _______ (mention year of change) and I wish to submit
a fresh FATCA CRS self certification form enclosed herewith.

$Note1
Reason/ justification (along with documentary proof in the form of VISA etc.) to establish/ justify country of tax
residency being different from country of documented residence (address or contact number)
Student (Student Visa)
Diplomat (Diplomatic Visa)
Mariner/ Sea fearer (Continuous Discharge Certificate (CDC))
Temporary visit (Temporary work visa, Teacher, Tourist or other VISA)
Athlete or Artist or Professional (Appropriate VISA)
Recently shifted residence (Appropriate VISA)
Not qualifying as tax resident as not meeting requisite no. of days stay (Appropriate VISA)
Other , please specify with Appropriate VISA _________________

In case of U.S. persons, where Nationality or Country of Birth is U.S. but tax residency is of other country, the
following documents are provided:
Non-US passport or any non-US government issued document evidencing nationality or citizenship; AND
Certified Copy of Certificate of loss of US Nationality/ Reasonable explanation for not obtaining such certificate

Certification: I/We have understood the information requirements of this Form as per the CBDT notified Rules
114F to 114H and hereby confirm that the information provided by me/us on this Form is true, correct, and
complete. I/We understand that my personal details as provided /available in the bank records will be used for
CBDT reporting / Central KYC Registry. I hereby consent to receiving information from Central KYC Registry
through SMS / Email.

As provided in the FATCA-CRS self-certification form, I/We will inform the Bank within 30 days should there be any
changes in details provided.

In the event of any mismatch in details and sufficient curing documents not provided by me in a timely, I/We
understand that the Bank may be constrained to report information relating to my accounts to tax authorities.

Signature of the account holder

Date: ___ / ____ / ______ Place: ___________________