控制人税收居民身份声明文件（样表）

Declaration of Controller Tax Residencial Identity

(Sample form)

姓名：                                  

Name

本人声明：□ 1.仅为中国税收居民

I declare        I am a tax resident of China only

□ 2.仅为非居民 

I am a non-resident only

□ 3.既是中国税收居民又是其他国家（地区）税收居民 

I’m both a tax resident of China and a tax resident of other countries (regions)

如在以上选项中勾选第2项或第3项，请填写下列信息：

If you checked Item 2 or 3 above, please fill in the following information:

一、机构信息

I. Institutional information

所控制机构名称（英文）：                                                                       

Name of the controlled organization (in English)

机构地址（英文或拼音）：       （国家）      （省）      （市）                                 

Organization address              (country)     (province)      (city)

(in English or Pinyin)

税收居民国（地区）及纳税人识别号：                                                            

Tax resid ent country (region) and Taxpayer identification number

二、控制人信息

II. Control person information

姓（英文或拼音）：               名（英文或拼音）：                出生日期：                   

Surname (in English or Pinyin)       First name (in English or Pinyin)     Date of birth 

现居地址（中文）：       （国家）      （省）      （市）                （境外地址可不填此项）

Current address            (country)    (province)      (city)         (Overseas address is not required)

(in Chinese)

（英文或拼音）：           （国家）            （省）             （市）                       

(in English or Pinyin)          (country)             (province)              (city)

出生地 （中文）：       （国家）      （省）      （市）                 （境外地址可不填此项）

Place of birth             (country)     (province)      (city)          (Overseas address is not required)

(in Chinese)

（英文或拼音）：           （国家）            （省）             （市）                       

(in English or Pinyin)          (country)             (province)              (city)

税收居民国（地区）及纳税人识别号：

Tax resident country (region) and Taxpayer identification number

1.                                                              

2.（如有）(If any)                                               

3.（如有）(If any)                                               

如不能提供居民国（地区）纳税人识别号，请选择原因：

If the taxpayer identification number of the resident country (region) cannot be provided, please select the reason:

□ 居民国（地区）不发放纳税人识别号

The resident country (region) does not issue taxpayer identification number

□ 账户持有人未能取得纳税人识别号，如选此项，请解释具体原因：

The account holder fails to obtain the taxpayer identification number. If this option is selected, please specify the reasons:

三、本人确认上述信息的真实、准确和完整，且当这些信息发生变更时，将在30日内通知贵机构，否则本人承担由此造成的不利后果。

III. I confirm that the above information is true, accurate and complete, and when the information is changed, I will notify your institution within 30 days, otherwise I shall bear the adverse consequences caused by it.

签名：             日期：

Signature              Date

签名人身份： □ 本人   □ 机构授权人 

Identity of signatory       Myself     Authorized person

 by the organization

备注：

上述声明文件均参考OECD声明样表制定，并结合我国业务实际进行了简化处理，仅选取了必填内容。此附件表格为参考表格，金融机构可在此基础上进行修改完善，制定符合自身业务需要的声明文件，或者与本机构其他业务文件进行整合。

Note:

The above declaration documents are made with reference to the OECD declaration sample table, and simplified according to the actual business in China, only the required content is selected. The attached form is a reference form, on which financial institutions can modify and improve, formulate declaration documents that meet their own business needs, or integrate with other business documents of the institution.

此英文版本仅做参考，具体权利义务条款以中文版本为准。

This English version is for reference only. The specific rights and obligations of the Chinese version shall prevail.