Home > Self-certification declaration Self-certification declaration Important notice> 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.> As a financial institution, we are not allowed to give tax advice. Please contact a specific tax adviser if you require guidance regarding how to determine your tax status.Full name*Physical address*Date of birth*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. Jursdiction of residenceTINIf you are tax residence of any additional countries please provide Jurisdiction of Residence details and the TIN number (or reason why the TIN is unavailable) below.If TIN is unavailable please select a reason whyReason A: The jurisdiction where I am a resident for tax purposes does not issue TINs to its residents.Reason B: You are unable to obtain a TIN. Explain why you are unable to obtain a TIN if you have selected this reason.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.If you selected Reason B, please explain why the account holder is unable to obtain a TIN.or I am a tax resident of New Zealand only DeclarationI 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 Credit Union Baywide 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 Credit Union Baywide 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.* Tick to confirm that you acknowledge and agree to the above declaration. * This iframe contains the logic required to handle Ajax powered Gravity Forms.