FATCA Self-Certification – Declaration of Non-U.S. Person

In accordance with the Foreign Account Tax Compliance Act (FATCA) and applicable local laws and regulations, I, the undersigned, hereby declare the following:

1. I am not a U.S. person for tax purposes.
  This means that:

  • I am not a U.S. citizen or U.S. tax resident

  • I do not hold a U.S. passport or Green Card

  • I was not born in the United States, or if I was, I have since relinquished my U.S. citizenship and can provide documentation upon request

  • I am not a U.S. resident alien under U.S. Internal Revenue Code (i.e., I do not meet the substantial presence test)

  • I do not have a U.S. tax identification number (TIN)

2. I understand that if I reside in the United States for 183 days or more during any calendar year, I may be considered a U.S. person under the substantial presence test for U.S. tax purposes.

3. I understand that I must notify Elephants within 30 days if my tax residency status changes and I become a U.S. person for tax purposes.

4. I agree to provide any additional documentation or information as may be required under applicable laws and regulations, including IRS Form W-8BEN, if requested.

5. I acknowledge and consent that if I am found to be, or become, a U.S. person for tax purposes, I authorize Elephants to disclose my information to the relevant tax or regulatory authorities, including the U.S. Internal Revenue Service (IRS), in accordance with applicable laws and regulations.

6. I understand that it is my responsibility to determine my U.S. tax status. Further information on U.S. tax residency and FATCA requirements is available at the official IRS website: https://www.irs.gov/.

7. I certify that the information provided herein is true, complete, and accurate.