致澳门国际银行股份有限公司（「银行」）.PDFVIP

致：澳門國際銀行股份有限公司( 「銀行」) 銀行專用For bank use only To: Luso International Banking Limited(“the Bank”) 自證證明表格(實體) – 附件 客戶號CIF No. ： Self-Certification Form (Entity)- Annex 開戶分行Branch ： 重要提示： Important Notes: 1. 這是由控制人向申報金融機構「銀行」提供的自證證明表格，以作自動交換金融賬戶資料用途。申報金融機構「銀行」可把收集所得的資 料交給財政局，財政局會將資料轉交到另一稅務管轄區的稅務當局。 This is a self-certification form provided by a controlling person to a reporting financial institution “the Bank” for the purpose of automatic exchange of financial account information. The data collected may be transmitted by the reporting financial institution “the Bank” to the Financial Services Bureau （“DSF” ）for transfer to the tax authority of another jurisdiction. 2. 如控制人的稅務居民身份有所改變，應盡快將所有變更通知申報金融機構「銀行」。 A controlling person should report all changes in his/ her tax residency status to the reporting financial institution “the Bank”. 3. 除不適用或特別註明外，必須填寫這份表格所有部份。如這份表格上的空位不夠應用，可另紙填寫。在欄/部標有星號(*)的項目為申報金融 機構「銀行」須向財政局申報的資料。 All parts of the form must be completed (unless not applicable or otherwise specified). If space provided is insufficient, continue on additional sheet(s). Information in fields/parts marked with an asterisk (*) are required to be reported by the reporting financial institution “the Bank” to the Financial Services Bureau （“DSF” ）. 附《資料補充續頁(實體-附件)》共 份 Enclosed: .copies of Supplementary Information Continuation Sheets (Entity-Annex) 第一部控制人的身份識辨資料 Part 1 Identification of Controlling Person (1) 控權人姓名: Name of Controlling Person 稱謂 (例如：先生、太太、女士、小姐) Title (e.g. Mr, Mrs, Ms, Miss) 姓氏* Last Name or Surn