Self-certification for the purpose of the automatic exchange of financial information under Art. 142t, para. 1 of the Tax and Social Security Procedure Code (TSSPC) from
Part 1. Name of the Account Holder - individual
- First name:
- Middle name:
- Last name:
Part 2. Residential address
- Country:
- City or town:
- Address (District, Street, No, Floor, Apt):
- Postal code:
Part 3. Date and place of birth
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Date of birth:
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Place of birth:
Part 4. Nationality
- Nationality:
- If the Account Holder has more than one nationality (including green card in the case of USA), please mark with an “X” and list in the field below all countries of which the Account Holder is a citizen. X
- Other nationality:
Part 5. Jurisdiction of tax residence and Tax Identification Number (TIN)
- Jurisdiction of which the Account Holder is a resident for tax purposes:
- Tax Identification Number issued by that Jurisdiction:
If the Account Holder is a Bulgarian tax resident, please fill in the Unified Civil Number (UCN), Personal Number of a Foreigner (PNF) or official number issued by the NRA.
Part 6. If the Account Holder is a tax resident of more than one Jurisdiction, please fill in information for each Jurisdiction separately. If necessary multiply the table.
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- Other Jurisdiction of which the Account Holder is a resident for tax purposes:
- City or town:
- Address (District, Street, No, Floor, Apt):
- Postal code:
- Tax Identification Number issued by that other Jurisdiction:
- Other information:
I declare that the provided information is true, correct, complete and submitted voluntarily. I undertake the obligation to inform immediately Deltastock in writing in case of any change to that information and to provide any other data or documents, if necessary.
I agree Deltastock to process, store, use and disclose my personal data to third parties in cases provided by law and I confirm that I have received the information under Art. 19, para. 1 of Personal Data Protection Act.
I declare that I am notified about the possibility the information under Art. 142b of TSSPC containing my personal data, account balance or value as well as the derived income to be subject to automatic exchange of financial information under chapter sixteen, section IIIa of the TSSPC and to be reported to the Jurisdiction/s of which I am a tax resident in pursuance of the international commitments of the Republic of Bulgaria.
I am aware of the penal liability under Art. 313 of the Penal Code for declaring of false information.
Date:
Signature:
