Foreign Account Tax Compliance (FATCA) Self-Certification Form

Foreign Account Tax Compliance (FATCA) Self-Certification Form — Form Fields

This finance template includes 12 fields. Self-certify tax residency and FATCA status for accounts held at financial institutions. Free to customize and use on ZenBuild.

• Account Holder Full Name (text, required)
• Date of Birth (text, required)
• Country of Birth (text, required)
• Email Address (email, required)
• Current Residential Address (text, required)
• Country of Tax Residency (dropdown selection, required) — options: United States, United Kingdom, Canada, Australia, Germany, France, Other (list below)
• Other Country of Tax Residency (if applicable) (text, optional)
• Tax Identification Number (TIN or SSN) (text, required)
• Are you a US Person (citizen, resident, or green card holder)? (multiple choice, required) — options: Yes, No
• FATCA Status (for entities) (checkboxes, optional) — options: Active NFFE, Passive NFFE, Exempt beneficial owner, Certified deemed-compliant FFI, Not applicable (individual account)
• Government-Issued ID (file upload, required)
• Additional Tax Residency Notes (long text, optional)