Declarations and Signature. I acknowledge and agree that (a) the information contained in this form is collected and may be kept by FSSL/FSFL 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 FSSL/FSFL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which I may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am the Account Holder of all the Account and other account(s) to which this form relates. I undertake to advise FSSL/FSFL of any change in circumstances which affects my tax residency status or causes the information contained herein to become incorrect, and to provide FSSL/FSFL with a suitably updated self-certification form within 30 days of such change in circumstances. I declare that the information given and statements made in this form are true, correct and complete. Signature Name Date(dd/mm/yyyy) 開戶資料表格 附表 4 自我證明表格 –個人 (根據:《稅務條例》（第 112 章）法律條文)) 帳 戶 名 稱 : 帳 戶 號 碼 : 如資料與開户書不同，需填寫第 1 部分 第 1 部 個人帳戶持有人的身分識辨資料 （對於聯名帳戶或多人聯名帳戶，每名個人帳戶持有人須分別填寫一份表格）
Declarations and Signature. SUPPORTING DOCUMENTATION: Please attach to your Proof of Claim Form the documents that support your Proof of Claim Forms as further specified above. DO NOT SEND ORIGINAL DOCUMENTS. If such documentation is not available, please attach an explanation of why the documents are unavailable. VERIFICATION OF CLAIMS: All Proof of Claim Forms submitted are subject to verification by the Receiver and approval by the Court. It is important to provide complete and accurate information to facilitate this effort. Claimants may be asked to supply additional information to complete this process CONSENT TO JURISDICTION: If you submit a Proof of Claim Form in this case, you consent to the jurisdiction of the District Court for all purposes related to this claim and agree to be bound by its decisions, including, without limitation, a determination as to the validity and amount of any claims asserted against the Receivership Entities. In submitting a Proof of Claim Form, you agree to be bound by the actions of the District Court even if that means your claim is limited or denied. I (WE) DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT ALL OF THE FOREGOING INFORMATION SUPPLIED ON THIS PROOF OF CLAIM FORM BY THE UNDERSIGNED IS TRUE AND CORRECT. Executed this day of (Month/Year) (Sign your name here) (Type or print your name here) (Capacity of person(s) signing, e.g., Beneficial Purchaser or Acquirer, Executor or Administrator) Reminder Checklist:
Declarations and Signature. I 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 the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am the account holder / I am authorized to sign for the account holder # of all the account(s) to which this form relates. I undertake to advise Excellent Success Investments Limited 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 Excellent Success Investments Limited with a suitably updated self-certification form within 30 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. Signature Name Capacity Date (dd/mm/yyyy) # Delete as appropriate (Indicate the capacity if you are not the individual identified in Part 1. If signing under a power of attorney, attach a certified copy of the power of attorney.) WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. $10,000). 附表 4 致 ： 馬有成投資有限公司(“馬有成投資”) 香港灣仔軒尼詩道 139 號中國海外大廈 22 樓 自我證明表格 – 個人 帳 戶 名 稱 ： _ 帳 戶 號 碼 ： 重要提示： ⚫ 這是由帳戶持有人向申報財務機構提供的自我證明表格，以作自動交換財務帳戶資料用途。申報財務機構可把收集所得的資料交給稅務局，稅務局會將資料轉交到另一稅務管轄區的稅務當局。 ⚫ 如帳戶持有人的稅務居民身分有所改變，應盡快將所有變更通知申報財務機構。 ⚫ 除不適用或特別註明外，必須填寫這份表格所有部分。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 （*）的項目為申報財務機構須向稅務局申報的資料。 第 1 部 個人帳戶持有人的身分識辨資料 （對於聯名帳戶或多人聯名帳戶，每名個人帳戶持有人須分別填寫一份表格）
Declarations and Signature. 第 3 部聲明及簽署 I acknowledge and agree that (a) the information contained in this form is collected and may be kept by GF Futures (Hong Kong) Co., Limited 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 GF Futures (Hong Kong) Co., Limited to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). 本人知悉及同意，廣發期貨(香港)有限公司可根據《稅務條例》（第 112 章）有關交換財務帳戶資料的法律條文，（a）收集本表格所載資料並可備存作自動交換財務帳戶資料用途及（b）把該等資料和關於帳戶持有人及任何須申報帳戶的資料向香港特別行政區政府稅務局申報，從而把資料轉交到帳戶持有人的居留司法管轄區的稅務當局。 I certify that I am the account holder / I am authorized to sign for the account holder # of all the account(s) to which this form relates. 本人證明，就與本表格所有相關的帳戶，本人是帳戶持有人/ 本人獲帳戶持有人授權簽署本表格#。 I undertake to advise GF Futures (Hong Kong) Co., Limited 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 GF Futures (Hong Kong) Co., Limited with a suitably updated self-certification form within 30 days of such change in circumstances. 本人承諾，如情況有所改變，以致影響本表格第 1 部所述的個人的稅務居民身分，或引致本表格所載的資料不正確，本 人會通知廣發期貨(香港)有限公司，並會在情況發生改變後 30 日內，向廣發期貨(香港)有限公司提交一份已適當更新的自我證明表格。 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. 本人聲明就本人所知所信，本表格內所填報的所有資料和聲明均屬真實、正確和完備。 Signature 簽署* Name 姓名 Capacity 身分 (Indicate the capacity if you are not the individual identified in Part 1. If signing under a power of attorney, attach a certified copy of the power of attorney.) （如你不是第 1 部所述的個人，說明你的身分。如果你是以受權人身分簽署這份表格，須夾附該授權書的核證副本。） Date (dd/mm/yyyy) 日 期 （ 日 / 月 / 年 ）* # Delete as appropriate 刪 去 不 適 用 者 WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fin...
Declarations and Signature. I acknowledge and agree that (i) the information contained in this form is collected and may be kept by FSSL/FSFL for the purpose of automatic exchange of financial account information, and (ii) such information and information regarding the controlling person and any reportable account(s) may be reported by FSSL/FSFL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with tax authorities of another jurisdiction or jurisdictions in which I may be resident for tax purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112) . I certify that I am the Controlling Person / I am authorized to sign for the controlling person # of all the Account(s) and other accounts (if any) held by the entity Account Holder(s) to which this form relates. I undertake to advise FSSL/FSFL of any change in circumstances which affects my tax residency status or causes the information contained herein to become incorrect, and to provide FSSL/FSFL with a suitably updated self-certification form within 30 days of such change in circumstances. # Delete as appropriate I declare that the information given and statements made in this form are true, correct and complete. Signature Name Capacity (Indicate the capacity if you are not the Controlling Person. If signing under a power of attorney, attach a certified copy of the power of attorney.) Date (dd/mm/yyyy) 開戶資料表格 附表 6 自我證明表格 –控權人 (根據:《稅務條例》（第 112 章）法律條文)) 帳戶名稱: 帳戶號碼: 如資料與開户書不同，需填寫第 1 部分第 1 部 控權人的身分識辨資料
Declarations and Signature. I acknowledge and agree that (a) the information contained in this form is collected and may be kept by Granville Financial 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 Granville Financial to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am the account holder / I am authorized to sign for the account holder # of all the account(s) to which this form relates. I undertake to advise Granville Financial 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 Granville Financial with a suitably updated self-certification form within 30 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. Signature : Name : （Indicate the capacity if you are not the individual identified in Capacity : Date (dd/mm/yyyy) :
Declarations and Signature. I acknowledge and agree that (a) the information contained in this form is collected and may be kept by FSSL/FSFL 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 FSSL/FSFL to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the Account Holder may be resident for tax purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am authorized to sign for the Account Holder of all the Account and other account(s) to which this form relates. I undertake to advise FSSL/FSFL of any change in circumstances which affects the tax residency status of the Entity Account Holder or causes the information contained herein to become incorrect, and to provide FSSL/FSFL with a suitably updated self-certification form within 30 days of such change in circumstances. I declare that the information given and statements made in this form are true, correct and complete. Signature Name Capacity (e.g. director or officer of a company, partner of a partnership, trustee of a trust etc.) Date (dd/mm/yyyy) 開戶資料表格附表 5 自我證明表格 –實體 (根據:《稅務條例》（第 112 章）法律條文)) 帳戶名稱: 帳戶號碼: 如資料與開户書不同，需填寫第 1 部分 第 1 部 實體帳戶持有人的身分識辨資料 （對於聯名帳戶或多人聯名帳戶，每名實體帳戶持有人須分別填寫一份表格）
Declarations and Signature. I acknowledge and agree that (a) the information contained in this form is collected and may be kept by Global Fiduciary Services Limited 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 Global Fiduciary Services Limited to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the account holder may be resident for tax purposes, pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112). I certify that I am the account holder / I am authorized to sign for the account holder # of all the account(s) to which this form relates. I undertake to advise Global Fiduciary Services Limited 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 Global Fiduciary Services Limited with a suitably updated self-certification form within 30 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. Signature Name Capacity Date (dd/mm/yyyy) (Indicate the capacity if you are not the individual identified in Part 1. If signing under a power of attorney, attach a certified copy of the power of attorney.) # Delete as appropriate WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self- certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. $10,000). 致 ： Global Fiduciary Services Limited 香港灣仔告士打道66號筆克大廈21樓2101室 自我證明表格 – 個人 重要提示： 這是由帳戶持有人向申報財務機構提供的自我證明表格，以作自動交換財務帳戶資料用途。申報財務機構可把收集所得的資料交給稅務局，稅務局會將資料轉交到另一稅務管轄區的稅務當局。 如帳戶持有人的稅務居民身分有所改變，應盡快將所有變更通知申報財務機構。 除不適用或特別註明外，必須填寫這份表格所有部分。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（*）的項目為申報財務機構須向稅務局申報的資料。 第 1 部 個人帳戶持有人的身分識辨資料 （對於聯名帳戶或多人聯名帳戶，每名個人帳戶持有人須分別填寫一份表格）
Declarations and Signature. I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder's relationship with BH Mubasher Financial Services setting out how BH Mubasher may use and share the information supplied by me. I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable Account(s) may be provided to the tax authorities of the country/jurisdiction in which this account(s) is/are maintained and exchange with tax authorities of another country/jurisdiction or counties/jurisdictions in which the account holder may be tax resident pursuant to intergovernmental agreements to exchange financial account information. I certify that I am the account holder (or am authorized to sign for the account holder) of all the account(s) to which this form relates. I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete. I undertake to advise BH Mubasher Financial Services within 10 days 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 or incomplete, and to provide BH Mubasher Financial Services with a suitably updated self-certification and declaration within up to 10 days of such change in circumstances.
Declarations and Signature. I acknowledge and agree that (i) the information contained in this form is collected and may be kept by Granville Financial for the purpose of automatic exchange of financial account information, and (ii) such information and information regarding the controlling person and any reportable account(s) may be reported by Granville Financial to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region and exchanged with tax authorities of another jurisdiction or jurisdictions in which the controlling person may be resident for tax purposes pursuant to the legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112) . I certify that I am the controlling person / I am authorized to sign for the controlling person # of all the account(s) held by the entity account holder(s) to which this form relates. I undertake to advise Granville Financial 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 Granville Financial with a suitably updated self-certification form within 30 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. Signature : Name : (Indicate the capacity if you are not the individual identified Capacity : in Part 1. If signing under a power of attorney, attach a Date (dd/mm/yyyy) : certified copy of the power of attorney.) # Delete as appropriate WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading, false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e. $10,000). Form W-8BEN(Rev. July 2017) Department of the Treasury Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals) ▶ For use by individuals. Entities must use Form W-8BEN-E. ▶ Go to xxx.xxx.xxx/XxxxX0XXX for instructions and the latest information. ▶ Give this form to the withholding agent or payer. Do not send to the IRS. OMB No. 1545-1621 Do NOT use this form if:...
