FATCA and CRS - Individual and Controlling

Person Self-Certification

Reference no
FI3712742

Please consult your professional tax advisor on your tax residency and any related guidance on
the Foreign Account Tax Compliance Act (FATCA) and the Common Reporting Standard (CRS).

NOTES FOR COMPLETING THIS FORM – the form does not save details entered and information will
be lost if it is not completed and submitted in one go. To assist you to do this, you will need the
following information before starting:
• Nedbank CIS number(s) – this can be found on the communication we sent to you
• Your SA ID number
• Your foreign passport number if applicable
• All Nedbank CIS number(s) of entities or account holders for which you are a controlling
person
• Registration number of entity for which you are a controlling person
• Both SA and foreign tax identification number(s) as applicable

Completing the form takes 5 - 8 minutes.

.
Please note that, for the purposes of this document, a number of the technical terms used in the self-
certification form are defined in the attached glossary of terms; which can be accessed through the
following link: Glossary of terms for individual and controlling person self-certification

If you do not want to click on a link, please type the following address in your browser:
https://www.nedbank.co.za/content/nedbank/desktop/gt/en/supplimentary/fatca_crs-individual-
glossary.html

Part 1 - Identification of accountholder / controlling person

Nedbank CIS number (if this is not provided, leave blank)

Title
Mr
First name
Olivier
Surname
Munga
Second name
Eyaba
Initials
OEM
Country of birth
Congo - the Democratic Republic of the
Place of birth (city or town)
Lubumbashi
Date of birth
1980/09/03

Please provide all identification types, countries and numbers, applicable to client,
accountholder(s) / controlling person(s): Nedbank Limited Reg No 1951/000009/06.
Authorised financial services and registered
credit provider.
Identification Type
SA ID
P O Box 1144, Johannesburg, 2000,
South-Africa Tel: +27 (0)11 294 4444
Identification number Website: nedbank.co.za
8009035475188
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 FATCA and CRS - Individual and Controlling
Person Self-Certification

South African tax reference number

2203314170

Current physical address

If your address has changed and / or is different to the information on our records, we
will ask you to bring proof into the branch to enable us to re FICA (Financial
Intelligence Centre Act) you.

South African or Foreign address?

● South Africa
Foreign
Please tick the box if this is an in-care-of address.

Unit number
3
Building name

Street number
1
Street name
Banbury road
Suburb
LYME PARK
Town or City

BRYANSTON
Province
Gauteng
Postcode / Zip code
02191

Postal address

✔ Tick this box if your postal address is the same as your physical address

Part 2 - Certify citizenship, nationality and country of tax obligation

Please select appropriate options:

Do you have tax obligations, tax liabilities or tax residencies outside of South
Africa?

Yes Nedbank Limited Reg No 1951/000009/06.

Authorised financial services and registered
● No credit provider.

Are you a US citizen, a US person or a US national ? P O Box 1144, Johannesburg, 2000,

South-Africa Tel: +27 (0)11 294 4444
Website: nedbank.co.za
Yes
● No Page 2 of 4
 FATCA and CRS - Individual and Controlling
Person Self-Certification

Part 4 - Entity/Entities that hold(s) account(s) at Nedbank and in relation to which you
are a controlling person, if applicable:

Nedbank CIS number(s) - can be found on the communication we sent to the entity
account holder
Name of account holder
Olivier Eyaba Munga
Registration number of entity (if registered)

Nedbank CIS number for the account holder(s) you are a controlling person of

110190172509

Part 5 - Declarations and acceptance of terms and conditions

I, the undersigned:
(i) certify that all statements made in this declaration are, to the best of
my knowledge and belief, correct and complete;

(ii) undertake to advise Nedbank within 30 days of any change in

circumstances that affects the accountholder's tax residency, status and/
or causes the information contained herein to become incorrect, and to
provide Nedbank with an updated self-certification (this form) within 90
days of such change in circumstances;

(iii) understand that the information contained in this form and

information regarding any reportable account(s) may be provided to the
South African Revenue Service, and exchange with tax authorities of
other countries, in terms of South African tax legislation;

(iv) undertake to notify the accountholder of the completion of this form

and advise them that the information in this form and information
regarding any reportable account(s) may be provided to the South African
Revenue Service, and exchange with tax authorities of other countries, in
terms of South African tax legislation; and

(v) understand that, by selecting "Yes" below it is deemed that I have

attached my signature to this document.
✔ Please tick if you have completed and are submitting this on behalf of another person

Name of person completing and submitting the form

Olivier E Munga
Please state the capacity under which you are completing and submitting this form
Myself
Please tick if you are signing under Power of Attorney

Date
26/02/2018 Nedbank Limited Reg No 1951/000009/06.
Authorised financial services and registered
Please tick to confirm that you accept the above mentioned terms. credit provider.
✔
Yes
P O Box 1144, Johannesburg, 2000,
South-Africa Tel: +27 (0)11 294 4444
No Website: nedbank.co.za

Please note that you cannot continue if you have not accepted the terms and conditions. If
you do not accept, we will be required to issue a letter of non-compliance. Page 3 of 4
FATCA and CRS - Individual and Controlling
Person Self-Certification

Submit by Email

Nedbank Limited Reg No 1951/000009/06.

Authorised financial services and registered
credit provider.

P O Box 1144, Johannesburg, 2000,

South-Africa Tel: +27 (0)11 294 4444
Website: nedbank.co.za

Page 4 of 4