个人税收居民身份声明文件
Individual Tax Residency Self-certification Form

姓名（中文）
Name(Chinese)

第一联开户信用社（银行）留存

本人声明
I hereby declare

 1. 仅为中国税收居民   PRC tax resident only

 2. 仅为非居民  Non-resident only

 3. 既是中国税收居民又是其他国家（地区）税收居民  Both PRC and tax resident in other jurisdiction

如您在以上选项中勾选第1项，请直接在签名处签名；如您在以上选项中勾选第2项或者第3项，请填写下列信息，并在签名处签名。
If option 1 is selected,please directly sign the document; if option 2 or 3 is selected,please fill in the following information and sign the document.

姓（英文或拼音）
Last Name(English or Pinyin)

名（英文或拼音）
First Name(English or Pinyin)

出生日期
Date of Birth

现居地址（英文或拼音）
Current residence address
 (English or Pinyin)

（国家/地区）(Country/region)

（市）(City)

（详细地址）(Detailed address)

出生地址（中文）
（境外地址可不填此项）
Place of birth (Chinese) (skip this in case of an overseas address)

（国家/地区）(Country/region)

（市）(City)

（详细地址）(Detailed address)

出生地址（英文或拼音）
Place of birth (English or Pinyin)

（国家/地区）(Country/region)

（市）(City)

（详细地址）(Detailed address)

序号
S/N

税收居民国/ 地区
Tax residency country/ region

纳税人识别号
TIN

若无法提供 “ 纳税人识别号 ” ，请选择原因 A 或原因 B
If a TIN cannot be provided,please select reason A or B

若选择原因B，请解释具体原因
If reason B is selected,please explain in details

1

□ A              □ B

2

□ A              □ B

3

□ A              □ B

原因A：居民国（地区）不发放纳税人识别号
Reason A: The Country/region of residence where the individual is resident does not issue TINs to its residents.
原因B：账户持有人未能取得纳税人识别号（若选此项，请解释具体原因）
Rcason B: The Account Holder is otherwise unable to obtain a TIN (Please explain why you are unable to obtain a TIN if you have selected this reason.)

本人确认上述信息的真实、准确和完整，且当这些信息发生变更时，将在30日内通知贵行，否则本人承担由此造成的不利后果。
I hereby confirm the authenticity,accuracy and completeness of the above mentioned information,and will notify the Bank within 30 days when there is a change of circumstances.Otherwise,I will bear any adverse consequences.

          本人/代理人签名：
Signature/Signature of agent:
                                                                                                                    日期：                 年                      月                     日
                                                                                                                            Date:                       Year                     Month                   Day

      银行签章：
Signature of Bank：

                       经办签章：
  Signature or seal of handler：