Statement of Reportable Account under section 508(1)

A.1 REPORTING ENTITY DETAILS

A.1.1

Reporting Entity Name

A.1.2

Income-tax Department Re- porting Entity Identification Number

A.1.3

Global Intermediary Identifica- tion

Number (GIIN)

A.1.3

Registration Number

A.1.5

Reporting Entity Category

Insert 2 character code

A.2 STATEMENT DETAILS

A.2.1

Statement Type

Insert 2 character code

A.2.2

Statement Number

A.2.3

Original Statement id

A.2.4

Reason for Correction

Insert 1 character code

A.2.5

Statement Date

A.2.6

Reporting Period

A.2.7

Report Types

Insert 2 character codes

A.2.8

Number of Reports

A.3 PRINCIPAL OFFICER DETAILS

A.3.1

Name

A.3.2

Designation

A.3.3

Address

A.3.4

City / Town

A.3.5

Postal Code

A.3.6

State Code

Insert 2 character codes

A.3.7

Country Code

Insert 2 character codes

A.3.8

Telephone

A.3.9

Mobile

A.3.10

Fax

A.3.11

Email

B.1 ACCOUNT DETAILS (To be provided for each person being reported)

B.1.1

Report Serial Number

B.1.2

Original Report Serial Number

B.1.3

Account Type

B.1.4

Account Number

B.1.5

Account Category

B.1.6

Account Number Type

Insert 1 character code

B.1.7

Account Holder Name

B.1.8

Account Status

Insert 1 character code

B.1.9

Account Treatment

Insert 1 character code

B.1.10

Equity Interest Type

Insert 2 character code

B.1.11

Self- certification

Insert 1 character code

B.1.12

Documentation Status

Insert 1 character code

B.1.13

Joint Account

Insert 1 character code

B.1.14

Number of Joint Account Holders

B.1.15

Date of closure of account, if closed during the year

B.1.16

Currency in which account is maintained

B.2 BRANCH DETAILS

B.2.1

Branch Number Type

Insert 1 character code

B.2.2

Branch Reference Number

B.2.3

Branch Name

B.2.4

Branch Address

B.2.5

City Town

B.2.6

Postal Code

B.2.7

State Code

Insert 2 character code

B.2.8

Country Code

Insert 2 character code

B.2.9

Telephone

B.2.10

Mobile

B.2.11

Fax

B.2.12

Email

B.3 ACCOUNT SUMMARY

B.3.1

Account balance or value at the end of reporting period

B.3.2

Aggregate gross interest paid or credited

B.3.3

Aggregate gross dividend paid or credited

B.3.4

Gross proceeds from sale of property

B.3.5

Aggregate gross amount of all other income paid or credited

B.3.6

Aggregate gross amount cred- ited

B.3.7

Aggregate gross amount deb- ited

B.4 INDIVIDUAL DETAILS (To be provided for individual account holder )

B.4.1

Name

B.4.2

Customer ID

B.4.3

Father’s Name

B.4.4

Spouse’s Name

B.4.5

Gender

Insert 1 character code (Refer Instructions)

B.4.6

PAN

B.4.7

Aadhaar Number

B.4.8

Identification Type

Insert 1 character code

B.4.9

Identification Number

B.4.10

Occupation Type

B.4.11

Occupation

B.4.12

Birth Date

B.4.13

Nationality

Insert 2 character code

B.4.14

Country of Residence as per tax laws

Insert 2 character code

B.4.15

Place of Birth

B.4.16

Country of Birth

Insert 2 character code

B.4.17

Tax Identification Number (TIN) allotted by tax resident country

B.4.18

TIN Issuing Country

Insert 2 character code

B.4.19

Address Type

Insert 2 character code

B.4.20

Address

B.4.21

City / Town

B.4.22

Postal Code

B.4.23

State Code

Insert 2 character code

B.4.24

Country Code

Insert 2 character code

B.4.25

Mobile/Telephone Number

B.4.26

Other Contact Number

B.4.27

Remarks

B.5 LEGAL ENTITY DETAILS (To be provided for entity account holder)

B.5.1

Name of the Entity

B.5.2

Customer ID

B.5.3

Account Holder Type for US Reportable Person

Insert 2 character code

B.5.4

Account Holder Type for Oth- er Reportable Person

Insert 2 character code

B.5.5

Entity Constitution Type

Insert 1 character code

B.5.6

Date of Incorporation

B.5.7

Nature of Business

B.5.8

PAN

B.5.9

Identification Type

Insert 1 character code

B.5.10

Identification No.

B.5.11

Identification issuing Country

Insert 2 character code

B.5.12

Place of Incorporation

B.5.13

Country of Incorporation

Insert 2 character code

B.5.14

Country of Residence as per tax laws

Insert 2 character code

B.5.15

Tax Identification Number (TIN) allotted by tax resi- dent country

B.5.16

TIN Issuing Country

B.5.17

Address Type

Insert 1 character code

B.5.18

Address

B.5.19

City / Town

B.5.20

Postal Code

B.5.21

State Code

Insert 2 character code

B.5.22

Country Code

Insert 2 character code

B.5.23

Mobile/Telephone Number

B.5.24

Other Contact Number

B.5.25

Remarks

B.6 CONTROLLING PERSON DETAILS (To be provided for each controlling person of the entity)

B.6.1

Controlling Person Type

Insert 3 character code

B.6.2

Name

B.6.3

Customer ID

B.6.4

Father’s Name

B.6.5

Spouse’s Name

B.6.6

Gender

Insert 1character code

B.6.7

PAN

B.6.8

Aadhaar Number

B.6.9

Identification Type

Insert 1character code

B.6.10

Identification Number

B. 6.11

Self- certification

Insert 1character code

B.6.12

Occupation Type

Insert 1character code

B.6.13

Occupation

B.6.14

Birth Date

B.6.15

Nationality

Insert 2charactercode

B.6.16

Country of Residence as per tax laws

Insert 2 character code

B.6.17

Place of Birth

B.6.18

Country of Birth

Insert 2charactercode

B.6.19

Tax Identification Number (TIN) allotted by tax resi- dent country

B.6.20

TIN Issuing Country

Insert 2charactercode

B.6.21

Address

B.6.22

City / Town

B.6.23

Postal Code

B.6.24

State Code

Insert 2charactercode

B.6.25

Country Code

Insert 2charactercode

B.6.26

Mobile/Telephone Number

B.6.27

Other Contact Number

B.6.28

Remarks”