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Foreign Country Tax Information Declaration

I declare that all statements and information provided by me in this application are, to the best of my knowledge and belief, correct and complete.

I acknowledge that information contained in this form and information regarding the account holder may be provided to the Australian Taxation Office and exchanged with tax authorities of another country or countries in which I may be a tax resident (including to the United States if the account holder is a US citizen) in accordance with intergovernmental agreements to exchange financial account information.

I undertake to advise NPBS within 60 days of any change in circumstances which causes the Foreign Country Tax Resident information provided to become incorrect or incomplete, and to provide NPBS with an updated self-certification and any documentary evidence as required.