Existing members

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Smith SINS Termination Form

1. Employee details

Reason for termination (please select one of the following)

2. Wire transfer

Individual Self Certification

Tax regulations require us to collect information about each investor’s tax residency. In certain circumstances (including if we do not receive a valid self–certification from you) we may be obliged to share information on your account with the relevant taxation body.

If you have any questions about your tax residency or question on how to complete this form, please contact your tax advisor.

Should any information provided change in the future, please ensure you advise us of the changes promptly.

1. Tax Residency*

You are required to indicate all countries in which you are resident for tax purposes and the associated Tax Reference Number in the table below. If you are a US citizen or resident, please include United States in the table along with your US Tax Identification Number.

If you are a UK, Jersey, Guernsey, Isle of Man or Gibraltar resident then please supply your National Insurance or Social Security Number as appropriate, in addition to your Tax Reference Number.

2 Declaration

*As you may be aware, the US passed the Foreign Account Tax Compliance Act, (FATCA) in 2010. Beginning on July 1, 2014 foreign financial institutions (FFI) such as the Participants in the Plan are required to report information regarding accounts of relevant US persons. Additionally, certain other countries including the UK have passed similar laws where reporting is required upon payment of funds from a foreign account. Consequently all plan participants are required to provide information regarding their tax residency.