Account Opening Form

For Non Resident IndiansFor Non Resident Indians

DCB Bank LimitedDCB Bank Limited194-Ver 1.0-Jan 2013194-Ver 1.0-Jan 2013 M009 / OCt 15 / 2.4M009 / OCt 15 / 2.4

Instruction for filling Account Opening Form

Please write your NAME as it appears in all your support documents

Hint boxes give tips and highlight important points across the form

Please fill the form preferably in ‘BLACK’ ink only

Please counter sign in full against any overwriting / alteration

Specify the addresses along with City, State and PIN Code

Please tick the appropriate boxes

Please fill the form in CAPITAL LETTERS onlyABC

ALL PHOTOCOPIES of documents to be SELF-ATTESTED by the applicant

When filling the form please ensure that you fill Form DA-1 enclosed with this form to avail the nomination facility. While the nomination facility is optional, we recommend that you avail of it.

A) Mandatory documents for all categories

¨ Photocopy of the passport pages where your name, address, specimen-signature, photograph are recorded

¨ Copy of valid Visa / Work Permit / Residence Permit (the Visa could be either in the passport or issued separately)

¨ Proof of your mailing address. Please tick the documents submitted, from the table below

¨ Latest passport size photographs, duly affixed on the AOF and signed across

¨ Initial payment for each account or deposit selected on the account

¨ If you are a Person of Indian origin, please provide any of the following documents

i. Person of Indian Origin (PIO) / Overseas Citizen of India (OCI) Card

ii. Passport issued by a foreign country where nationality is mentioned as Indian, or Indian passport held by you at any point in time

iii. Copy of the birth certificate or Indian passport held by parents or grandparents, along with proof of relationship

iv.Copy of the Indian passport of spouse along with relationship proof

Introduction Documents

B) If you have not met our Branch staff in person while submitting your forms & supporting documents, the following procedure needs to be followed:

The photocopies of the (a) Passport, (b) Visa / Work Permit / Residence Permit and (c) Mailing Address must be attested by :

(I) An overseas banker - (applicable only in Argentina, Australia, Austria, Belgium, Brazil, Canada, China, Denmark, Finland, France, Germany, Greece, Bahrain, Qatar, Kuwait, Oman, Saudi Arabia, UAE, Hong Kong, Iceland, Ireland, Italy, Japan, Luxembourg, Mexico, the Netherlands, New Zealand, Norway, Portugal, Russian Federation, Singapore, South Africa, Spain, Sweden, Switzerland, Turkey, the UK and the United States of America) OR

(ii) An overseas banker (other than in the countries listed above) - provided that, the account opening amount is through a cheque drawn on the same bank branch OR

(iii) Any branch of an Indian bank abroad (in any country) OR

(iv) Notary Public or equivalent authority OR

(v) The Indian diplomatic mission in the country of residence

OR

If you are unable to get your documents attested as stated above, you will need to submit two self-attested proofs of your overseas address, among the list of eligible documents stated above.

List of eligible documents for proof of communication address

Copy of bank statement / passbook – overseas or Indian (not more than 3 months old – not downloaded from internet banking) if mailing address and statement of account provided is of India, the statement should be of an NRI account OR, the non resident status should appear / be certified by the bank on the statement of account.

Overseas Indian

Copy of utility bill for electricity / gas / telephone / water / rent receipt(not more than 3 months old)

Copy of appointment letter from employer indicating the address (on organisation’s letterhead - with stamp, not more than 1 year old)

Letter from warden of university hostel containing the address (for on-campus lodging)

Copy of registered purchase / sale deed or agreement

Copy of ration card

Copy of Govt. ID Card (SSN / Green Card / PIO Card / OCI Card)

Certificate from Indian diplomatic mission containing the contact address

Copy of credit card statement (not more than 3 months old)

Certificate from employer confirming the address (on organisation’s letterhead - with stamp)

Copy of driving license (for list of countries please refer to point B (i))

Copy of passport

3

Mailing Address: Overseas India (You must tick mark one option, proof of your mailing address is required)

Personal Details : Applicant 1 (* Fields are Mandatory)

State:

All communication regarding your

accounts will be through your

Preferred Mobile number and Preferred

Email ID

Maximum32 characters

Maximum 19 characters.

This namewould

appear on theDebit Card

Marital Status: Single Married*Mother’s Maiden Name:

*Overseas Address:

City: Pin:

State: Country:

*India Address:

City: Pin:

Landmark:

*Passport Details: Passport No. YYYYMMDD

Type of Visa:*Visa Details: YYYYMMDD

*Preferred Email:

*PAN: Form 60

If PAN number is not available

please fill in Form 60

Please refer toclause 23 underT&C for meaning

*Are you a politically exposed person? NoYes

Customer Profile

*Education: Non Graduate Graduate Post Graduate Professionally Qualified Others

*Occupation: Self Employed Salaried Housewife Retired Others

Profession: Finance Art Legal Teaching Agriculture Medicine Engineer Management

Architect Information Technology Others

*Gross Annual Income (`): 3 Lakhs - < 5 LakhsLess than 50K

5 Lakhs - < 10 Lakhs

50K - < 1.5 Lakhs

10 Lakhs - < 50 Lakhs

1.5 Lakhs - < 3 Lakhs

50 Lakhs and above

Name of the Company:

Designation:

YYYYMMDDDate:

Please affixa recent

photograph.

Signature

Please affix

a recent

photograph

Sign across the photo

Name:

*Valid Until:

*Valid Until:

Please signin “Black Ink”

withinthe box.

“Signatureshall be

consideredfor all Cheque

clearancesand

any futurecommunicationwith the Bank”

I do not have any permanent address in India.OR

(First Name) (Middle Name) (Last Name)

*Short Name:

Existing Customer ID(If applicable):

*Date of Birth: YYYYMMDD

*Nationality: IndianOther (pl. specify)

*Preferred Mobile No.:

*Telephone (with ISD Code):

(Country Code) (Area Code) (Number)

(Country Code) (Number)

*Name: Mr. Mrs. Ms. Dr. Prof. Others

*Gender: Male Female Third Gender

Resident IndianNon Resident Indian

*Residential Status:

4

Mailing Address: Overseas India (You must tick mark one option, proof of your mailing address is required)

Please refer toclause 23 underT&C for meaning

*Are you a politically exposed person? NoYes

Customer Profile

*Education: Non Graduate Graduate Post Graduate Professionally Qualified Others

*Occupation: Self Employed Salaried Housewife Retired Others

Profession: Finance Art Legal Teaching Agriculture Medicine Engineer Management

Architect Information Technology Others

*Gross Annual Income (`): 3 Lakhs - < 5 LakhsLess than 50K

5 Lakhs - < 10 Lakhs

50K - < 1.5 Lakhs

10 Lakhs - < 50 Lakhs

1.5 Lakhs - < 3 Lakhs

50 Lakhs and above

Name of the Company:

Designation:

YYYYMMDDDate:Signature

Please affix

a recent

photograph

Sign across the photo

Name:

State:

Maximum32 characters

Maximum 19 characters.

This namewould

appear on theDebit Card

Marital Status: Single Married*Mother’s Maiden Name:

*Overseas Address:

City: Pin:

State: Country:

*India Address:

City: Pin:

Landmark:

*Passport Details: Passport No. *Valid Until: YYYYMMDD

Type of Visa:*Visa Details: *Valid Until: YYYYMMDD

*Preferred Email:

*PAN: Form 60

I do not have any permanent address in India.

Joint Applicant (* Fields are Mandatory)

##(Guardian to fill a Minor Declaration Form separately) If applicable, please attach age proof

Please affixa recent

photograph.

Please signin “Black Ink”

withinthe box.

“Signatureshall be

consideredfor all Cheque

clearancesand

any futurecommunicationwith the Bank”

OR

All communication regarding your

accounts will be through your

Preferred Mobile number and Preferred

Email ID

If PAN number is not available

please fill in Form 60

(First Name) (Middle Name) (Last Name)

*Short Name:

Existing Customer ID(If applicable):

*Date of Birth: YYYYMMDD

*Nationality: IndianOther (pl. specify)

*Preferred Mobile No.:

*Telephone (with ISD Code):

(Country Code) (Area Code) (Number)

(Country Code) (Number)

*Name: Mr. Mrs. Ms. Dr. Prof. Others

*Gender: Male Female Third Gender

5

for credit to new NRO Account

(If you are opening more than one account, please indicate appropriately for each account)

Mode of Funding Accounts

Cash Demand Draft / Cheque No. Drawn on

Wire Transfer from(Remitting Bank's Name & Address)

Debit NRO Account No.

for credit to new NRE AccountDebit NRE Account No.

Currency & Amount (in figures and words)

Credit my / our Account No. DCB BankInterest Payment:

Issue a Demand Draft and mail to my correspondence addresson Ordinary deposit

If you are opening more than one deposit, please indicate appropriately for each deposit.

Days / Months / Years (Please refer to the interest rate table on www.dcbbank.com for details on interest rates and tenure)

Ordinary Cumulative

Amount (in figure) (in words)

Tenure

Mode of Funding Deposits

Type of Deposit:

Minimum tenurefor FCNR (B)

and DCB NRE Deposits is

1 year.

Source of Funds for Credits in the Account:

Other (please specify)

InvestmentsSavings Sale of PropertySalary

Inheritance

Business Proceeds

Professional Fee

Approximate Value `Foreign Inward Remittances in a year:

Account Usage

Expected Annual Turnover in the account:

Upto ` 1 crore

Less than ` 1 lakh

Upto ` 5 crores

Expected number of transactions in a month:

Upto ` 1 lakh

Upto ` 10 crores

Up to 20

Upto ` 10 lakhs

Upto ` 25 crores

21 to 50

Upto ` 50 lakhs

More than ` 25 crores

More than 50

This section is mandatory

Mode of Operation

Single Either or Survivor*

Joint Mandate

* If the joint applicant is a resident Indian then the DCB NRE Account / DCB NRE Deposits / DCB FCNR (B) Deposits will be opened on a Former / Survivor basis.

Former or Survivor

Account Details

DCB Elite Account Number (Mention last 8 digits):

Savings Accounts:

DCB Classic NRE Savings Account

DCB Savings Classic NRO Account

DCB Elite NRE Savings Account

DCB Elite NRO Savings Account

Preferred City:

Preferred Branch:

Please visitwww.dcbbank.comfor complete listof our branches

This section is mandatory

Current Accounts:

DCB Classic NRE Current Account

DCB Current Classic NRO Account

Term Deposit Accounts

DCB FCNR (B) Deposit: Currency AUD CAD EURO GBP USD

DCB NRE Deposit DCB NRO Deposit

DCB NRE Recurring Deposit: INR ______________________ montly Deposit

DCB NRO Recurring Deposit: INR ______________________ montly Deposit

DCB NRO Tax Saver Fixed Deposit (Note: DCB NRO Tax Saver Fixed Deposit maximum limit 1.5 lakhs and cannot be closed prematurely.)

Renewed for Days / Months / Years

Credited to my / our Account No. DCB Bank

DD at my correspondence address payable at

Maturity Instructions The amount due to me / us on maturity should be

6

* DCB International Visa Debit cum ATM Cards will be issued for NRE Accounts. DCB Domestic Visa Debit cum ATM Cards will be issued for NRO Accounts

Note: DCB Debit / ATM Card and DCB Internet Banking are being provided complimentary at no extra cost to all our Non Resident account holders.In case, you want to opt out of the said facility, you may please indicate by ticking the box below:

Access Channels

No, I do not want DCB Debit / ATM Card to be activated for my account/s.

No, I do not want DCB Internet Banking to be enabled for my accounts.

Form 60 (to be filled by those who do not have either PAN or GIR)

• Are you a Tax Assessee: Yes No

• If Yes,

a) Details of Ward / Circle / Range where the last return of income was filed:

b) Reason for not having PAN / GIR No.:

I,

do hereby declare that what is stated above is true to the best of my / our knowledge and belief. Verified at this

day of 20

Signature of the Declarant

Preferable forSingle & Joint

Account holders

Nomination Details (Form DA 1)

Yes, I want to nominate the following person No, I do not want to nominate anyone on my behalf

I / we nominate the following person to whom in the event of my / our / minor’s death the amount of the deposit / in the account may be returned by DCB Bank.

Nominee Name:

Address:

YRelationship with Applicant, if any YYYMMDDDate of Birth:YearsAge:

* As the nominee is a minor on this date, I / we appoint (Name & Adress)

Nominationunder Section45ZA of the

BankingRegulation Act, 1949

and Rule 2(1) of the Banking Companies (Nomination) Rules 1985 in

respect of bankdeposits.

to receive the amount of the deposit / in the account on behalf of the nominee in the event of my /our / minor’s death during the minority of the nominee.

In case you have specified a nominee above, please indicate if you wish to make mention of the nominee name on the passbook, statement & DCA issued in respect of

your account and / or the passbook issued to you

I / We do hereby declare that what is stated above is true to the best of my / our knowledge and belief.

Yes No

Signature(s) of depositor(s)

Residential Status of the Nominee: Non Resident Indian Resident Indian

This section is mandatory

Note : Your Term Deposit will automatically be renewed for the same period at the prevailing interest rates on maturity if we do not receive prior notice before maturity.

Bank Name:

Address:

Account No.

Wire Transfer (please provide overseas Bank Name, Address and Account Number)

7

I/We, hereby solemnly declare and undertake as under:

1. I am / We are Non-Resident Indian(s) of Indian Origin.

2. I / We understand that the above account will be opened on the basis of the statements/ declarations made by me / us and will be opened in the form and as per various Regulations framed under the Foreign Exchange Management Act, 1999 ("the Act") and in particular, the Foreign Exchange Management (Deposit) Regulations, 2000 ("the Regulations") as amended from time to time. I / We also agree that if any of the statements/ declarations made herein found to be not correct in material particulars, you are not bound to pay any interest on the deposit made by me / us and to discontinue the services.

3. I / We further declare that the undersigned has / have the authority to give this declaration and undertaking on behalf of the firm / company. Applicable when the declaration / undertaking is signed on behalf of the firm / company.

4. The account will be put into use only for bonafide transactions not involving any violations of the provisions of any Government / Exchange Control Regulation.

5. I / We agree that the rate and the manner of interest to be paid shall be as per the Regulations and no claim will be made by me / us for any interest on the deposit/s for any period after date/s of maturity of the deposit/s.

6. I / We agree to abide by the provisions of the FCNR (B) / NRE / NRO / RFC Account schemes as laid down and the Regulations as amended from time to time by the Reserve Bank of India (RBI).

7. I / We hereby undertake to intimate you about my / our return to India for permanent residence immediately on arrival.

8. I / We authorise DCB Bank Limited (the “Bank”) to automatically renew the deposit on due date for an identical period (unless otherwise specifically instructed before due date). The earlier Deposit Confirmation Advice given to me/us will be treated as discharged receipt on due date. I / We understand that the interest applicable upon renewals will be at the applicable ruling rates on the date of maturity and that the fresh Deposit Confirmation Advice will be made available.

9. I / We agree that if premature withdrawal is permitted at my / our request the payment of interest on the deposit may be allowed in accordance with the prevailing stipulations laid down by the RBI in this regard.

10. I / We shall not make available to any person resident in India, any foreign currency against reimbursement in rupees or in any other manner in India.

11. I / We confirm that all debits / credits to my / our account/s shall be as specified in the Act and the Regulations. Further, in case of NRO A/c, I / we undertake that all debits to my / our account/s for the purpose of investment in India and credits representing sale proceeds of investments in India shall be in accordance with the Regulations and which are covered either by general or special permission of the RBI.

12. I / We will be liable to comply with the Rules of the Act and the Regulations and the amendments thereof in force from time to time and as stipulated by the RBI.

13. I / We understand that the Bank may at its absolute discretion, discontinue any of the services completely or partially without any notice to me / us and without assigning any reason thereof. I / We agree that the Bank may debit my / our account/s for service charges as applicable from time to time.

14. I / We have read, understood and hereby accept and agree to the Terms and Conditions given for all the products and services I / We have requested.

15. I / We agree and undertake that in case of FCNR (B) Accounts, if the remittance from outside India is not in designated currency and the same is converted to the designated currency as stipulated in the Regulations, it shall be at my/our entire risk and costs and I/we shall not challenge the rate of conversion.

16. I / We hereby agree and confirm to bear any losses or claims that may arise directly or indirectly on account of the Bank acting on any instructions received by it by fax or any electronic media given by me/us or on my / our behalf and agree to keep the Bank indemnified from any such losses and / or claims.

17. I / We do hereby declare that the information furnished in this form is true to the best of my / our knowledge and belief.

18. I / We hereby agree to indemnify and forever keep indemnified the Bank and its successors and assigns of, from and against any and all claims, actions, penalties that may be made, suffered or incurred by the Bank by reason of my / our non-compliance with the Act and / or the Regulations as amended from time to time.

19. FEMA Declaration: I/We hereby declare that any transaction involving foreign exchange hereunder shall not involve and shall not be designed for any purpose of any contravention or evasion of the provisions of the Act or any rule, regulation, notification, direction or order made thereunder.

I/We also hereby agree and undertake to give such information/documents as shall satisfy the Bank with regard to any foreign exchange transaction in terms of the above declaration.

I/We also understand that if I/we refuse to comply with any such requirement or make any unsatisfactory compliance therewith, the Bank shall refuse in writing to undertake any transaction on my/our account and shall, if it has reason to believe that any contravention is contemplated by me/us, report the matter to the RBI and/or any such authority as the Bank deems fit.

20. PIO declaration (where applicable):

(i) I/We confirm that I/we am/are a Person / Persons of Indian Origin (PIO) by virtue of having (a) at any time held an Indian passport or (b) I/We or either of my/our parents or any of my / our grandparents were citizens of India by virtue of the Constitution of India or the Citizenship Act, 1955 or (c) my/our spouse is an Indian Citizen or a person referred to in (a) or (b);

(ii) For Citizens of Bangladesh or Pakistan Only : I/We have obtained specific approval from the RBI to open accounts for Non-Resident Indians and a copy of the same has been submitted along with my/our application form.

21. DECLARATION FOR LOANS / ADVANCES: The Bank may, on receipt of a written application from Mr./Ms. ________________________________________________ and / or _______________ the former / the latter / the first named or either or Survivor of us / any one of us or survivors or survivor of us in his / her / their discretion and subject to such terms and conditions as the Bank may stipulate, (a) Grant a loan / advance against the security of the term deposit to be issued in my/our name/joint names. In case of loan or overdrafts against FCNR (B) or DCB NRE Deposits, premature withdrawal of the Term Deposit is not permitted.

22. DECLARATION FOR PRE-MATURE PAYMENT: Subject to 21 above, the Bank on request from the depositor would allow withdrawal of the Term Deposit before completion of the period of the deposit agreed upon at the time of placing the deposit. The Bank shall declare their penal interest rates policy for premature withdrawal of the Term Deposit. The Bank shall make depositors aware of the applicable rate for premature withdrawal of such deposits along with the deposit rate. In case of deposits held jointly for the instructions, premature termination must be signed by all holders.

23. DEFINITION OF POLITICALLY EXPOSED PERSON: Politically Exposed Persons are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States or of Governments, senior politicians, senior government/judicial/military officers, senior executives of state-owned corporation, important political party officials, etc. In addition, a ‘Politically Exposed Person’ includes the immediate family members of a Politically Exposed Person such as spouses, children, parents and other relatives. Politically Exposed Person includes even close associates like advisors, secretaries and other associates of a Politically Exposed Person who conduct transactions on behalf of a Politically Exposed Person.

24. The Bank is authorised to arrange a correspondent bank/agent for realising the proceeds of foreign currency cheques deposited.

The Bank has a Cheque Collection Policy in place, under which if the instrument(s) for collection is / are returned unpaid at any time, the returning and other charges may be debited to my / our account/s.

If any Cheque / draft credited to my / our account/s provisionally prior to final realisation under your special cash letter services is returned unpaid, the amount may be recovered from my / our account/s at the appropriate exchange rate along with interest applicable at such rates as may be decided by you. I / We undertake to refund the amount, if already drawn by me / us, immediately on demand if my/our account/s does not have sufficient balance to recover the amount with interest and / or any other charges.

25. I / We confirm having read and understood terms and conditions for all the services I/we have requested above. I / We accept and agree to be bound by the said terms and conditions for the use of the above selected services. I / We authorise the applicant to access the account(s) via the channels selected and authorise to link new account/s opened by the applicant to the channels selected. I / We accept and agree to be bound by the said terms and conditions for the use of the above selected services. The Terms and Conditions are as per current regulatory environment; the same are bound to change without prior notice as per changes in the regulatory framework.

26. For Application Forms submitted online:

I / We understand, agree and undertake that in case of my/our submission of the duly filled-in online Application Form on the Bank’s website www.dcbbank.com, I/we am/are required to send a scan copy of all KYC documents to nri@dcbbank.com immediately and also submit the signed physical copy of my/our Application Form and KYC documents within 30 (thirty) days of my/our submission of online Application Form.

I / We understand and agree that my/our cheque book/s and Debit/ATM card/s will be inactive and withdrawals from / debits to my/our account/s will not be allowed by the Bank, until physical copies of my/our Application Form and KYC documents are submitted by me/us and received by the Bank.

I / We also understand and agree that in case I/we fail to submit my/our Application Form and KYC documents within 30 (thirty) days of my/our submission of online Application Form, the Bank is entitle at its sole discretion to close my/our account/s. If there are any funds remitted by me/us into my/our account/s, they will be sent back to the address mentioned in the Application Form vide a Demand Draft.

I / We understand and agree that the associated charges/costs incurred by the Bank will be debited from my/our account/s, before remitting the funds back to me/us.

I / We also understand and agree that in case of foreign exchange transactions, the rate of exchange applied by the Bank will be as per the prevailing market rates and shall not be questioned / disputed by me/us for any reason whatsoever.

Declaration cum Terms and Conditions

Signature of Applicant Signature of Joint Applicant

To,DCB Bank Limited

Notwithstanding anything to the contrary contained in any other document / agreement, I / We, the undersigned, hereby request and authorise you to rely and act on all instructions or communications for any purpose (including but not limited to the instructions / communication pertaining to the operation of all my / our accounts or to any other facilities or services that may be provided by you from time to time) which may from time to time be or purported to be given by telephone, facsimile, untested telexes and faxes, telegraph, cable, email or any other form of electronic communication by me / us (including such instructions / communication as may be or purported to be given by those authorised to operate my / our account(s) with you)

"Instructions" - I / We understand and acknowledge that there are inherent risks involved in sending the Instructions to you via telephone, facsimile, untested telexes and faxes, telegraph, cable, email or any other form of electronic communication and hereby agree and confirm that all risks shall be fully borne by me / us and I / We assume full responsibility for the same, and you will not be liable for any losses or damages including legal fees arising upon your acting, or your failure to act, wholly or in part in accordance with the instructions so received.

In consideration of you agreeing, subject to the terms and conditions hereunder, to act upon the instructions as aforesaid, I / We hereby irrevocably agree and undertake:

That you shall be entitled to act or refuse to act as you see fit, without incurring any liability whatsoever to me or to any other person, upon any Instructions for any purpose which may from time to time be or purported to be given by telephone, facsimile, untested telexes and faxes, telegraph, cable, email or any other form of electronic communication by me / us (including such instructions as may be or purported to be given by those authorised to operate my / our account(s) with you), even if such Instructions or communication are not followed up by written confirmation to you.;

That the Instructions shall be conclusively presumed for your benefit to be duly authorised by and legally binding on us, and we shall be fully responsible for the same. You shall not be responsible to ensure the authenticity, validity or source of any instructions and shall not be liable if any instructions turn out to be unauthorised, erroneous or fraudulent.

That you shall be entitled (but not obliged) to keep records of our instructions given or made by telephone, facsimile, untested telexes and faxes, telegraph, cable, email or any other form of electronic communication in such form, physical or electronic, as you may in your sole discretion deem fit, and your records shall be conclusive and binding on me / us. You shall be entitled to dispose of or destroy any such records at any time as determined by you at your sole discretion;

That you shall be authorised to disclose all instructions as you may deem fit, to your affiliates, counterparties, service providers, regulators and other authorities or where you are required by law to do so.

That you shall be entitled to require any instruction in any form to be authenticated by use of any password, identification code or test as may be specified by you from time to time and I / We shall ensure the secrecy and security of such password, code or test and I / We shall be solely responsible for any improper use of the same;

That, notwithstanding the above, you may, under circumstances determined by you in your absolute discretion, require from me / us confirmation of any instructions in such form as you may specify before acting on the same; and we shall submit such confirmation to you immediately upon receipt of your request. Pursuant to receipt of instructions, you shall have the right but not the obligation to act upon such instruction;

That you shall not be liable to us or any third party for, and that I / We (jointly and severally) agree to indemnify you and keep you indemnified from and against all claims either by me or any other, actions, demands, liabilities, costs, charges, damages, losses, expenses and consequences of whatever nature (including legal fees on a full indemnity basis) and howsoever arising, which may be brought or preferred against you or that you may suffer, incur or sustain by reason of or on account/s of your having so acted whether wrongly or mistakenly or not, or of your failing to act wholly or in part in accordance with the Instructions and the terms of this letter. In consideration of agreeing to accept instructions issued by me from time to time in respect of my non-resident account/s to be opened with _______________________________ Branch, in the form of email transmission from my email ID ________________________________ not bearing an original signature (“email instructions"). I confirm that:

• I am aware and understand the possible risks involved in connection with giving of any email instructions.

• is hereby irrevocably and unconditionally authorized to act on my email instructions, which in its sole discretion believes to have been sent from my email ID as has been registered with or otherwise appear to comply with the terms of the mandate for my non-resident account/s to be opened with and shall not be liable and/or responsible for acting in good faith on email instructions which have been sent from my email ID referred to herein in any circumstances whatsoever.

• I undertake to keep , its officers, directors and any employees indemnified at all time from and against, all actions, proceedings, claims, loss, damage, cost and expenses which may be brought against you or suffered or incurred by you and which shall have arisen either directly or indirectly out of or in connection with your accepting email instructions from me and acting thereon, whether or not the same are confirmed in writing by me or not.

That I / We confirm that I / We have the capacity and authority to accept this document and that this document constitutes our valid, legal, effective and enforceable obligation.

That this declaration shall be governed and construed to be in accordance with the laws of India and I / We hereby irrevocably submit to the non-exclusive jurisdiction of the courts in Mumbai.

DCB BankDCB Bank

DCB Bank DCB BankDCB Bank DCB Bank DCB Bank

DCB Bank

Terms & Conditions for instructions to be given by Fax, Telephone and other means of Electronic Communication

To,DCB Bank Limited

Dear Sir/Madam,

I, _____________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________ (insert full name and address) having understood the provisions of the Indian Income-tax Act, 1961, in particular those related to tax residence and the scope of income taxation, declare and confirm that:

I am / will be a non-resident within the meaning of the Indian Income-tax Act, 1961. I am a tax resident of the _____________________ (name of the DTAA Country) within the meaning of the Agreement for Avoidance of Double Taxation between India and the ___________________ (name of the DTAA Country) (“the tax treaty” for short) and therefore, entitled to the benefits of the tax treaty.

My PAN (Permanent Account Number) is ____________________. In case I do not provide my PAN details, I shall not be given the DTAA benefit. I undertake to keep the Bank informed of any change in my residency. I also understand that on any change in my country of residency, I will be required to submit revised documentation for benefiting from lower deduction of taxes under DTAA for the country I will be now residing in. Until such time, the Bank will withhold taxes at the applicable rate of 30% + cess.

I currently hold Passport No. _________________ and Visa No. _________________ issued by the Government of _________________ , copies of which are attached herewith.

I am the beneficial owner of the funds from which the bank fixed deposit/s will be made as well as of the interest paid by the Bank thereon and Article ________ (relevant article dealing with interest) of the tax treaty will govern the Indian income tax liability on such interest. As such, the Indian income tax will be limited to________ (DTAA Tax Slab as per Reckoner) of the gross interest paid.

I shall provide Tax Residency Certificate and Form No. 10F (if applicable) as defined under Indian Income Tax provisions. I acknowledge that DTAA benefit would be effective subject to the Tax Residency Certificate.

I undertake to promptly inform the Bank in writing should there be any change in the facts given above.

I also undertake that the benefit of DTAA is applicable for the current financial year and for the period commencing 1st April of the next financial year I will submit fresh set of similar documents to avail the benefit.

I undertake to indemnify the Bank for any tax loss (including but not limited to tax, interest and penalty) suffered by the Bank as a result of either relying on this declaration or my delay/default in confirming the change, if any, in the facts mentioned above. This obligation shall survive indefinitely.

I undertake to indemnify the Bank for any tax demand (including but not limited to tax, interest and penalty) suffered by the Bank as a result of either relying on this declaration or my delay/default in confirming the change, if any, in the facts mentioned above. I also authorize DCB Bank to recover the said demand from any of my bank accounts / fixed deposit placed with the Bank. I shall provide DCB Bank with all information/documents that may be necessary for any proceedings before Income-tax / Appellate Authorities in India.

I confirm that, I have read and understood the applicable terms and conditions of this product/service and the relevant provisions of the Double Taxation Avoidance Agreement between India and _______(country of residence) and the relevant provisions of the Income Tax Act, 1961 which can also be referred on the website www.incometaxindia.gov.in

I hereby declare that the contents above are correct, complete and truly stated.

Yours faithfully

Name: _____________________________________________________________

Address: _____________________________________________________________________________________________

Signature Date: _________________ Place: _______________________________________ 8

Signature of Applicant Signature of Joint Applicant

DTAA Self Declaration

Complete ISA of mandate holder to be furnished

(Separate forms required for Multiple Accounts)

The Branch Manager,

DCB Bank Limited

Branch

Dear Sir,

Account Numbers: DCB NRE Deposit

DCB NRO Deposit

1. I / We hereby authorise the Mandate Holder to:

a) Draw cheques on the said account.

b) To deposit and/or discount cheques and other instruments in the said account and for this purpose to endorse on my / our behalf cheques, drafts, pay orders and other instruments payable to me / us.

c) To make deposits from balances available in the account in my / our names and renew such deposits for such periods as may be given in writing by the mandate holder.

d) To certify balance confirmation statement of accounts issued by the Bank in respect of the said account.

e) To give instructions in writing involving debits to the said account transfers there from etc.

f) To make withdrawals for investments in India where necessary permission from RBI has been obtained by me/us.

g) To use the ATM / Debit Card issued in respect of the mentioned account.

h) I / We and the mandate holder acknowledge that the issue and usage of the card is governed by the terms and conditions as in force time to time and agree to be bound by the same.

I) I / We and the mandate holder acknowledge that it is my / our responsibility to obtain a copy of Exchange Control guidelines and read the same.

j) I / We and the mandate holder accept that the terms and conditions are liable to be amended by from time to time.

k) I / We further unconditionally and irrevocably authorize to debit my / our account annually with an amount equivalent to the free and charges for the use of the said ATM / Debit card if any.

2. I / We declare that as per Exchange Control guidelines issued by RBI.

a) The mandate holder can exercise the authority conferred by this letter to withdraw for local payments only, and make investment in India where I / we hold general permission or have obtained specific permission from RBI.

b) The mandate facility permits the mandate holder to remit funds in foreign currency to the account holder(s) only.

3. I / We hereby undertake that I / we and our / my mandate holder shall comply with the provisions of the Exchange Control (Guidelines issued by the RBI and the Foreign Exchange Management Act, 1999 and all regulation thereof, including the Foreign Exchange Management (Deposit) Regulations, 2000. I / We hereby undertake to indemnify DCB Bank against any loss, damage, claim, action, proceedings, costs, charges and expenses that may be suffered or incurred by DCB Bank on account for any activity undertaken by the mandate holder by the use of the ATM Card.

4. The specimen signature of the mandate holder who has been authorized to operate upon the account is given below. The signature has been duly attested and verified by me / us.

5. This authority shall continue in force until I/we expressly revoke it by a notice in writing delivered to you.

Yours faithfully,

DCB

DCB Bank

DCB BankDCB

OR (Account Holder's Name):

I / We hereby request you to issue the Mandate Holder facility on the above account numbers to :

Name: Mr. / Ms.

Mandate Holder Declaration

YYYYMMDDDate:

Address:

City: Pin:

Preferred Email:

State: Country:

Telephone:(with STD Code)

Account Holder :st1 Holder’s Signature nd2 Holder’s Signature

I have read and understood all the conditions stated above and hereby agree to comply with the same. I will operate the account by signing as under:

Mandate Holder:

Signature of Mandate Holder

Date

Signature of Mandate Holder has been verified by me / us:

Photograph of

Mandate Holder

(Sign across

Photograph)

9

OR Joint Account Holder Name:

Merchant Navy Declaration Form

Signature of applicant

I hereby confirm that I have just returned after completion of my contract with ________________________________________________ (name of company) registered in

_____________________________________________________________________________________ (address of the principal).

I am on a break for ____________________ days / months and will be joining on a new contract on/ by ________________________ (date / time frame). I request you to

kindly open an c DCB FCNR (B) Deposit NRE NRO account in my name on the basis of the documents submitted

I also confirm that I will inform the Bank incase I am unable to proceed on a new contract or choose not to go on a new contract, and have the non-resident accounts

opened in my name redesignated to Resident / RFC accounts (if eligible).

Yours Sincerely

c DCB account c DCB

YYYYMMDDDate:

Relationship with Guardian

Signature of Guardian

Details of Guardian:

Details of Minor:

Minor Declaration Form

Name of the Minor:

Name of the Guardian:

Nature of Guardianship Natural Legal (Please furnish copy of court order)

Source of funds Own funds Minor’s funds

I hereby declare that I shall represent the said minor in all transactions connected with this account until the said minor attains majority. I declare that the account will be operated for the benefit of the minor. I shall indemnify the Bank against the claim on the account of the minor for any withdrawal transaction made by me in his/her account.

YYYYMMDDDate:

Signature/s of account holder/s:

(Applicant) (Joint Applicant)

I / We (name of a/c holder/s), the undersigned, are desirous of opening an with

DCB Bank Limited. I / We have submitted to the Bank my/our Entry Work/Residence Visa(s) dated _________ (Visa issuance date) expiring on _________ (Visa expiry

date) for this purpose. I / We hereby agree to furnish the Bank with the copy/ies of my/ our regular Visa(s) immediately on issuance and confirm that I /we have no

objection if the Bank freezes transactions in the said account/s or closes the said account/s in case of my / our non-submission of regular Visa (ies) prior to the date of

expiry of the Visa/s i.e. _________ I / We also confirm that this procedure will also apply in case I / we are joint holders of the account/s.

c FCNR (B) Deposit c NRE account c NRO account

Temporary entry work / residence Visa declaration

Letter From Customer - Recording A Different Signature(When Signature recorded on any of the document provided for Signature Proof is different from the one recorded on the AOF)

To be signed by the Customer in the presence of the Bank Official attesting the Signature

The Branch Manager

DCB Bank Limited

____________________ Branch

Sir / Madam,

With reference to the ____________________________________________________________________ (name of the document on which the signature differs) provided

by me as proof of my signature along with the Account Opening Form, I request you to please record with yourselves my specimen signature as below, as the

signature on the above referred document differs from the one provided on the Account Opening Form :

_________________________________________________________________________________________________ (Signature as per document submitted)

_________________________________________________________________________________________________ (Signature now requested to be admitted)

This difference in the signature is because ________________________________________________________________________________________________

Yours faithfully,

___________________________________

(Signature of the Customer) Signed in my presenceName & Signatures of the Officer

(Name of the Customer) along with Signature Code Number

YYYYMMDDDate:

10

For Branch Use

Customer has been Met in Person Customer has opened the account through the Non-Face to Face process

Declaration if the customer has been met by the branch Staff:

I / We declare, that we have met the above prospective customer/s personally at _________________________________________________________) and that he / she /

they have signed the AOF and other forms in my / our presence. I / We have inspected the documents of proof of identity and address in original and that the copies

thereof enclosed to the AOF (and mentioned in Checklist) have been duly verified by us against the originals and are satisfied with the same.

Name of the Branch Staff

HRMS No.:

Signature of the Branch Staff

Declaration to be signed by the Branch Head/BOM certifying that the documents have been sourced per process (Met in Person/Non

Face to Face):

I hereby confirm that the above named Mr./ Ms. _____________________________________________________________ HRMS No.____________________ is a Branch

Staff / CBE and I am satisfied with the above declaration regarding the ISA documents and verification of other contents in this due diligence form.

Name of the Branch Head / BOM

HRMS No.:

Signature

Declaration if the customer has sent his documents through the Non-Face to Face process:

I/We declare that we have not met the customer in person and have not seen or verified any of the documents. The customer has been contacted through

phone/email and have submitted the documents as per the Non-Face to Face process. I have inspected the documents and noted that they are in order with the

process requirements.

Name of the Branch Staff

HRMS No.:

Signature of the Branch Staff

Bank Use only

Account No.:

Customer ID:

Branch: SOL Code: Date: YYYYMMDD

RM / CSE / RO / CBE (Code):Segment Code

NPC Funding

Txn. / ID No.: YYYYMMDDDate: YYYMMDDValue Date: Y

Application Number :

Section II Tick this box, if any of the below mentioned address is same as Account Opening Form (Skip to Section III)

Permanent Residential Address

House / Flat No.:

Street:

City / Town:

Province / State:

Pincode:

Landmark:

Country:

Mailing Address (If different from the Permanent Residential Address)

House / Flat No.:

Street:

City / Town:

Province / State:

Pincode:

Landmark:

Country:

(Mandatory for each Account Holder including POA, Guardian, Mandate holder etc.)

Note - The information in this section is being collected in order to fully comply with Foreign Account Tax Compliance Act (FATCA) requirements and the Common Reporting Standards (CRS) requirements.

FATCA / Self / CRS Declarationfor Individual Accounts

Section III: Tax Resident / Citizenship Information

For the Purpose of taxation, I am resident in or a citizen of the following countries:

Country / Countries Tax Resident (please tick) Citizen (please tick) Local Tax Identification Number (TIN) TIN Type

If the country does not issue a TIN or if a TIN cannot be obtained please provide an explanation:

I hereby certify that I am not tax resident in, or citizen of, any other country besides those listed above. (Please tick)

I hereby certify that I am/am not a U.S. person, including a resident alien individual.

For more information refer:http://www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCAhttp://www.oecd.org/ctp/exchange-of-tax-information/automatic-exchange-nancial-account-information-common-reporting-standard.pdf(We are unable to provide advice about your tax residency. If you have any questions about your tax residency, please contact your tax advisor)

1. Customer ID

2. Name of Account Holder

3. Family Name or Surname(s)

4. Title

5. First Name

6. Middle Name / Father's Name

7. Date of Birth

8. Country of Birth

9. Place within the County of Birth

10. Country/ies of Citizenship

11. Country/ies of Tax Residency

12. Tax Identification Number (PAN equivalent of the foreign country)

13. POA or a mandate holder who has an address outside India

14. Telephone number outside India

Yes No

Part A (All fields are Mandatory)

Section I Details of Account Holder

Declaration & Acknowledgement

1. I declare that all statements made in this Declaration are, to the best of my knowledge and belief, correct and complete. I undertake to advise DCB Bank Limited. promptly of any change in circumstances which causes the information contained herein to become incorrect and to provide DCB Bank Limited with a suitably updated Declaration within 30 days of such change in circumstances.

2. I authorize DCB Bank Limited to provide, directly or indirectly, to any relevant tax authorities/government authorities and/or other regulatory authorities locally/internationally or any party authorized to audit or conduct a similar control of DCB Bank Limited for tax purposes, the information contained in this Form and to disclose to such tax authorities or such party any additional information that DCB Bank Limited may have in its possession.

3. I certify that I am beneficial owner or am authorized to sign for the individual who is the beneficial owner of all the income to which this form relates and/or am using this form to document myself as an individual who is the Account Holder.

4. In the event if DCB Bank Limited is put to any hardships or claims from any authorities due to any false, untrue or misleading representation/information furnished by me as contained herein, I shall be solely liable and responsible for the same.

Customer Name: _______________________________________________________________________ Customer Signature: _______________________________________

Date: _______________________

If you have signed this Form on behalf of the beneficial owner, please indicate the capacity in which you are acting (and attach proof whereof, alongwith this Declaration):

________________________________________________________________________________________________________________________________________________________________

For Bank Use

Account Relation Type: ______________________________________

Form Type Submitted:

Name of Bank Official: ________________________________________________________________________

HRMS Number: ____________________________

Date: ________________________

Occupation Type:____________________________________________

W-8 BEN W-9

__________________________________________Signature of Bank Official

Note

1. The Income–Tax (11th Amendment) Rules, 2015 warrants DCB Bank Limited to collect certain tax related information about its clients.

2. This Form is designed to capture the citizenship and residency for tax purposes of the person entitled to the income and assets associated with an account (the beneficial owner).

3. Please complete, where applicable, the relevant sections in relation to all relevant accounts and provide any additional information as may be required. Please be advised that in certain circumstances we may be required to share this information with relevant tax authorities.

4. If the Account Holder is holding an account for the benefit of another individual, an agent, custodian, nominee or signatory, investment adviser, intermediary or in other similar capacity and is not the Beneficial Owner, please provide :

5. The Individual Self Certification Form with your details as Account Holder, duly completed and signed, and A separate duly completed and signed Individual Self Certification Form for each Beneficial Owner containing the Beneficial Owner’s details.

6. If you are a US citizen or resident of the US for tax purposes under US Internal Revenue Service (“IRS”) regulations you should also provide a completed, signed and dated IRS Form W-9.

7. If you have any questions about how to complete this form, please contact your tax advisor.

8. Please note that for accounts opened with a DCB Bank Limited, in order to be compliant with Income Tax Act, this Self-Certification Form is required in addition to any U.S. W-8 or W-9 form you may have provided for U.S. FATCA purposes.

Part B

Fill Form:1. W-9 - If you are a U.S.A. citizen or U.S.A. tax resident OR2. W-8 BEN - If you are a tax resident of any country (other than India or U.S.A)

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

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2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

▶Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

▶Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt f om backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of ▶U.S. person ▶Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

Form W-9 (Rev. 12-2014)

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien;

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup WithholdingWhat is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your InformationYou must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

PenaltiesFailure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific InstructionsLine 1You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Form W-9 (Rev. 12-2014)

Line 2If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, ExemptionsIf you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 7

Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be 1reported and direct sales over $5,000

Generally, exempt payees 21 through 5

Payments made in settlement of payment card or third party network transactions

2 However, the following payments made to a corporation and reportable on Form

Exempt payees 1 through 4

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.

1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Form W-9 (Rev. 12-2014)

Part II. CertificationTo establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the RequesterFor this type of account: Give name and SSN of:

1. Individual The individual2. Two or more individuals (joint

account)The actual owner of the account or, if combined funds, the first

1individual on the account

3. Custodian account of a minor (Uniform Gift to Minors Act)

2The minor

4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

1The grantor-trustee

1The actual owner

5. Sole proprietorship or disregarded entity owned by an individual

3The owner

6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of:

7. Disregarded entity not owned by an individual

The owner

8. A valid trust, estate, or pension trust 4Legal entity

9. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

10. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

11. Partnership or multi-member LLC The partnership12. A broker or registered nominee The broker or nominee

13. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))

The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2

3

Circle the minor’s name and furnish the minor’s SSN.

You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 2.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity TheftIdentity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

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Date: YYYYMMDD

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Employee code:

1st Applicant’s Name:

Joint Applicant 1:

Joint Applicant 2:

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Branch:

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