FIDELITY CLEARING CANADA ULC

Foreign Account Tax Compliance Act – Self Certification FormTo be used for Entity accounts only and must be accompanied by a Treaty Statement for QI purposes.

Entity Name Account Number

A. Specified U.S. PersonIn the case of a corporation or partnership, indicate whether it is created, incorporated or organized in Canada?

Yes No

If “no”, indicate whether the entity is a specified U.S. person Yes No If ‘Yes’, provide U.S. TIN

In the case of a trust, indicate whether it is a specified U.S. person? Yes No If ‘Yes’, provide U.S. TIN

B. Financial Institution Is the entity a financial institution?

Yes No

If “Yes”, indicate its status Financial institution with valid GIIN

  Non-participating financial institution (NPFI) 

  Other – provide status (for example, deemed-compliant financial institution) 

C. Entity Type/Character (Not required if the entity is a specified U.S. person or a financial institution)

Check any that apply to the entity:

Active trade or business – less than 50% of the entity’s gross income is passive income and less than 50% of its assets produce or are held for the production of passive income

A corporation with shares that regularly trade on an established securities market

A registered charity or a club, association, or arrangement in Canada operated exclusively for cultural, athletic, or educational purposes

A government or international organization (or agency thereof)

If no category above applies indicate whether the entity is: An active NFFE A passive NFFE

D. Controlling PersonsIf the entity is a passive NFFE, signing below certifies that none of the controlling persons of this entity are US citizens or US residents for tax purposes. If any of the controlling persons of the entity are a US citizen or US resident for tax purposes, please check the box provided and provide an attachment listing the full name, address and US TIN for each such person.

(Check per instructions above)

I declare that the information provided on this form is, to the best of my knowledge and belief, correct and complete.

Print Name  First, M.I., Last Title

Client Signature Date MM - DD - YYYY

SIG

N

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Supportive Guidance and Additional ResourcesSelf-certification may be required if you are opening a new account, for a pre-existing account opened prior to June 30, 2014 where indications of being a U.S. person were identified or if there is a change of circumstance. Certification can be accomplished by either using this form or using the appropriate IRS form. The following guidance is offered to assist you with completing this self-certification form. For guidance in completing the appropriate IRS form please visit the IRS website noted below.

Section A:   If the entity is a specified U.S. person, please tick “No” in section A 1), “Yes” in section A 2) and please provide your U.S. Tax Identification Number (TIN) in the space provided. There is no need to complete parts B, C and D, however please complete the signature section providing your name, title, signature and date.

Section B:   A financial institution is defined in the Canada-US Intergovernmental Agreement (IGA) as “Custodial Institution, a Depository Institution, an Investment Entity or a Specified Insurance Company”. If the entity for which self-certification is being obtained fits this definition please check “Yes” in section B 1) and provide your GIIN in the space provided if you have obtained one. If not, please ignore part B and move to section C. A GIIN can be obtained from the IRS at the website noted under Additional Resources. Next, please provide the status of your entity. A non-participating financial institution is defined in the IGA under article 1 part r. If other applies, please refer to Annex I in the IGA for additional guidance and definitions for other entity classifications.

Section C:   This section is to be completed only if the entity for which this form is being completed is not a specified U.S. person and is not a financial entity. To assist in defining an entity status, please refer to Annex I, section VI part B or Article 1 of the IGA. Additional resources can be found in the CRA guidance notes, chapter 2 as well as chapter 4.

Section D:   This section must be completed unless the account has already been identified as belonging to a specified U.S. person in Section A. Please check the box provided only if controlling persons of this entity for which this form is being completed are either U.S. citizens or U.S. residents for tax purposes. If not, please complete the signature section of the form which is your certification that none of the controlling persons are either U.S. citizens or U.S. residents for tax purposes. 

Additional Resources:          •   IGA (Canada-US Intergovernmental Agreement)

http://www.fin.gc.ca/treaties-conventions/pdf/FATCA-eng.pdf

• CRA FATCA Guidance Notes http://www.cra-arc.gc.ca/tx/nnrsdnts/nhncdrprtng/gdnc-eng.html

• FATCA Registration, Resources and Support Information provided by the IRS http://www.irs.gov/Businesses/Corporations/FATCA-Registration

• FATCA Related Forms – IRS http://www.irs.gov/Businesses/Corporations/FATCA-Related-Forms

• IRS FATCA Homepage http://www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA

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