STATE BANK OF INDIA, VANDAVASI BRANCH,

19B/1, Sannadhi Street,

Vandavasi, Tiruvannamalai Dt,
Tamilnadu, India, 604 408.
Phone:9442519718 Fax : 04183-226248.

Dear Sir,
Sub: Other Indicia Request for self-certification and documentary evidence

1. We refer to your Account no and other account under CIF held with us as on 31 December 2015.
2. The Finance (No.2) Act, 2014 has amended section 285BA of the Income tax Act, 1961 to include the
obligation of reporting tax information by prescribed reporting financial institutions. This amendment has
prescribed Rules 114F to 114H detailing the due diligence procedures and reporting requirements by the
Reporting Financial Institutions which have been published vide Notification No. S.O. 2155(E) dated 7 August
2015 read with Guidance Note dated 31 August 2015 on these Rules. Further, the RBI has also formally notified
these Rules vide its Circular No. RBI/2015-16/165 DBR.AML.BC.No.36/14.01.001/2015-16 dated 28 August
2015.

3. During the course of due-diligence carried out by State Bank of India pursuant to the above law/ Rules/
provisions, the following Other indicia have been found to be associated with your account (as ticked b below)
as per our records:
i) A resident of any country or territory outside India other than the United States of America (the U.S.) for
tax purpose.
ii) Current residence address in any country or territory outside India other than the U.S.,
iii) Current mailing address in any country or territory outside India other than the U.S.,
iv) Current post box no in any country or territory outside India other than the U.S.
v) One or more telephone numbers in any country or territory outside India other than the U.S. (and no
telephone number in India)
vi) Standing instructions (with respect to financial accounts other than depository accounts) to transfer
funds to an account maintained in any country or territory outside India other than the U.S.

4. As per CBDT Rules, the presence of any of the above indicia in an account would indicate that the account
holder may be a resident of any country or territory outside India other than the U.S. under the tax laws of such
country or territory and hence your account appears to be an Other Reportable Account. Accordingly it may
please be appreciated that the Indicia found needs either to be cured or confirmed by you through self-
certification and documentary evidence.
5. Therefore, you are kindly requested to provide the following documents together with the enclosed self-
certification within 15 days of receipt of this letter.
Other Indicia Found Documents required to cure Other Indicia
i) A resident of any country or territory All the following documents:
outside India other than the United States a. self-certification indicating the
of America (the U.S.) for tax purpose. country/territory(ies) of residence for tax
ii) Current residence address in any country purposes that does not include any
or territory outside India other than the country or territory outside India in the
U.S., format enclosed;
iii) Current mailing address in any country or
territory outside India other than the U.S., AND
iv) Current post box no in any country or
territory outside India other than the U.S. b. Documentary evidence in support of non-
v) One or more telephone numbers in any reportable status.
country or territory outside India other
than the U.S. (and no telephone number
in India)
vi) Standing instructions (with respect to
financial accounts other than depository
accounts) to transfer funds to an account
 maintained in any country or territory
outside India other than the U.S.

6. Further, you may kindly observe that the enclosed self-certification also provides for confirming / declaring the
Other indicia if the same is applicable to you which will help us correctly identify your account as Other
Reportable account and report it accordingly. In case, none of the above indicia is actually applicable to you,
supporting documents are required to be submitted to the Bank.

7. The CBDT Rules mandate reporting of account as Other Reportable account wherever the self-certification
together with the required documents detailed in para 5 above is not received.
8 As both the account holder and the Banks are under obligation to mandatorily comply with the provisions of
CBDT Rules, we request you to kindly extend your co-operation and patronage to us by providing us with the
required self-certification & documentary evidence.

9. In case you require any clarification or assistance with respect to the above, please contact your Branch
Manager or Relationship Manager, FATCA & CRS, (Telephone No 9442519718).

Yours faithfully,

For State Bank of India