SIX SIS Ltd Mailing address:
Brandschenkestrasse 47 P.O. Box 1758
CH-8002 Zurich CH-8021 Zurich
T +41 58 399 3111
Form 128
Safecustody account opening, modification and closing request 10/2011
(also valid as interim Withholding Statement)
BP ID*: Contact
person*:
Company*: Phone*:
QI-EIN*: Email:
1. Please carry out the following instructions* For SIX SIS-internal use only
Task:_____________________
Please choose an instruction CIM __________ / CRM __________
Investors Domicil as follows (parts 2. - 5., where applicable): Vollständigkeitsprüfung
Unterschriftenprüfung
Market
Datum/Visum:___________________
2. Account type* Steuerkategorieprüfung
Datum/Visum:___________________
Description: Please choose an account type Type -
Depoteröffnung
De-Linked
Eröffnungsauftrag CUMD
Depot-Nr. Vostro P:_______________________
Vostro X:_______________________
3. Evaluation currency: CHF (default CHF)
Linked
Eröffnungsauftrag PNWM
4. External account reference:
Ext. Acc. Ref.:___________________
(Please indicate the desired account description; optional) Eröffnungsauftrag CUMD
5. Type of QI allocation and taxation category (see "Overview SCA tax categories")* Vostro P:_______________________
For this account we are acting as Nostro P:______________________
Vostro X:______________________
9
Please choose your QI status
Nostro X:______________________
Specification: Datum/Visum:__________________
Please choose your details
Taxation category: Depotmutation CUMD
T.C. Please choose the taxation category/market
Datum/Visum:___________________
Requested form: Requested Form Depotschliessung
Additional forms*: Positionsprüfung i.O.
De-Linked
Déclaration de Non-Résidence (France) Dichiarazione (Italy) Schliessungsauftrag CUMD
Linked
Other: Schliessungsauftrag PNWM
Schliessungsauftrag CUMD
Requested forms are attached.
Datum/Visum:___________________
We confirm that for this new account the W-8 IMY, already under file with you, is valid as
Bestätigung BP
well.
Erl. Datum:_____________________
Visum: ________________________
Place / Date:: Company seal and signature:
* = mandatory fields
Name of signatory in block letters:
Please fax a copy of this form to: +41 58 499 4223
Please send the original form to: SIX SIS Ltd
Customer Master Data and Administration
P.O. Box 1758
CH-8021 Zurich
In case of questions, please call: +41 58 399 4222
Mailing address:
P.O. Box 1758
CH-8021 Zurich
Form 128
10/2011
or SIX SIS-internal use only
Vollständigkeitsprüfung
Unterschriftenprüfung
atum/Visum:___________________
Steuerkategorieprüfung
atum/Visum:___________________
De-Linked
Eröffnungsauftrag CUMD
stro P:_______________________
stro X:_______________________
Eröffnungsauftrag PNWM
t. Acc. Ref.:___________________
Eröffnungsauftrag CUMD
stro P:_______________________
stro P:______________________
stro X:______________________
ostro X:______________________
atum/Visum:__________________
Depotmutation CUMD
atum/Visum:___________________
Depotschliessung
De-Linked
Schliessungsauftrag CUMD
Schliessungsauftrag PNWM
Schliessungsauftrag CUMD
atum/Visum:___________________
l. Datum:_____________________
sum: ________________________
ion
Auftragsart
Please choose an instruction
Open a new vostro safecustody account (de-linked)
Open a new vostro safecustody account (linked)
Close safecustody account
Modify safecustody account
SecLend Borrower Liability
SNB Extended Cover Vostro Account
Vostro Safe Custody Account for x-clear SFX
TCM Vostro Safe Custody Account
TCM Collateral Pool Vostro Account
Depot-Typ Code
Please choose an account type -
Ordinary 01
Lending 02
Collateral for external entities 03
Collateral 04
Custody Cover Account SNB 05
Borrower Liability 08
Collateral Custody account for CCP (irregular pledge) 09
Reinvestment 13
Restricted 14
Escrow 15
Tax exempt 16
Street name 17
Resident 18
SecLend Lender Loan 19
SecLend Borrower Liability 20
SNB Extended Cover Vostro Account 21
Vostro Safe Custody Account for x-clear SFX 22
23
Vostro Safe Custody Account for Unsecuritised Position(s)
TCM Vostro Safe Custody Account 24
TCM Collateral Pool Vostro Account 25
Evaluation Currency QI Status Description
CHF Please choose your QI status
1. QI with primary NRA withholding responsibility and with 1099
AUD reporting and backup withholding responsibility
2. QI with primary NRA withholding responsibility, but no 1099
CAD reporting and no backup withholding responsibility
3. QI without primary NRA withholding responsibility, but with
DKK 1099 reporting and backup withholding responsibility
4. QI without primary NRA withholding responsibility, no 1099
EUR reporting and no backup withholding responsibility
GBP 5. NQI Business Partners
HKD 6. Proprietorship positions
JPY 7. Resident positions
USD 8. Various (Special Tax Rate)
ZAR
9
#QI #QI Description #QI
9 9 No selection available 9
1 1 QI with primary NRA withholding responsibility 1
2 2 NRA investors 2
3 2 US investors (linked account) 2
4 3 NRA income allocation 2
5 3 NRA asset allocation 2
6 3 US investors 3
7 4 NRA income allocation 3
8 4 NRA asset allocation 3
4 US investors (linked account) 3
5 NQI Business Partners - non-US securities 3
5 NQI US securities for NRA disclosed 3
5 NQI US securities for US investors 3
6 NRA investors (must be documented) 3
7 Resident client(s) 3
8 Special Tax Rate - to be defined by SIS 3
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3
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3
3
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3
3
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6
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8
Auswahlliste Details Auswahlliste Taxation Category
Please chose your details
9 No selection available 9
Description
No selection available
QI with primary NRA withholding responsibility
NRA investors
US investors (linked account)
US investors (linked account)
US investors (linked account)
NRA income allocation
NRA income allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
US investors
NRA income allocation
NRA income allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
NRA asset allocation
US investors (linked account)
US investors (linked account)
US investors (linked account)
NQI Business Partners - non-US securities
NQI Business Partners - non-US securities
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for NRA disclosed
NQI US securities for US investors
NQI US securities for US investors
NRA investors (must be documented)
NRA investors (must be documented)
NRA investors (must be documented)
NRA investors (must be documented)
Resident client(s)
Resident client(s)
Resident client(s)
Resident client(s)
Special Tax Rate - to be defined by SIS
Auswahlliste Taxation Category
Please choose your details
Detailed Description
-
QI with primary NRA withholding responsibility
QI with primary NRA withholding responsibility
W9 non-exempt US a/c (omnibus or segregated)
Undisclosed/undocumented non-exempt US a/c (omnibus)
Exempt US a/c (omnibus)
Swiss Bank Business Partners
Non-Swiss Business Partners
US non-treaty account 30/30
US treaty 30/0
US treaty 25/17.5
US treaty 25/15
US treaty 20/15
US treaty 15/15
US treaty 15/12.5
US treaty 15/12
US treaty 15/10
US treaty 15/5
US treaty 15/0
US treaty 10/15
US treaty 10/10
US treaty 10/0
Exempt account (govt/supernat/charities/US exempt etc.)
Exempt Account (foreign private foundation)
Undocumented non-US a/c
Swiss QI STRUSA a/c 15/30
Special _______________________________________
Exempt account (govt/supernat/charities/US exempt etc.)
Swiss Bank Business Partners
Non-Swiss Business Partners
US non-treaty account 30/30
US treaty 30/0
US treaty 25/17.5
US treaty 25/15
US treaty 20/15
US treaty 15/15
US treaty 15/12.5
US treaty 15/12
US treaty 15/10
US treaty 15/5
US treaty 15/0
US treaty 10/15
US treaty 10/10
US treaty 10/0
Exempt account (govt/supernat/charities/US exempt etc.)
Exempt Account (foreign private foundation)
Undocumented non-US a/c
Swiss QI STRUSA a/c 15/30
Special _______________________________________
W9 non-exempt US a/c (omnibus or segregated)
Undisclosed/undocumented non-exempt US a/c (omnibus)
Exempt US a/c (omnibus)
NQI non-Swiss Business Partners
NQI Swiss Business Partners
US non-treaty account 30/30
US treaty 30/0
US treaty 25/17.5
US treaty 25/15
US treaty 20/15
US treaty 15/15
US treaty 15/12.5
US treaty 15/12
US treaty 15/10
US treaty 15/5
US treaty 15/0
US treaty 10/15
US treaty 10/10
US treaty 10/0
Exempt account (govt/supernat/charities/US exempt etc.)
Exempt Account (foreign private foundation)
Special _______________________________________
W9 non-exempt US a/c (omnibus or segregated)
Exempt US a/c (omnibus)
Swiss & non-Swiss Business Partners -own positions treaty a/c 15/0
Swiss Business Partners - own positions with STRUSA 15/30
Business Partners own positions exempt 0/0
Business Partners non-treaty 30/30
France
Canada
Belgium
other:
Please choose the taxation category/market
Taxation Category Required form Listenberechnung
- -
37 W-8IMY (9a, b, c)
37 W-8IMY (9a, b)
34 W-8IMY (9a, b)
35 W-8IMY (9a, b)
36 W-8IMY (9a, b)
1 W-8IMY (9a, c)
3 W-8IMY (9a, c)
11 W-8IMY (9a, c)
12 W-8IMY (9a, c)
13 W-8IMY (9a, c)
14 W-8IMY (9a, c)
15 W-8IMY (9a, c)
16 W-8IMY (9a, c)
17 W-8IMY (9a, c)
18 W-8IMY (9a, c)
19 W-8IMY (9a, c)
20 W-8IMY (9a, c)
21 W-8IMY (9a, c)
22 W-8IMY (9a, c)
23 W-8IMY (9a, c)
24 W-8IMY (9a, c)
31 W-8IMY (9a, c)
32 W-8IMY (9a, c)
33 W-8IMY (9a, c)
38 W-8IMY (9a, c)
__ ____________________
31 W-8IMY (9a, c)
1 W-8IMY (9a)
3 W-8IMY (9a)
11 W-8IMY (9a)
12 W-8IMY (9a)
13 W-8IMY (9a)
14 W-8IMY (9a)
15 W-8IMY (9a)
16 W-8IMY (9a)
17 W-8IMY (9a)
18 W-8IMY (9a)
19 W-8IMY (9a)
20 W-8IMY (9a)
21 W-8IMY (9a)
22 W-8IMY (9a)
23 W-8IMY (9a)
24 W-8IMY (9a)
31 W-8IMY (9a)
32 W-8IMY (9a)
33 W-8IMY (9a)
38 W-8IMY (9a)
__ ____________________
34 W-8IMY (9a) plus W-9
35 W-8IMY (9a) (no W-9 submitted)
36 W-8IMY (9a) plus W-9
41 W-8IMY NQI (10a)
42 W-8IMY NQI (10a)
11 W-8IMY NQI (10b) plus BEN/EXP
12 W-8IMY NQI (10b) plus BEN/EXP
13 W-8IMY NQI (10b) plus BEN/EXP
14 W-8IMY NQI (10b) plus BEN/EXP
15 W-8IMY NQI (10b) plus BEN/EXP
16 W-8IMY NQI (10b) plus BEN/EXP
17 W-8IMY NQI (10b) plus BEN/EXP
18 W-8IMY NQI (10b) plus BEN/EXP
19 W-8IMY NQI (10b) plus BEN/EXP
20 W-8IMY NQI (10b) plus BEN/EXP
21 W-8IMY NQI (10b) plus BEN/EXP
22 W-8IMY NQI (10b) plus BEN/EXP
23 W-8IMY NQI (10b) plus BEN/EXP
24 W-8IMY NQI (10b) plus BEN/EXP
31 W-8IMY NQI (10b) plus BEN/EXP
32 W-8IMY NQI (10b) plus BEN/EXP
__ ____________________
34 W-8IMY NQI (10b) plus W-9
36 W-8IMY NQI (10b) plus W-9
39 W-8 BEN
40 W-8 BEN
43 W-8 EXP
44 W-8 BEN
6 W-8IMY (9a, c) + No additional Forms required
6 W-8IMY (9a, c) + Resident Décleration
6 W-8IMY (9a, c) + No additional Forms required
6
__
T.C. Requested Form
Listenberechnung