The original file is kept in the office. This is the text saved from it.
1 page
100%
✓
Y O O S U M I
1 8 0 2 1 9 6 1
✓ Chairman
HIROSHI OSUMI
CHIZUKO OSUMI
MIKA OSUMI
Japanese
2-10-10 Nishi-Ikebukuro, Toshima,
Tokyo, 171-0021, Japan
4-25, Mejiro, Toshima, Tokyo, Japan
TR8929979
Chairman
OY418@IRIS.CO.JP
+81-80-5188-8948
✓
Business
✓
cll> COMMERCIAT BANK OPENING OATE
FIISK DEPTT FILE NO :
tltrll
NAME
1 2
NAME
3
NAME
4 NAME
5
NAME
6
ttllttltl
✓ ✓ ✓
Date:
Customer Declaration /Consent: Foreign Account Tax Compliance Act, USA
I/We________________________________________________________________________________
And________________________________________________________________________________
of (address)__________________________________________________________________________
____________________________________________________________________________________
Holder of Passport Number/s____________________________________________________________
who fall under the definition of a US Persons/linkage entities under the provisions of The Foreign
Account Tax Compliance Act (“FATCA”) which is a US legislation aimed at collecting tax by US
citizens and residents through overseas assets. We confirm that we understand that FATCA is extra-
territorial by design and requires “US Persons /linkage entities ” to rep ort their financial assets held
overseas.
We hereby authorize Commercial Bank of Ceylon Plc, Bangladesh who is recognized as a Foreign
Financial Institutions (FFIs) /Banks in terms of the FATCA to report all information pertaining to
my/our accounts and investments made by Me/Us with you to the Internal Revenue Service(IRS) of
U.S.A
We hereby confirm that this concurrence is granted by us with full knowledge and understanding
and in terms Bangladesh Bank relevant circular instruction.
__________________________
Authorized Signatory
Customer/Name of the Company:
✓