Consent Form for U.S. Persons, Private Clients

Consent of the Client who is a foreign taxpayer to information transfer

I, ____________________________________________________________________,

(surname, name, patronymic of the foreign citizen (for a legal entity you also need to specify your title and the name of the organisation)

being a foreign taxpayer of _________________________________________________________________

(foreign state the foreign citizen belongs to)

Please tick the appropriate box:

______ express my consent to the transmission of information to the tax authority and (or) to the foreign tax agents which are authorised by the foreign tax authority to charge foreign taxes and duties and also to Russian authorised bodies in the manner and to the amount established by the government of the Russian Federation.

______ express my refusal of consent to the transfer of information (the Bank has informed me that it has the right to refuse to carry out banking transactions, as well as to conclude a Bank Account (Deposit) Contract or to unilaterally terminate the Bank Account (Deposit) Contract).

 

__________________________    _____________________________________

(signature, full name)

 

_____ _____________201__

 

Accepted by the officer

 ___________________________ _________________ __________________

(officer’s title, signature, full name)

 _____ _____________201__