Westpac Banking Corporation ABN 33 007 457 141
AFSL and Australian credit licence 233714
Customer Information Certificate – Domestic Proprietary Company
Definition: a company incorporated in Australia that is limited by share capital, whose membership is limited to
50 non-employee shareholders and that is prohibited from offering invitations to the public to subscribe to its shares
or debentures.
Please note that this certificate may have been pre-populated with information that the Bank has previously collected from
the customer. In completing this form you are responsible for completing any blank sections, checking the accuracy of any
pre-populated section, informing us if any of the information is not correct and supplying the correct information in substitution.
Bank use
only (initials)
1
Yes  Go to 2
Is the company registered with ASIC as a
proprietary company?
2
Full name of company as registered with ASIC
3
Does the company have a business name other
than the company name registered with ASIC?
4
ACN
5
Does the company have an ABN?
 Complete the applicable Customer
Information Certificate
No
Yes 
(insert registered business name)
No
Yes 
(insert ABN)
No
6
Company’s office address as registered with ASIC
(not a PO box)
7
Company’s principal place of business address
(not a PO box)
Same as company’s office address above as
registered with ASIC
8
State or Territory as registered with ASIC
9
Date registered with ASIC
/
10
Is the company a tax resident of any country
outside of Australia?
Yes
11
Country(ies) outside of Australia in which the
company is a resident for tax purposes and
country’s associated Tax Identification Number
(TIN)*
*A TIN is an identifying number or equivalent used
for tax purposes. If a ‘TIN’ is not available, please
specify the reason against the appropriate
country.
/
No  Go to 12
1.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
2.
Country of tax residence:
TIN:
Note: If the company has more than 3 countries in
which it is a tax resident, please provide the
details on a separate paper.
OR
TIN not issued by this country
TIN pending issue by country's tax authority
3.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
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12
Full name (all given names including middle
name(s) and family name) of each Director
Note: An initial, nickname, alias, shortened name
or part of a name is NOT acceptable.
13
Is the company regulated, i.e. licensed and
subject to regulatory oversight, by?
ASIC and holds an Australian Financial Services
Licence (AFSL)
Note: A company is regulated by ASIC only if the
company holds an Australian Financial Services
Licence (AFSL) and/or an Australian Credit
Licence (ACL).
ASIC and holds an Australian Credit Licence
(ACL)
Australian Prudential Regulation Authority (APRA)
Private Health Insurance Administration Council
(PHIAC)
 Go to 15
None of the above
14
Licence details (e.g. licence number)
Insert licence details 
Go to 19
15
Beneficial Owner – Owner
Yes  Go to 18
Does the company have any INDIVIDUALS
(NATURAL PERSONS), who ultimately own
directly or indirectly, through one or more
shareholdings, 25 per cent or more of the issued
capital of the company?
No
 Go to 16
Note: This includes INDIVIDUALS (NATURAL
PERSONS) who are owners of an underlying
company and who ultimately own 25 per cent or
more of the issued capital of the company listed
above at Q2.
16
17
Beneficial Owner – Controller
Yes  Go to 18
Does the company have any INDIVIDUALS
(NATURAL PERSONS), who ultimately control,
through a capacity to make financial and
operating decisions on behalf of the company?
No
Beneficial Owner – Other
 Go to 17
Go to 18
The company must have at least one ultimate
beneficial owner. If you have answered “No” to
Q15 and Q16 above, provide the details of any
INDIVIDUALS (NATURAL PERSONS), who have
25 per cent or more voting rights (including a
power of veto) or hold the position of senior
managing official (or equivalent), e.g. CEO?
18
Provide the details of each INDIVIDUAL
(NATURAL PERSON) who is a beneficial owner
BENEFICIAL OWNER 1
All given names:
Note: the identity of all beneficial owners must be
verified. This can be completed through the
provision of certified copies of identification
documents or via electronic verification.
Electronic verification is only available to
individuals with an Australian residential address
and an Australian mobile number.
Foreign Tax Residency Information:
A Tax Identification Number (TIN) is an
identifying number or equivalent used for tax
purposes. If a ‘TIN’ is not available, please
specify the reason against the appropriate
country.
Note: If the beneficial owner has more than 3
countries in which they are a tax resident, please
provide the details on a separate paper.
Family name:
Other name(s) known by (if any):
Date of birth:
/
/
Permanent residential address, including country
(not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 1 a tax resident of any country
outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which
beneficial owner 1 is a resident for tax purposes and
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each country’s associated TIN.
1.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
2.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
3.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
BENEFICIAL OWNER 2
All given names:
Family name:
Other name(s) known by (if any):
Date of birth:
/
/
Permanent residential address, including country
(not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 2 a tax resident of any country
outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which
beneficial owner 2 is a resident for tax purposes and
each country’s associated TIN.
1.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
2.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
3.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
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BENEFICIAL OWNER 3
All given names:
Family name:
Other name(s) known by (if any):
Date of birth:
/
/
Permanent residential address, including country
(not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 3 a tax resident of any country
outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which
beneficial owner 3 is a resident for tax purposes and
each country’s associated TIN.
1.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
2.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
3.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
BENEFICIAL OWNER 4
All given names:
Family name:
Other name(s) known by (if any):
Date of birth:
/
/
Permanent residential address, including country
(not a PO Box):
Email address for electronic verification purposes:
Foreign Tax Residency Information:
Is beneficial owner 4 a tax resident of any country
outside of Australia?
Yes
No
If yes, please indicate the country(ies) in which
beneficial owner 4 is a resident for tax purposes and
each country’s associated TIN.
1.
Country of tax residence:
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TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
2.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
3.
Country of tax residence:
TIN:
OR
TIN not issued by this country
TIN pending issue by country's tax authority
19
Full name of person providing this certificate
20
Capacity of person providing this certificate
(select appropriate box)
Director
Secretary
Financial Controller
Authorised Representative (e.g. solicitor, accountant)
21
Certification
I hereby certify that:
1. I am authorised to complete this certificate on behalf of the Customer;
2. The details included in this certificate are true and correct as at the date of this certificate;
3. All documents in the possession or control of the Customer that verify the information in this certificate have been
supplied to the Bank and all documents so supplied are true and correct as at the date of this certificate; and
4. I acknowledge that the Bank will rely on this certificate to determine whether to provide services to the Customer in
compliance with the law.
22
Signature of person providing this certificate
23
Date

/
/
Privacy Statement: The personal information the Bank is collecting from you on this form will be used to satisfy the Bank's
identification requirements under the Anti-Money Laundering & Counter-Terrorism Financing Act and Rules. If you do not provide
all the information requested, the Bank may not be able to provide any product or service to the Customer. The Bank will use
and disclose your personal information to other members of the Westpac Group, anyone the Bank engages to do something on
its behalf, and other organisations that assist the Bank with its business which may include organisations located outside of
Australia and to government agencies and regulators, in some cases offshore. Details are in the Bank’s privacy policy. The
Bank's privacy policy, available at westpac.com.au or by calling 132 032 (or from overseas +61 2 9293 9270), contains
information about how the Bank handles your personal information, how you can access the personal information the Bank holds
about you and seek its correction, how you may complain about a breach of the Australian Privacy Principles and how the Bank
will deal with your complaint.
You agree that where you have provided personal information about other individuals in this form you will tell those individuals
that you have supplied their information to the Bank and make them aware of the contents of this Privacy Statement and that for
each Beneficial Owner whose email address has been provided to the Bank you have made them aware of, and obtained their
consent to, the Bank contacting them by email for the purpose of each Beneficial Owner electing to proceed with the Bank
conducting online verification of their identity to satisfy the Bank’s identification requirements.
Westpac Group means Westpac Banking Corporation and its related bodies corporate.
Note: It is an offence under the Anti-Money Laundering & Counter-Terrorism-Financing Act 2006 to knowingly provide false or
misleading information or knowingly produce a false or misleading document. Penalty: Imprisonment for 10 years.
Our Reporting Obligations: We are required to identify tax residents of a country(ies) other than Australia in order to meet
account information reporting requirements under local and international laws.
If at any time after account opening, information in our possession suggests that you, the entity and/or any individual who holds
ownership and/or control in the entity of 25% or more (Controlling Person/Beneficial Owner) may be a tax resident of a
country(ies) other than Australia, you may be contacted to provide further information on your foreign tax status and/or the
foreign tax status of the entity and/or any Controlling Person/Beneficial Owner. Failure to respond may lead to certain reporting
requirements applying to the account.
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By completing this application you certify that if at any time there is a change to the foreign tax status details for you, the entity
and/or any controlling persons/beneficial owner, you will inform the bank. You also certify that if at any time there is a change of
a controlling person/s/beneficial owner/s in your entity, you will inform the bank.
A controlling person/beneficial owner refers to the individual(s) that directly or indirectly owns a legal interest in the entity of 25%
or more and/or exercises actual effective control over the entity, whether from an economic or other perspective such as through
voting rights. In addition, in the case of a trust, a controlling person/beneficial owner includes the settlor(s), trustee(s),
appointer(s), protector(s), beneficiary(ies) or classes of beneficiaries and in the case of an entity other than a trust, the term
includes persons in equivalent or similar positions.
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