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FOR INFORMATIONAL PURPOSES ONLY - irs.gov

FOR INFORMATIONAL PURPOSES ONLY Periodic Certification Participating FFIs 1 Identifying Information 1. The periodic certification can only be completed by the Responsible Officer (RO). Confirm the RO information and make updates as needed. Any updates made will be saved to your registration 2. Identify the type of financial institution of the participating FFI:2 [ ] Custodial institution [ ] Depository institution [ ] Holding company or treasury center [ ] Investment entity [ ] Specified insurance company 3. Describe the financial institution s business (or each line of business):3 4. Did the participating FFI acquire accounts in a merger or bulk acquisition during the certification period?4 Select the applicable option for the periodic certification for the period of <start date> to <end date>: [ ] I am completing the periodic certification of [ ] I am unable to complete a periodic certification at this [ ] I am not required to complete a periodic certification for this certification Periodic Certification Certification Type Certification of Compliance Initial Questions: 1.

FOR INFORMATIONAL PURPOSES ONLY Periodic Certification – Participating FFIs 3 a. Describe the material failure and provide the approximate date(s) when the failure occurred.

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