PSNL209514021907

Comp/Feb/Int/4934

Declaration – Current Tax Residential Status

<DD/MM/YYYY>

To: The QROPS Team

HDFC Life Insurance Company Limited
14th Floor, Lodha Excelus, Apollo Mill Compound,
N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011

I, <<PH Full Name>>, residing at ___________________, country India hereby declare that my tax
residential status for the financial year starting from <01/04/YYYY> to <31/03/YYYY> is as under:

(Please tick the relevant box as applicable)

Resident Indian Non-Resident India (Please Specify) _________________________

I have made this declaration with complete knowledge and an independent and sound state of mind, fully
aware of the UK laws relating to tax charge and the implications there under. I understand that my
declaration herein will be the sole basis in determining my residency status for tax purposes. In case
there is any tax charge, interest, liability and/or penalty levied by HMRC on HDFC Life due to
wrong/incorrect confirmation provided by me hereunder, then I undertake to indemnify and hold HDFC
Life harmless against any such claims/liability.

Further, I hereby authorise HDFC Life to share this declaration with HMRC or any other
regulatory/statutory authority.

(Signature of the Policy Holder)

Date: D D M M Y Y Y Y Place:

Credentials of the Witness:

Signature of
Name of the Witness:
the Witness

Address:

Date: D D M M Y Y Y Y Place:
Off
Contact No.: Res
Mob
Email ID:
*******This is an electronically generated communication and does not require a signature.*******