{"id":2356,"title":"Self-Certification Form for Individuals (Section 285BA of the Income-tax Act, 1961 relating to FATCA/CRS reporting)","purpose":"service","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/final-lic-self-certfication-individuals-23-april-2023","sha256":"25c9ba329d00b90ce5f47ef560cf1c9396d67c7a64b7cb9c2cace41426fce1ed","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is for individuals associated with LIC policies (policyholder, joint policyholder, annuitant, beneficiary, assignee, payee) to self-certify their tax residency status for FATCA and CRS reporting purposes.","notes":["All information must be mandatorily provided by each relevant individual associated with the policy.","Tax Identification Number (TIN) or functional equivalent is mandatory along with proof.","TIN need not be reported if not issued by the jurisdiction; functional equivalents may be reported.","Country of tax residence is determined by days of stay, citizenship, or immigration rules.","LIC does not provide tax advice; individuals should provide information based on their understanding or tax consultant advice.","Use the OECD notified jurisdictions list as of July 2021 for additional declarations.","If 'Residence for Tax Purposes in Jurisdiction(s) outside India' is NO, only the initial declaration is required.","If YES, all tax residency details must be filled and proof attached."],"title":"Self-Certification Form for Individuals (Section 285BA of the Income-tax Act, 1961 relating to FATCA/CRS reporting)","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Identification and Tax Residency Declaration","fields":[{"help":"","type":"text","label":"CUSTOMER ID","options":[],"required":null,"pdf_field":""},{"help":"Select the category that applies to you","type":"choice","label":"Policy Holder/ Joint Policy Holder/ Annuitant/ Joint Annuitant/ Beneficiary/Assignee/ Re-assignee/Payee (Kindly tick the relevant category)","options":["Policy Holder","Joint Policy Holder","Annuitant","Joint Annuitant","Beneficiary","Assignee","Re-assignee","Payee"],"required":true,"pdf_field":""},{"help":"Enter full name as per policy records","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the relevant application or policy number","type":"text","label":"Proposal/Application Number/ Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you are a tax resident outside India","type":"yes-no","label":"Residence for Tax Purposes in Jurisdiction(s) outside India: YES / NO","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or related individual"},{"title":"Tax Residency Details (if YES to residence outside India)","fields":[{"help":"List all countries of tax residence if more than one","type":"table","label":"Country/countries of tax residency*","options":[],"required":true,"pdf_field":""},{"help":"Provide address in each tax residence country","type":"table","label":"Address in the jurisdiction for Tax Residence","options":[],"required":true,"pdf_field":""},{"help":"Provide TIN or equivalent and attach proof","type":"table","label":"Tax Identification Number (TIN)/Functional equivalent Number (Kindly attach proof of TIN / functional equivalent)","options":[],"required":true,"pdf_field":""},{"help":"Country that issued the TIN or equivalent","type":"table","label":"TIN/Functional equivalent Number Issuing Country","options":[],"required":true,"pdf_field":""},{"help":"Validity period of the attached proof","type":"table","label":"Validity of documentary evidence provided","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or related individual"},{"title":"Personal Details","fields":[{"help":"Enter father's full name","type":"text","label":"Father’s Name (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter spouse's full name if applicable","type":"text","label":"Spouse’s Name (optional)","options":[],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender (mandatory)","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter PAN number if available","type":"text","label":"PAN (optional only if father’s name and date of birth provided)","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhar number if available","type":"text","label":"Aadhar Number (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Select the type of identification document provided","type":"choice","label":"Identification Type (mandatory)","options":["Passport","Election Id Card","PAN Card","ID Card","Driving License","UIDAI Letter","NREGA job card","Others","Not Categorised"],"required":true,"pdf_field":""},{"help":"Enter the number from the selected ID document","type":"text","label":"Identification Number (As given in proof of identity document. This information is mandatory if PAN or Aadhar number is not provided)","options":[],"required":true,"pdf_field":""},{"help":"Select your occupation type","type":"choice","label":"Occupation Type (mandatory)","options":["Service","Business","Others","Not Categorised"],"required":true,"pdf_field":""},{"help":"Specify your occupation if desired","type":"text","label":"Occupation (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Enter your date of birth","type":"date","label":"Date of Birth (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter place of birth","type":"text","label":"Place of Birth (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter country of birth","type":"text","label":"Country of Birth (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter your citizenship","type":"text","label":"Citizenship (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter your nationality","type":"text","label":"Nationality (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Select the type of address provided","type":"choice","label":"Address type (mandatory)","options":["Residential Or Business","Residential","Business","Registered Office","Unspecified"],"required":true,"pdf_field":""},{"help":"Provide full address details","type":"text","label":"Address (all sub-fields mandatory): Number, Building Name, Street, Locality, City/Town, State/Province/County, Postal Code, Country","options":[],"required":true,"pdf_field":""},{"help":"Provide mailing address if different","type":"text","label":"Mailing address (if different from above): Building Name, Street, Locality, City/Town, State/Province/County, Postal Code, Country","options":[],"required":false,"pdf_field":""},{"help":"Enter contact number","type":"phone","label":"Telephone number / mobile number","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or related individual"},{"title":"Part II - Additional Declaration (for OECD notified jurisdictions)","fields":[{"help":"List OECD jurisdictions where you are tax resident","type":"text","label":"Name of Jurisdiction(s) covered in OECD list in which you are tax resident","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you obtained residence rights under CBI/RBI scheme","type":"yes-no","label":"Did you obtain residence rights under any CBI/ RBI scheme in the above jurisdiction? (Yes / No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if you hold residence rights elsewhere","type":"yes-no","label":"Do you hold residence rights in any other jurisdiction(s) (i.e. other than jurisdiction provided above)? - Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List other countries where you hold residence rights","type":"text","label":"If Yes, please state the Name of Such Country(s)","options":[],"required":false,"pdf_field":""},{"help":"Indicate tax residency status in other countries","type":"yes-no","label":"Are you a tax resident of such Country (Yes/ No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if you spent more than 90 days in other jurisdictions","type":"yes-no","label":"Have you spent more than 90 days in any other jurisdiction(s) (other than jurisdiction provided above) during the previous year? - Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List countries where you spent more than 90 days","type":"text","label":"If Yes, please state the Name of such Country(s)","options":[],"required":false,"pdf_field":""},{"help":"Indicate tax residency status in those countries","type":"yes-no","label":"Are you a tax resident of such Country (Yes/ No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if you filed tax returns in other jurisdictions","type":"yes-no","label":"Have you filed personal income tax returns during the previous year in any other jurisdiction (other than jurisdiction provided above) – Yes/ No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List countries where you filed tax returns","type":"text","label":"If Yes, please state the Name of such Country(s)","options":[],"required":false,"pdf_field":""},{"help":"Indicate tax residency status in those countries","type":"yes-no","label":"Are you a tax resident of such Country (Yes/ No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details for countries answered Yes above","type":"table","label":"Country/countries of tax residency","options":[],"required":false,"pdf_field":""},{"help":"Provide address for each such country","type":"table","label":"Address in the jurisdiction for Tax Residence","options":[],"required":false,"pdf_field":""},{"help":"Provide TIN or equivalent and attach proof","type":"table","label":"Tax Identification Number (TIN)/Functional equivalent Number (Kindly attach proof of TIN / functional equivalent)","options":[],"required":false,"pdf_field":""},{"help":"Country issuing the TIN or equivalent","type":"table","label":"TIN/ Functional equivalent Number Issuing Country","options":[],"required":false,"pdf_field":""},{"help":"Validity of attached proof","type":"table","label":"Validity of documentary evidence provided","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or related individual if applicable"},{"title":"Declaration and Undertakings","fields":[{"help":"Date of signing declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature (s)","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Print your name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or related individual"}],"deadlines":["Declare and disclose any changes within 30 days from the date of change"],"applies_to":"All policyholders, joint policyholders, annuitants, joint annuitants, beneficiaries, assignees, re-assignees, and payees under LIC policies","attachments":["Proof of Tax Identification Number (TIN) or functional equivalent","Supporting Annexures as applicable"],"declarations":["The information provided is true, correct, and complete to the best of knowledge.","The individual authorizes LIC to collect, store, communicate, and process information including sharing with authorities.","The individual undertakes responsibility to update information within 30 days of any change.","LIC may report to regulators or take action if material facts are not disclosed or information is incorrect.","LIC has the right to investigate information from public sources to confirm details provided.","The individual agrees to furnish additional information or documents as required due to changes in law.","The individual shall indemnify LIC for any loss arising from incorrect or incomplete information."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"+91-22-68276827","label":"Customer Care Phone Number","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of LIC\nMission/Vis","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"8976862090","label":"Customer Care Phone Number","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"e Insurance Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"'Yogakshema' , Jeevan Bima Marg, P.O. Box No19953, Mumbai – 400 021.","label":"Corporate Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"any grievances, email at\nco_complaints[at]licindia[dot]com\nCorporate Office\n: Life Insurance Corporation of India \r\n\t\t\t\t'Yogakshema' , Jeevan Bima Marg, P.O. Box No19953, \r\n\t\t\t\tMumbai – 400 021. IRDAI Reg No- 512\nFor any query regarding this website, please contact the Web Information Manager\nSmt. Himali As","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"co_healthsc@licindia.com","label":"Senior Citizens Health Grievance Email","level":null,"hours":null,"applies_to":"health","source_url":"https://licindia.in/documents/20121/124155/Sample_Policy_Document_LIC-s-Arogya-Rakshak.pdf/ed974eaa-4330-7732-6a85-43cfd7980a67?t=1669266625981","quote":"District Court Judge is member of each of the Claims Dispute Redressal Committees. For Senior Citizens:\nEmail address: co_healthsc@licindia.com Health Toll free Number: 18004259876\nOf IRDAI:\nIn case the customer is not satisfied with the response or do not receiv","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-22-68276827","label":"LIC Call Center","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of LIC\nMission/Vis","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"8976862090","label":"LIC Call Center","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"e Insurance Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"sms","value":"SMS LICHELP <pol.no.> to 9222492224","label":"Grievance Redressal SMS","level":null,"hours":null,"applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"Branch / Division / Zonal / Corporate Level.\n(For details click on the `Grievances' tab on the homepage).\nSMS LICHELP :\nSMS LICHELP <pol.no.> to 9222492224.\nDetails of Health Insurance TPA along with Toll Free Numbers\n(Content: English | Format: PDF | View/Download |Size: 44","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/lic/2356-self-certification-form-for-individuals-section-285ba-of-the-income-tax-act-1961"}