Beneficial Ownership Certification Form

Collects and certifies beneficial ownership information for a legal entity customer, including individuals owning 25% or more and one control person, in support of 31 CFR 1010.230 customer due diligence requirements.

Legal Entity Information

• Legal Entity Name
  Enter the full legal name of the customer entity.
• Entity Type
  Select the legal form of the customer entity.
• Tax ID Last 4 Digits
  Optional. Collect only if needed for internal matching. Do not enter the full tax ID.
• Primary Business Address
  Provide the principal business address.

Beneficial Owners

• Beneficial Owner Details
  Add each individual who owns 25% or more of the entity.
• Owner Full Name
• Date of Birth
  Collect only if required by your customer identification program.
• Residential Address
  Optional. Collect only if needed for verification or regulatory requirements.
• Ownership Percentage
  Enter the percentage owned by this individual.
• Ownership Type
  Select how the ownership interest is held.

Control Person

• Control Person Full Name
• Title or Role
  Example: CEO, Managing Member, General Partner, President.
• Date of Birth
  Collect only if required by your compliance program.
• Residential Address
  Optional. Collect only if needed for verification or regulatory requirements.
• Is this control person also a beneficial owner?
  Select yes if the control person is already listed as a beneficial owner.

Certification and Consent

• PII Collection Disclosure Acknowledgement
  I understand this form collects personal information for compliance purposes, will be used only for beneficial ownership certification and related due diligence, and may be retained in an audit trail according to policy.
• Certification Statement
  I certify that the information provided is true, complete, and accurate to the best of my knowledge.
• Certifier Name
  Name of the person completing and certifying this form.
• Certifier Title
  Title or authority of the person certifying on behalf of the entity.
• Certification Date
  Date the certification was completed.
• Signature
  Provide an electronic signature to confirm the certification.