Beneficial Ownership Certification Form

Captures beneficial ownership and control person information for a legal entity customer under 31 CFR 1010.230, with certification and compliance review.

Entity Information

• Legal Entity Name
• Entity Type
• Tax Identification Status
• Tax Identification Number
  Enter the EIN or other identifier only if needed for account setup and permitted by policy.

Certification Scope

• Is this legal entity subject to beneficial ownership certification?
• Does an exemption apply?
• Exemption Basis
• Exemption Explanation
  Briefly explain why the entity is exempt. Do not include unnecessary PII.

Beneficial Owners

• Beneficial Owner(s)
  Add one entry for each individual who owns 25 percent or more of the entity.

Control Person

• Control Person First Name
• Control Person Last Name
• Control Person Title or Role

Certification and Attestation

• Certifying Representative Name
• Certifying Representative Title
• Certification Date
• Attestation

Compliance Review

• Review Status
• Review Notes
  Internal notes for audit trail and compliance documentation.