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 customer due diligence requirements under 31 CFR 1010.230.

Form Purpose and Consent

• I understand this form is used for beneficial ownership certification under 31 CFR 1010.230.
• I consent to the collection and use of the personal information provided in this form for customer due diligence and compliance review.
• Submission type
• Legal entity name
• Legal entity type
• If other, specify entity type

Legal Entity Information

• Tax identification number ending
  Enter only the last 4 digits if your institution requires it. Do not enter a full tax ID unless specifically required by policy.
• State or country of formation
• Business address
• Date of formation
• Brief business purpose
  Optional. Provide a short description if needed for compliance review.

Beneficial Owners

• Does any individual own 25% or more of the legal entity?
• Individuals owning 25% or more
• Beneficial owner details
• No individual owns 25% or more

Control Person

• Control person full name
• Title or role
• Date of birth
• Residential address
  Collect only if required by your institution's policy.
• Identification type
• Identification number ending
  Enter only the last 4 characters if needed for verification. Do not enter full ID numbers unless required.

Certification and Review

• Certifier name
• Certifier title or authority
• Certification statement
  I certify that the information provided is true, complete, and accurate to the best of my knowledge and that I am authorized to submit this certification on behalf of the legal entity.
• Signature
• Date signed
• Compliance reviewer notes