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Run: Beneficial Ownership Certification Form

Use this Beneficial Ownership Certification Form to collect legal entity details, identify owners with 25% or more ownership, and name one control person for...

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Legal Entity Information

Legal Entity Name (required)

Enter the full legal name of the customer entity.

Entity Type (required)

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 (required)

Provide the principal business address.

Beneficial Owners

Beneficial Owner Details (required)

Add each individual who owns 25% or more of the entity.

Owner Full Name (required)

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 (required)

Enter the percentage owned by this individual.

Ownership Type (required)

Select how the ownership interest is held.

Control Person

Control Person Full Name (required)

Title or Role (required)

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? (required)

Select yes if the control person is already listed as a beneficial owner.

Certification and Consent

PII Collection Disclosure Acknowledgement (required)

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.

Yes No N/A

Certification Statement (required)

I certify that the information provided is true, complete, and accurate to the best of my knowledge.

Yes No N/A

Certifier Name (required)

Name of the person completing and certifying this form.

Certifier Title (required)

Title or authority of the person certifying on behalf of the entity.

Certification Date (required)

Date the certification was completed.

Signature (required)

Provide an electronic signature to confirm the certification.

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Email (required)

Your name (optional)

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