I. General
Instructions What is this form?
To help the government fight financial crime,
Federal regulation requires certain financial institutions to obtain,
verify, and record information about the beneficial owners of legal
entity customers. Legal entities can be abused to disguise involvement
in terrorist financing, money laundering, tax evasion, corruption,
fraud, and other financial crimes. Requiring the disclosure of key
individuals who own or control a legal entity (i.e., the beneficial
owners) helps law enforcement investigate and prosecute these crimes.
Who has to complete this form?
This form must be completed by the person opening
a new account on behalf of a legal entity with any of the following
U.S. financial institutions: (i) a bank or credit union; (ii) a broker
or dealer in securities; (iii) a mutual fund; (iv) a futures commission
merchant; or (v) an introducing broker in commodities.
For the purposes of this form, a legal entity includes a corporation, limited liability company,
or other entity that is created by a filing of a public document with
a Secretary of State or similar office, a general partnership, and
any similar business entity formed in the United States or a foreign
country. Legal entity does not include sole proprietorships,
unincorporated associations, or natural persons opening accounts on
their own behalf.
What information
do I have to provide?
This form requires you
to provide the name, address, date of birth and Social Security number
(or passport number or other similar information, in the case of foreign
persons) for the following individuals (i.e., the beneficial owners):
(i) Each
individual, if any, who owns, directly or indirectly, 25 percent or
more of the equity interests of the legal entity customer (e.g., each
natural person that owns 25 percent or more of the shares of a corporation); and
(ii) An individual
with significant responsibility for managing the legal entity customer
(e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating
Officer, Managing Member, General Partner, President, Vice President,
or Treasurer).
The number of individuals that satisfy this definition
of “beneficial owner” may vary. Under section (i), depending on the
factual circumstances, up to four individuals (but as few as zero)
may need to be identified. Regardless of the number of individuals
identified under section (i), you must provide the identifying information
of one individual under section (ii). It is possible that in some
circumstances the same individual might be identified under both sections
(e.g., the President of Acme, Inc. who also holds a 30% equity interest).
Thus, a completed form will contain the identifying information of
at least one individual (under section (ii)), and up to five individuals
(i.e., one individual under section (ii) and four 25 percent equity
holders under section (i)).
The financial institution may also ask to see a copy of
a driver’s license or other identifying document for each beneficial
owner listed on this form.
II. Certification of Beneficial Owner(s)Persons opening an account
on behalf of a legal entity must provide the following information:a. Name and title of natural person
opening account:
b. Name and address of legal entity for which
the account is being opened:
c. The following information for each
individual, if any, who, directly or indirectly, through any contract,
arrangement, understanding, relationship or otherwise, owns 25 percent
or more of the equity interests of the legal entity listed above:
Certification
of Beneficial Owner
| Name |
Date of Birth |
Address
(Residential or Business Street Address) |
For U.S. Persons:Social Security Number |
For Non-U.S. Persons: Social
Security Number, Passport Number and Country of Issuance,
or other similar identification number1 |
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(If no individual
meets this definition, please write “Not Applicable.”)
d. The following information for one individual with significant responsibility for managing the legal
entity listed above, such as:
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An executive officer or senior manager (e.g., Chief Executive Officer,
Chief Financial Officer, Chief Operating Officer, Managing Member,
General Partner, President, Vice President, Treasurer); or
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Any other individual who regularly performs similar functions. (If appropriate, an individual listed under section (c) above may
also be listed in this section (d)).
Certification
of Beneficial Owner
| Name/Title |
Date of Birth |
Address
(Residential or Business Street Address) |
For U.S. Persons: Social Security Number |
For Non-U.S. Persons: Social
Security Number, Passport Number and Country of Issuance,
or other similar identification number1 |
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I,
(name of natural person
opening account), hereby certify, to the best of my knowledge,
that the information provided above is complete and correct.
Signature:
Date:
Legal Entity
Identifier
(Optional)
