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31 CFR 1010.230 CERTIFICATION REGARDING BENEFICIAL OWNERS OF (Department of the Treasury - FINCEN)

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OMB Control Number 1506-0070
31 CFR § 1010.230 CERTIFICATION REGARDING
BENEFICIAL OWNERS OF LEGAL ENTITY CUSTOMERS
I. GENERALINSTRUCTIONS
This is an optional form provided for your convenience. The required information may be provided in other formats. When
completed, this form is provided to the financial institution where the account is opened. DO NOT SEND TO FinCEN.
Where may I obtain a copy of the form?
A copy (pdf) may be downloaded from the FinCEN website at www.fincen.gov under the “Filing Information” tab. The form may
be completed on a computer using the free Adobe Reader software.
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 any 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; and (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 associa-
tions, or natural persons opening accounts on their own behalf.
What information do Ihave to provide?
When you open a new account on behalf of a legal entity, the financial institution will ask for information about the legal
entity’s beneficial owner(s), including their name, address, date of birth and social security number (or passport number or
other similar information, in the case of Non-U.S. persons). 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.
Beneficial owners are:
(1) 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
(2)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 (1), 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 (1), you must provide the identifying information of one individual under section (2). 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 (2)), and up to five individuals (i.e., one individual under section (2) and four 25 percent equity
holders under section (1))
a legal entity may have multiple “beneficial owners,” this form requires you to list only those that own 25% or more (up
to five) under each of the two prongs of the definition above. If appropriate, the same individuals may be listed under
both prongs.
Rev. 6.6 Aug. 2017
CERTIFICATION OF BENEFICIAL OWNER(S)
The information contained in this Certification is sought pursuant to Section 1020.230
of Title 31 of the United States Code of Federal Regulations (31 CFR 1020.230).
All persons opening an account on behalf of a legal entity must provide the following information:
1. Last Name and title of Natural Person Opening Account
2. First Name
3. Middle Initial
4. Name and type of Legal Entity for Which the Account is Being Opened
4a. Legal Entity Address
4b. City
4c. State
4d. ZIP/Postal Code
SECTION I
(To add additional individuals, see page 3)
Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed
above.
Check here if no individual meets this definition and complete Section II.
5. Last Name 6. First Name 7. M.I.
8. Date of birth
(MM/DD/YYYY)
9. Address 10. City
11. State
12. ZIP/Postal Code
13. Country
14. SSN (U.S. Persons)
15. For Non-U.S. persons
(SSN, Passport Number or other similar identification number)
15a. Country of issuance:
Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.
SECTION II
Please provide the following information for an individual with significant responsibility for managing or directing the
entity, including, 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 Any other individual
who regularly performs similar functions.
16. Last Name 17. First Name 18. M.I.
19. Date of birth
(MM/DD/YYYY)
20. Address 21. City
22. State
23. ZIP/Postal Code
24. Country 25. SSN (U.S. Persons)
26. For Non-U.S. persons
(SSN, Passport Number or other similar identification number)
26a. Country of issuance:
Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.
I, __________________________ (name of person opening account), hereby certify, to the best of my
knowledge, that the information provided above is complete and correct.
Signature:
Date:
(MM/DD/YYYY)
Legal Entity Identifier (Optional)
Rev. 6.7 Sept., 2017
Additional Section 1 - Second Beneficial Owner (If required)
Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I.
8. Date of birth
(MM/DD/YYYY)
9. Address 10. City
11. State
12. ZIP/Postal Code
13. Country 14. SSN (U.S. Persons)
15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)
15a. Country of issuance:
Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.
Additional Section 1 - Third Beneficial Owner (If required)
Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I.
8. Date of birth
(MM/DD/YYYY)
9. Address 10. City
11. State
12. ZIP/Postal Code
13. Country
14. SSN (U.S. Persons)
15. For Non-U.S.persons
(SSN, Passport Number or other similar identification number)
15a. Country of issuance:
Additional Section 1 - Fourth Beneficial Owner (If required)
Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I.
8. Date of birth
(MM/DD/YYYY)
9. Address 10. City
11. State
12. ZIP/Postal Code
13. Country 14. SSN (U.S. Persons)
15. For Non-U.S. persons
(SSN, Passport Number or other similar identification number)
15a. Country of issuance:
Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.
Paperwork Reduction Act Notice
Public recordkeeping burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The OMB control number for this information collection is 1506-0070. You may submit
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
by calling the FinCEN Resource Center at 800-767-2825 or by email at frc@fincen.gov. Alternatively, you may mail us comments at Policy
Division, Financial Crimes Enforcement Network, P.O. Box 39, Vienna, VA 22183. Please include 1506–0070 in the body of the text.
Rev. 6.7 Sept., 2017
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31 CFR 1010.230 CERTIFICATION REGARDING BENEFICIAL OWNERS OF (Department of the Treasury - FINCEN)

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