Fillable Benecial Ownership Control Person/Entity Owner for Entities (Fidelity Investments)

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Benecial Ownership Control Person/Entity Owner for Entities (Fidelity Investments)

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The Benecial Ownership Control Person/Entity Owner for Entities (Fidelity Investments) form is 3 pages long and contains:

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Beneficial Ownership — Control Person/Entity
Owner for Entities
Use this form to provide information for the Control Person and Entity Owner(s) (as defined below) of an entity. These individuals
will not have any authority or be able to take any action on this account unless they are also listed as Authorized Individuals on this
account. This form must be signed by an Authorized Individual in Section 4.
For purposes of this form, “Control Person” and “Entity Owner(s)” are defined as:
1. Control Person: An individual person with significant responsibility for managing the entity (e.g., a Chief Executive Officer, Chief Financial
Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer). A Control Person is required
to be named in Section 2.
2. Entity Owner(s): Any individuals or entities that own, directly or indirectly, 25% or more of the equity interests of the entity for domestic
operating entities, or 10% or greater for domestic nonoperating or foreign entities. Note: If the Entity Owner is a trust or another entity,
additional information and documentation will be required to be submitted along with this form.
1. Entity Information
Entity Name
Entity Taxpayer ID Number
Fidelity Account Number Required Entity State/Country of Organization
Indicate the state of the business:
Operating Nonoperating
Examples can include, but are not limited to, a holding company, personal investment company, shell
company, or similar.
Entity Permanent Address This is the legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
2. Control Person Required
A Control Person is required to be named and is an individual person with significant responsibility for managing the entity (e.g., a Chief
Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer).
This individual is also an Entity Owner.
First Name Middle Name Last Name
Control Person Title Required (e.g., Chief Executive Officer, General Partner, President)
Date of Birth MM DD YYYY Social Security Number
Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Response required.
Check one.
Cannot be a PO Box or
mail drop.
Enter full first and last name as
evidenced by a government-
issued, unexpired document
(e.g., driver’s license, passport,
permanent resident card).
Cannot be a PO Box or
mail drop.
Questions? Go to Fidelity.com or call 800-343-3548.
1.951332.105 Page 1 of 3 029550401
Control Person continues on next page.
Enter full entity name as
evidenced by the relevant
formation document (e.g.,
partnership agreement,
articles of incorporation).
Print
Reset
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1.951332.105 Page 2 of 3 029550402
Citizenship
U.S. citizen
Foreign citizen Information in this box must be completed.
Permanent U.S. resident Nonpermanent U.S. resident Nonresident of U.S.
Country of Citizenship Country of Tax Residency Only applicable to nonresidents of the U.S.
City, State/Province, and Country of Birth
Passport
DHS Permanent Resident Card
Employment Authorization Document
Foreign National Identity Document
3. Entity Owner(s)
Provide information for all Entity Owner(s). If a Control Person in Section 2 is already identified as an Entity Owner, that individual does not
need to be listed again. Entity Owners are any individuals or entities that own, directly or indirectly, 25% or more of the equity interests of
the entity for domestic operating entities, or 10% or greater for domestic nonoperating or foreign entities. If there is more than one Entity
Owner, make a copy of this Section 3.
Important to note: If this Entity Owner is a trust or other entity, you must enter the full entity name as evidenced by the relevant
formation document (e.g., trust document, partnership agreement, articles of incorporation) and provide either a completed Beneficial
Ownership for Trusts or an additional Beneficial Ownership — Control Person/Entity Owner for Entities form, as applicable, along with
this form. All required forms and supporting documentation must be provided at the time this form is submitted, or we will be unable to
process your request.
There are no Entity Owners. You agree you will notify Fidelity if or when beneficial ownership information of the
entity changes.
Skip to Section 4.
First Name Middle Name Last Name
Entity Name
Date of Birth MM DD YYYY Social Security or Taxpayer ID Number
SSN
OR
TIN
Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Indicate your
citizenship status.
Check one and attach
a copy of a valid and
unexpired government ID
showing number and photo.
Enter full first and last name as
evidenced by a government-
issued, unexpired document
(e.g., driver’s license, passport,
permanent resident card).
Cannot be a PO Box or
mail drop.
2. Control Person, continued
Entity Owner(s) continues on next page.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 628538.6.0 (06/20)
1.951332.105 Page 3 of 3 029550403
Citizenship
U.S. citizen
Foreign citizen Information in this box must be completed.
Permanent U.S. resident Nonpermanent U.S. resident Nonresident of U.S.
Country of Citizenship Country of Tax Residency Only applicable to nonresidents of the U.S.
City, State/Province, and Country of Birth
Passport
DHS Permanent Resident Card
Employment Authorization Document
Foreign National Identity Document
4. Signature and Date Form cannot be processed without signature and date.
By signing below, you certify and acknowledge the following:
• To help the government fight financial crimes, federal regulation
requires Fidelity to obtain your name, date of birth, address, and
a government-issued ID number before opening your account,
and to verify the information. In certain circumstances, Fidelity
may obtain and verify comparable information for any person
authorized to make transactions in an account. Also, federal regu-
lation requires Fidelity to obtain and verify the beneficial owners
and control persons of legal entity customers. Requiring the dis-
closure of key individuals who own or control a legal entity helps
law enforcement investigate and prosecute crimes. Your account
may be restricted or closed if Fidelity cannot obtain and verify
this information. Fidelity will not be responsible for any losses or
damages (including, but not limited to, lost opportunities) that
may result if your account is restricted or closed.
• Information provided by you is true, accurate, and complete.
• You are authorized to provide this information on behalf of the
entity, and you affirm that you are authorized to make the repre-
sentations made herein.
• The Social Security number(s) and/or the TIN(s) provided on this
form is/are correct (or you are waiting for a number to be issued).
• You agree to promptly notify Fidelity if and when any beneficial own-
ership information changes.
PRINT AUTHORIZED INDIVIDUAL NAME
PRINT BUSINESS TITLE Required (e.g., President, Vice President)
AUTHORIZED INDIVIDUAL SIGNATURE DATE MM DD YYYY
SIGN
X X
Indicate your
citizenship status.
Check one and attach
a copy of a valid and
unexpired government ID
showing number and photo.
3. Entity Owner(s), continued
Did you sign the form and attach any necessary documents?
Send the ENTIRE form and any attachments to Fidelity Investments.
Questions? Go to Fidelity.com or call 800-343-3548.
Regular mail
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
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Benecial Ownership Control PersonEntity Owner for Entities (Fidelity Investments)

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Completed 28 April 2021

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