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Beneficial Owner Beneficial Owner BBG6784 A

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Certification Regarding Beneficial
Owners of Legal Entity Customers
Bank Name: Branch Name:
Banker Name: Office/Portfolio Number: Date:
Banker Phone: Branch Number: Banker AU: Banker MAC:
Enterprise Customer Number (ECN) (For Bank Use Only): Account Number:
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 ultimately 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 or maintaining business relationships 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, partnership, and any other similar business
entity formed in the United States or a foreign country.
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 non-U.S. persons) for the following beneficial owners:
(i) Each individual, if any, who owns, directly or indirectly,  percent or more of the equity interests of the legal entity customer (e.g., each
natural person that owns  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 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 or maintaining a business relationship on behalf of a legal entity must provide the following information:
Account open/maintenance Information
A. Full Legal Name and title of person representing the legal entity customer and opening account or maintaining the business relationship
Legal Name Title
CEO CFO COO
President Vice President Treasurer
General Manager General Partner Managing Member
Managing Partner Officer/Manager
B. Full Legal Entity Name and address for which the account is being opened/maintained. (P.O. Box is not permitted)
Name
Manual Submission Instructions:
Route signed and completed form to
Deposit Product Support Services.
Scanner Enabled Branches should scan.
BBG6784-A (Rev 03 - 03/19)
Page 1 of 3
Wells Fargo Confidential
FO01-0000BBG6784A-01
FO01-0000BBG6784A-01
Street Address City State ZIP/Postal Code
C L E A R
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. If no individual meets this
definition, please check “Beneficial Owner Not Applicable” below and skip this section.
Note: When the entity is owned by a Trust, the individual trustee must be listed in the owner section.
Beneficial Owner Not Applicable
-For a person with a Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN), provide the (SSN/ITIN) and leave
Primary ID Type, Description and ST/Ctry/Prov blank.
-For a non-U.S. person without a (SSN/ITIN), provide a Passport Number and Country of Issuance. In lieu of a passport, non-U.S. persons may
also provide a U.S. government-issued Alien ID or other foreign government-issued documents evidencing nationality or residence and
bearing a photograph or similar safeguard.
Owner 1 Information: ______% of ownership
Full Legal Name Street Address
Date of Birth Address Line 2
TIN type
SSN ITIN Number ___________________________
Address Line 3
Primary ID Type Primary ID Description City State Country
Primary ID St/Ctry/Prov ZIP/Postal Code
Enterprise Customer Number (ECN) (For Bank Use Only):
Owner 2 Information: ______% of ownership
Full Legal Name Street Address
Date of Birth Address Line 2
TIN type
SSN ITIN Number ___________________________
Address Line 3
Primary ID Type Primary ID Description City State Country
Primary ID St/Ctry/Prov ZIP/Postal Code
Enterprise Customer Number (ECN) (For Bank Use Only):
Owner 3 Information: ______% of ownership
Full Legal Name Street Address
Date of Birth Address Line 2
TIN type
SSN ITIN Number ___________________________
Address Line 3
Primary ID Type Primary ID Description City State Country
Primary ID St/Ctry/Prov ZIP/Postal Code
Enterprise Customer Number (ECN) (For Bank Use Only):
Manual Submission Instructions:
Route signed and completed form to
Deposit Product Support Services.
Scanner Enabled Branches should scan.
BBG6784-A (Rev 03 - 03/19)
Page 2 of 3
Wells Fargo Confidential
FO01-0000BBG6784A-02
FO01-0000BBG6784A-02
Certification Regarding Beneficial Owners of Legal Entity Customers
Manual Submission Instructions:
Route signed and completed form to
Deposit Product Support Services.
Scanner Enabled Branches should scan.
BBG6784-A (Rev 03 - 03/19)
Page 3 of 3
Wells Fargo Confidential
FO01-0000BBG6784A-03
FO01-0000BBG6784A-03
Owner 4 Information: ______% of ownership
Full Legal Name Street Address
Date of Birth Address Line 2
TIN type
SSN ITIN Number ___________________________
Address Line 3
Primary ID Type Primary ID Description City State Country
Primary ID St/Ctry/Prov ZIP/Postal Code
Enterprise Customer Number (ECN) (For Bank Use Only):
D. The following information for one individual with significant responsibility for managing the legal entity listed above, such as:
• 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.
(If appropriate, an individual listed under section (C) above may also be listed in this section (D)).
- For a person with a Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN), provide the SSN/ITIN and leave
Primary ID Type, Description and ST/Ctry/Prov blank.
- For a non-U.S. person without a SSN/ITIN, provide a Passport Number and Country of Issuance. In lieu of a passport, non-U.S. persons may
also provide a U.S. government-issued Alien ID or other foreign government-issued document evidencing nationality or residence and
bearing a photograph or similar safeguard.
Individual with Control Information
Full Legal Name Title
CEO CFO COO
President Vice President Treasurer
Street Address General Manager General Partner Managing Member
Managing Partner Officer/Manager
Date of Birth Address Line 2
TIN type
SSN ITIN Number ___________________________
Address Line 3
Primary ID Type Primary ID Description City State Country
Primary ID St/Ctry/Prov ZIP/Postal Code
Enterprise Customer Number (ECN) (For Bank Use Only):
Certified/Agreed To
I,______________________________________________________________________________________________, hereby certify, to
Full Legal Name of Person Opening Account
the best of my knowledge, that the information provided above is complete and correct.
Signature Date
Certification Regarding Beneficial Owners of Legal Entity Customers
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Completed 18 July 2020

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