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)
Manual Submission Instructions:
Route signed and completed form to
Deposit Product Support Services.
Scanner Enabled Branches should scan.
BBG6784-A (Rev 03 - 03/19)
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Wells Fargo Conﬁdential
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