Fillable Business Certification of Beneficial Owners (American Savings Bank Hawaii)

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Business Certification of Beneficial Owners (American Savings Bank Hawaii)

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© 2018 American Savings Bank, F.S.B.18D124 (10/18)
Business Certification of Beneficial Owners
Savings Bank
I. BUSINESS CERTIFICATION OF BENEFICIAL OWNER(S) – EACH Section must be completed.
Persons opening an account on behalf of a business must provide the following information:
Name
Business Name Business Type (Example: Corporation, Limited Liability Corporation, Partnership,etc.)
Business Physical Address (No PO Box)
I, the person identified in section I.A., above, hereby certify, to the best of my knowledge, that all of the information provided is
complete and acccurate. I, on behalf of the Business, also agree that a representative of the Business will notify American Savings
Bank of any change to the information either contained in this document or otherwise provided in connection with this document.
Signature:
_______________________________________________________________________
Date:
__________________________________
C. Information for one individual with significant responsibility for managing the business listed in Section B, such as:
An executive officer or senior manager (for example, 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.
Please provide a copy of a valid identification of the person listed in this Section if not appearing in person.
*Social Security Number for U.S. Persons and for Foreign persons, Passport Number and Country of Issuance
City State Zip
Title
B. Name and Address of Business for Which the Account is Being Opened
Name
Home Address (No PO Box) City
Date of Birth Title
State Zip
Social Security Number*
Employee Name Branch Date
FOR BANK USE ONLY Scan to IPS Image Services
D. 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 business listed in Section B:
Please provide a copy of a valid identification of each person listed below if not appearing in person.
*Social Security Number for U.S. Persons and for Foreign persons, Passport Number and Country of Issuance
Name
Home Address (No PO Box) City
Date of Birth
State Zip
Percent
Social Security Number*
%
Check here if NO INDIVIDUAL owns 25% or more of the equity interests of the business listed in Section B.
Business Account #:
(If appropriate, an individual listed under section (D) may also be listed in this section (C)).
A. Name and Title of Person Opening Account:
Name
Home Address (No PO Box) City
Date of Birth
State Zip
Percent
Social Security Number*
%
Name
Home Address (No PO Box) City
Date of Birth
State Zip
Percent
Social Security Number*
%
Name
Home Address (No PO Box) City
Date of Birth
State Zip
Percent
Social Security Number*
%
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© 2018 American Savings Bank, F.S.B.18D124 (10/18)
Business Certification of Beneficial Owners
Savings Bank
CERTIFICATION REGARDING BENEFICIAL OWNERS OF BUSINESS CUSTOMERS
II. 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 (also known as Business customers.) Businesses 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 Business (i.e. 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 (deposit, loan or safe deposit box) on behalf of a Business
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 Business 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. Business 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 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
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, 25 percent or more of the equity interests of the Business customer
(for example, 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 Business customer (for example, a Chief Executive Officer, Chief
Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer).
(iii) 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). lt is
possible that in some circumstances the same individual might be identified under both sections (for example, 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 and individual with significant responsibility listed on this form.
Indirectly
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– A person whose beneficial ownership is through another entity
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Business Certification of Beneficial Owners (American Savings Bank Hawaii)

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Completed 29 July 2020

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