Fillable CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account

Fill Online, Printable, Fillable, Blank CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account

On average this form takes 18 minutes to complete

The CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account form is 2 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 66 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
RM0006 05/18 Page 1 of 3
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:
a. Name and Title of Natural Person opening account or maintaining the business relationship:
b. Name and Address of Legal Entity for which the account is being opened/maintained:
LEGAL ENTITY TYPE:
For Profit Corporation
☐ Non-Profit Corporation ☐ Limited Liability Company (LLC) ☐ Limited Partnership (LP) ☐
Limited Liability Partnership (LLP) ☐ General Partnership ☐ Other: ☐
c. The following information for one individual with significant responsibility for managing the legal entity listed above:
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 (d)
above may also be listed in this section (c)).
Individual with Control – Information: Bank Use Only: OFAC EC
Individual Full Name:
Business or Residence Address:
City/State/Zip:
Social Security Number:
Date of Birth:
Primary ID Type:
ID Issue Date:
ID Number:
ID Expiration Date:
Non US Person SSN:
Country of Issuance:
d. The following information for each individual*, 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:
Beneficial Owner 1 Information: ____% of ownership Bank Use Only: OFAC EC
Individual Full Name:
Business or Residence Address:
City/State/Zip:
Social Security Number:
Date of Birth:
Primary ID Type:
ID Issue Date:
ID Number:
ID Expiration Date:
Non US Person SSN:
Country of Issuance:
Beneficial Owner 2 Information: ____% of ownership Bank Use Only: OFAC EC
Individual Full Name:
Business or Residence Address:
City/State/Zip:
Social Security Number:
Date of Birth:
Primary ID Type:
ID Issue Date:
ID Number:
ID Expiration Date:
Non US Person SSN:
Country of Issuance:
RM0006 05/18 Page 2 of 3
Beneficial Owner 3 Information: ____% of ownership Bank Use Only: OFAC EC
Individual Full Name:
Business or Residence Address:
City/State/Zip:
Social Security Number:
Date of Birth:
Primary ID Type:
ID Issue Date:
ID Number:
ID Expiration Date:
Non US Person SSN:
Country of Issuance:
Beneficial Owner 4 Information: ____% of ownership Bank Use Only: OFAC EC
Individual Full Name:
Business or Residence Address:
City/State/Zip:
Social Security Number:
Date of Birth:
Primary ID Type:
ID Issue Date:
ID Number:
ID Expiration Date:
Non US Person SSN:
Country of Issuance:
*If no individual meets this definition, please enter “Not Applicable” above and explain below (i.e. All <25%; Charity/Non-Profit; etc.):
e. Certifications:
I, (name of natural person opening account), hereby certify, to the best of
my knowledge, that the information above is complete and correct.
For auto-renewing certificates of deposit, I agree to notify Exchange Bank promptly in writing of any
change to the beneficial ownership information contained in this Certification of Beneficial
Ownership.
SIGNATURE:
DATE: Legal Entity Identifier (Optional): ____________________
Bank Use
Reference Number(s)
Rec’d by:
Date:
Input by:
Date:
(MM/DD/YYYY)
RM0006 05/18 Page 3 of 3
CERTIFICATION REGARDING
BENEFICIAL OWNERS OF LEGAL ENTITY CUSTOMERS
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 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 on behalf of a legal entity with any of the following U.S. financial
institutions: a bank or credit union, a broker or dealer in securities, a mutual fund, a futures commission merchant, or an introducing
broker in commodities.
For the purposes of this form, a legal entity includes a corporation, a 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 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 or other similar
information, in the case of Non-U.S. Persons) for the following individuals (i.e., the beneficial owners):
i. 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
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 number of individuals that satisfy this definition of “beneficial owner” may vary. Under section (d), 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 (d), you must provide the identifying information of one individual under section (c). Itis 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 (c)), and up
to five individuals (i.e., one individual under section (c) and four 25 percent equity holders under section (d)).
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. A legal entity may have multiple “beneficial owners,” this form requires you to list only those that own 25% or more
(up to four) under section d, above, and one individual with significant responsibility under section c.
In addition, the requirements vary for certain entity types:
• Because nonprofit corporations do not have ownership interests, only information related to the control of the nonprofit is
required under the rule.
• When a family/ living trust, directly or indirectly, through any contract or arrangement, owns 25 percent or more of the
equity interests of a legal entity customer, the beneficial owner under the ownership/equity prong is the trustee. Where there
are multiple trustees or co-trustees, one co-trustee who owns 25 percent or more of the equity interests of a covered legal
entity customer must be listed on the certification form.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document