Fillable Certication of Benecial Owner(s) c. The following information

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Certication of Benecial Owner(s) c. The following information

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Certification of
Beneficial Owner(s)
Persons opening an account on behalf of a legal entity must provide the following information:
a. Name and Title of Natural Person Opening Account:
b. Name, Type and Address of Legal Entity for Which the Account is Being Opened:
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:
NAME
DATE OF
BIRTH
ADDRESS
(Residential or Business Street Address)
FOR U.S. PERSONS:
Social Security
Number
FOR NON-U.S. PERSONS:
Social Security Number,
Passport Number and
Country of Issuance, or other
similar identification number
1
OWNERSHIP %
(If no individual meets this definition, please write “Not Applicable.”)
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)).
NAME / TITLE DATE OF BIRTH
ADDRESS
(Residential or Business Street Address)
FOR U.S. PERSONS:
Social Security
Number
FOR NON-U.S. PERSONS:
Social Security Number,
Passport Number and
Country of Issuance, or other
similar identification number
1
I, (name of natural person opening account), hereby certify, to the best of my
knowledge, that the information provided above is complete and correct. I also agree to notify SkyOne of any
changes in the information provided in this Certification.
Signature:
Date:
1
In lieu of a passport number, non-U.S. persons may also provide a social security number, an alien identification card number, or number and country of issuance of any other government-
issued document evidencing nationality or residence and bearing a photograph or similar safeguard.
A legal entity owns 25% or more of this legal entity. Completed Beneficial Ownership Addendum required.
FOR OFFICE USE ONLY
ACCOUNT # DATE OPENED OFFICE #
14600 Aviation Blvd
Hawthorne, CA 90250
800.421.7111 | www.skyone.org
REV 05/20
click to sign
signature
click to edit
APPENDIX A to § 1010.230
Certification Regarding Beneficial
Owners of Legal Entity Customers
GENERAL INSTRUCTIONS
What is the Certification of Beneficial Owner(s) 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 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, 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 (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). It is 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 percent 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 listed on the Certification of Beneficial
Owner(s) form.
14600 Aviation Blvd
Hawthorne, CA 90250
800.421.7111 | www.skyone.org
REV 05/20
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Completed 4 April 2022

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