Certification of Beneficial Owner(s)

Transcription

1 Certificatin f Beneficial Owner(s) GENERAL INSTRUCTIONS T help the gvernment fight financial crime, federal regulatin requires certain financial institutins t btain, verify, and recrd infrmatin abut the beneficial wners f legal entity custmers. Legal entities can be abused t disguise invlvement in terrrist financing, mney laundering, tax evasin, crruptin, fraud, and ther financial crimes. Requiring the disclsure f key individuals wh ultimately wn r cntrl a legal entity (i.e., the beneficial wners) helps law enfrcement investigate and prsecute these crimes. Wh has t cmplete this frm? Certain circumstances (such as when a new accunt is pened r changes are made t an existing relatinship) will require this frm t be cmpleted by a representative n behalf f the legal entity with any f the fllwing US financial institutins: (i) a bank r credit unin; (ii) a brker r dealer in securities; (iii) a mutual fund; (iv) a futures cmmissin merchant; r (v) an intrducing brker in cmmdities. Fr the purpses f this frm, a legal entity includes a crpratin, limited liability cmpany, partnership, and any ther similar business entity frmed in the United States r a freign cuntry that is privately held. Legal entity des nt include sle prprietrships, unincrprated assciatins, r individuals pening accunt n their wn behalf. The legal entity generally des nt include trusts unless the trust is a statutry trust filed with the secretary f state. In this instance the beneficial wner is the trustee. What infrmatin d I have t prvide? This frm requires yu t prvide the name, address, date f birth and scial security number (r passprt number r ther similar infrmatin, in the case f freign persns) fr the fllwing individuals (i.e., the beneficial wners): (i) Each individual, if any, wh wns, directly r indirectly, 25 percent r mre f the equity interests f the legal entity custmer (e.g., each natural persn that wns 25 percent r mre f the shares f a crpratin); and (ii) An individual with significant respnsibility fr managing the legal entity custmer (e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President r Treasurer). The number f individuals that satisfy this definitin f beneficial wner may vary. Under sectin (i), depending n the factual circumstances, up t fur individuals (but as few as zer) may need t be identified. Regardless f the number f individuals identified in sectin (i), yu must prvide the identifying infrmatin f at least ne individual under sectin (ii). It is pssible that in sme circumstances the same individual might be identified under bth sectins (e.g., the President may als hld a 30 percent equity interest). Thus, a cmpleted frm will cntain the identifying infrmatin f ne individual (as the cntrlling party under sectin ii) and may cntain up t fur individuals wh are 25 percent equity hlders under sectin (i), but will nt exceed five individuals in ttal fr the tw sectins. The financial institutin may als ask t see a cpy f a driver's license r ther identifying dcument fr each beneficial wner listed n this frm. 12/06/2017 V1

2 IDENTIFICATION REQUIREMENTS Certificatin f Beneficial Owner(s) Please ensure t cmplete the Beneficial Owner (and supplemental pages; if needed), the Cntrlling Party, and the Custmer Acknwledgement sectins f this frm! Beneficial wner(s) and the cntrlling party are required t disclse their citizenship status in rder t establish identificatin requirements. The ID lists belw utlines the primary and secndary identificatin ptins based n the individual s respnse t the citizenship questins. Nte: Individuals can select t recrd tw (2) unexpired primary identificatin dcuments (which cannt be the same) OR recrd ne (1) unexpired primary identificatin dcument and ne (1) unexpired secndary identificatin dcument. Individuals CANNOT recrd (2) unexpired secndary identificatin dcuments. ID List A (Individual is a Permanent Resident f the U.S.) Primary IDs Freign Passprt Permanent Resident Alien Card US Driver s License US State Identificatin Card Federal gvernment ID w/pht State gvernment ID w/pht Lcal gvernment ID w/pht Secndary IDs Cncealed Weapns Permit I-94 (search, stamp r frm) ITIN Letter Medicare/Medicaid Card Mexican Matricula ID Card Original Scial Security Card Recgnized Lcal Emplyment ID card US Military ID Valid Student ID ID List B (Individual is a Nn Resident Alien wh is in the U.S. temprarily) Primary IDs Canadian Driver s License Freign Passprt Mexican Matricula ID Card US DOJ Letter (Asylee r Refugee) Federal gvernment ID w/pht Secndary IDs 1-20 Academic/Vcatinal Schl Letter Driver s License Nn US r Canadian DS-2019 Exchange Student I-94 (search, stamp r frm) ITIN Letter US Emplyment Authrizatin Card US Visa State gvernment ID w/pht Lcal gvernment ID w/pht Valid Student ID ID List C (Individual is a Nn Resident Alien wh is OR is nt seeking permanent residency in the U.S.) Primary IDs Secndary IDs Canadian Driver s License 1-20 Academic/Vcatinal Schl Letter Freign Passprt Driver s License Nn US r Canadian Mexican Matricula ID Card DS-2019 Exchange Student US DOJ Letter (Asylee r Refugee) I-94 (search, stamp r frm) Federal gvernment ID w/pht ITIN Letter US Driver s License US Emplyment Authrizatin Card US Visa State gvernment ID w/pht Lcal gvernment ID w/pht Valid Student ID

3 CUSTOMER INFORMATION Certificatin f Beneficial Owner(s) Business Name Business Address City State Zip Cde TIN Number (EIN) BENEFICIAL OWNER(S) Please prvide the fllwing infrmatin fr all individuals wh directly r indirectly wn 25 percent r mre equity in the abve named business. If percentage f wnership is less than 25 percent, please check the bx belw. Ownership may arise in a variety f ways, fr example, thrugh a cntract, arrangement, understanding, r therwise. N individuals wn 25 percent r mre equity in the abve named business. 1. Is the custmer a US Citizen? Yes, STOP, IDs nt required N, prceed t #2 2. Is the custmer a permanent resident f the US? Yes, See ID List A N, prceed t #3 3. Is the custmer in the US temprarily? Yes, See ID List B N, prceed t #4 4. Is the custmer seeking permanent residency in the US? Yes, See ID List C N, See ID List C City State: Zip Cde: Date f Birth Percentage f Ownership % If the abve named individual indirectly maintains wnership f the business, please disclse the business in which the individual maintains direct wnership f: Primary Issuing Cuntry: Primary Expiratin Date: Secndary ID Type: Secndary Issuing State: Secndary Issue Date: Secndary ID Number: Secndary Issuing Cuntry: Secndary Expiratin Date: Page 1 - A

4 Certificatin f Beneficial Owner(s) Beneficial Ownership Sectin, cntinue 1. Is the custmer a US Citizen? Yes, STOP, IDs nt required N, prceed t #2 2. Is the custmer a permanent resident f the US? Yes, See ID List A N, prceed t #3 3. Is the custmer in the US temprarily? Yes, See ID List B N, prceed t #4 4. Is the custmer seeking permanent residency in the US? Yes, See ID List C N, See ID List C City State: Zip Cde: Date f Birth Percentage f Ownership % If the abve named individual indirectly maintains wnership f the business, please disclse the business in which the individual maintains direct wnership f: Primary Issuing Cuntry: Primary Expiratin Date: Secndary ID Type: Secndary Issuing State: Secndary Issue Date: Secndary ID Number: Secndary Issuing Cuntry: Secndary Expiratin Date: Page 1 - B

5 Certificatin f Beneficial Owner(s) Beneficial Ownership Sectin, cntinue 1. Is the custmer a US Citizen? Yes, STOP, IDs nt required N, prceed t #2 2. Is the custmer a permanent resident f the US? Yes, See ID List A N, prceed t #3 3. Is the custmer in the US temprarily? Yes, See ID List B N, prceed t #4 4. Is the custmer seeking permanent residency in the US? Yes, See ID List C N, See ID List C City State: Zip Cde: Date f Birth Percentage f Ownership % If the abve named individual indirectly maintains wnership f the business, please disclse the business in which the individual maintains direct wnership f: Primary Issuing Cuntry: Primary Expiratin Date: Secndary ID Type: Secndary Issuing State: Secndary Issue Date: Secndary ID Number: Secndary Issuing Cuntry: Secndary Expiratin Date: Page 1 - C

6 Certificatin f Beneficial Owner(s) Beneficial Ownership Sectin, cntinue 1. Is the custmer a US Citizen? Yes, STOP, IDs nt required N, prceed t #2 2. Is the custmer a permanent resident f the US? Yes, See ID List A N, prceed t #3 3. Is the custmer in the US temprarily? Yes, See ID List B N, prceed t #4 4. Is the custmer seeking permanent residency in the US? Yes, See ID List C N, See ID List C City State: Zip Cde: Date f Birth Percentage f Ownership % If the abve named individual indirectly maintains wnership f the business, please disclse the business in which the individual maintains direct wnership f: Primary Issuing Cuntry: Primary Expiratin Date: Secndary ID Type: Secndary Issuing State: Secndary Issue Date: Secndary ID Number: Secndary Issuing Cuntry: Secndary Expiratin Date: Page 1 - D

7 CONTROLLING PARTY Certificatin f Beneficial Owner(s) Please prvide the fllwing infrmatin fr ne individual wh has significant respnsibility fr managing the abve named business, such as an executive fficer r senir management (like the Chief Executive Officer, Managing Member) r an individual wh regularly perfrms similar functins. Nte, an individual listed in the first sectin may als be listed in this sectin. 1. Is the custmer a US Citizen? Yes, STOP, IDs nt required N, prceed t #2 2. Is the custmer a permanent resident f the US? Yes, See ID List A N, prceed t #3 3. Is the custmer in the US temprarily? Yes, See ID List B N, prceed t #4 4. Is the custmer seeking permanent residency in the US? Yes, See ID List C N, See ID List C City State: Zip Cde: Date f Birth Title/Psitin If the abve named individual indirectly maintains wnership f the business, please disclse the business in which the individual maintains direct wnership f: Primary Issuing Cuntry: Primary Expiratin Date: Secndary ID Type: Secndary Issuing State: Secndary Issue Date: Secndary ID Number: Secndary Issuing Cuntry: Secndary Expiratin Date: Page 2

8 Certificatin f Beneficial Owner(s) CUSTOMER ACKNOWLEDGEMENT I,, (name f persn cmpleting this frm), hereby certify t the best f my knwledge that the infrmatin prvided is crrect and cmplete. Signature Date Title r Psitin Page 3