AML/KYC Verification Form Template

Company/Business Name: [Company Name]
Department/Team: [Team]
Form ID (Optional): [ID]
Date Opened: [Date]
Completed By: [Name, Title]
Reviewer/Approver (If Any): [Name, Title]

Customer Type: ☐ Individual ☐ Business/Entity
Purpose of Relationship (Optional): [Product/service + reason]

1. Customer Information

1.1 Individual Customer (if applicable):

• Full legal name: [Name]

• Date of birth: [DOB]

• Nationality (optional): [__]

• Residential address: [__]

• Phone/email: [__]

• Occupation/employer (optional): [__]

1.2 Business/Entity Customer (if applicable):

• Legal entity name: [Name]

• Registration number: [__]

• Country/state of incorporation: [__]

• Registered address: [__]

• Operating address (if different): [__]

• Website (optional): [__]

• Primary contact name/title: [__]

• Phone/email: [__]

2. Identification Documents (Documentary Verification)

2.1 Documents Reviewed (Select all that apply):
☐ Passport
☐ Driver’s license
☐ National ID card
☐ Proof of address (utility bill/bank statement)
☐ Business registration certificate
☐ Articles/operating agreement/bylaws (optional)
☐ Tax ID confirmation (optional)
☐ Other: [List]

2.2 Document Details (No full numbers):

• Document type: [__]

• Issuer: [__]

• Last 4 digits/partial ID: [____]

• Expiration date: [Date]

• Verified name matches customer: ☐ Yes ☐ No (explain)

2.3 Document Review Result: ☐ Pass ☐ Fail ☐ Needs follow-up (notes: [__])

3. Non-Documentary Verification (If Used)

3.1 Method(s): ☐ database check ☐ email/phone verification ☐ micro-deposits ☐ video verification ☐ other: []
3.2 Results/notes: []

4. Beneficial Ownership and Control (Businesses)

4.1 Beneficial Owners (Attach additional page if needed):

• Name: [] | Ownership %: [] | Role: [Owner/Controller] | Country: [__]

• Name: [] | Ownership %: [] | Role: [Owner/Controller] | Country: [__]

4.2 Authorized Signers (if applicable): [Names/Titles].
4.3 Proof collected: ☐ ownership declaration ☐ cap table ☐ corporate registry extract ☐ other: [__]

5. Screening Checks

5.1 Sanctions List Screening: ☐ Clear ☐ Possible match ☐ Not performed (explain)
5.2 PEP Screening: ☐ Clear ☐ Possible match ☐ Not performed (explain)
5.3 Adverse Media (Optional): ☐ Clear ☐ Concern identified ☐ Not performed (explain)
5.4 Notes/Links (Internal): [Notes] (avoid including unnecessary personal data)

6. Risk Assessment

6.1 Risk Rating: ☐ Low ☐ Medium ☐ High
6.2 Reasons (Select all that apply):
☐ High-risk jurisdiction
☐ Unusual ownership structure
☐ High transaction volume expected
☐ PEP/sanctions/adverse media concerns
☐ Cash-intensive business
☐ Other: [Explain]

6.3 Enhanced Due Diligence Required: ☐ No ☐ Yes (steps): [List]

7. Decision and Approval

7.1 Decision: ☐ Approved ☐ Approved with conditions ☐ Rejected ☐ Pending
7.2 Conditions/Restrictions (If Any): [Limits, monitoring, document follow-up].
7.3 Approval Date: [Date]
7.4 Approver Signature (Optional): ___________________________
7.5 Internal Notes: [Notes]

8. Data Handling and Retention (Optional)

8.1 Data will be used for verification and risk compliance purposes only and stored securely with limited access.
8.2 Retention Period: [__] years/months (or “per policy/law”).

Signatures

Completed By: [Name, Title]
Date: [Date]
Signature: ___________________________

Reviewed By (Optional): [Name, Title]
Date: [Date]
Signature: ___________________________