Beneficial Ownership Certification Form Template

Entity Name: [Legal Entity Name]
Entity Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]
Reference Number: [Reference Number, if applicable]

1. Entity Information

Legal Name of Entity: [Entity Name]
Trade Name or DBA, if any: [Name]
Entity Type: [Corporation / LLC / Partnership / Trust / Other]
State or Country of Formation: [Jurisdiction]
Formation Date: [Date]
Tax ID / EIN: [Number, if applicable]

2. Business Details

Principal Business Address: [Address]
Mailing Address: [Address, if different]
Nature of Business: [Describe business activity]
Industry or Sector: [Industry]

3. Beneficial Owner Information

List each individual who is considered a beneficial owner of the entity.

Beneficial Owner 1
Full Name: [Full Name]
Date of Birth: [Date of Birth]
Residential Address: [Address]
Citizenship: [Country]
Ownership Percentage: [__]%
Type of Interest: [Direct / Indirect / Other]

Beneficial Owner 2
Full Name: [Full Name]
Date of Birth: [Date of Birth]
Residential Address: [Address]
Citizenship: [Country]
Ownership Percentage: [__]%
Type of Interest: [Direct / Indirect / Other]

Beneficial Owner 3
Full Name: [Full Name]
Date of Birth: [Date of Birth]
Residential Address: [Address]
Citizenship: [Country]
Ownership Percentage: [__]%
Type of Interest: [Direct / Indirect / Other]

Additional beneficial owners, if any:

[Insert additional owner details]

4. Control Person Information

If any individual exercises substantial control over the entity, provide details below:

Control Person Name: [Full Name]
Title or Role: [Title]
Date of Birth: [Date of Birth]
Residential Address: [Address]
Citizenship: [Country]
Basis of Control: [Executive authority / ownership control / voting power / other]

Additional control persons, if any:

[Insert details]

5. Ownership Structure Notes

Additional information about the ownership or control structure of the entity:

[Insert notes regarding parent companies, indirect ownership, trusts, layered ownership, or other relevant details]

6. Supporting Documents

The following documents are attached or available for review:

☐ certificate of formation or incorporation
☐ operating agreement or bylaws
☐ ownership chart
☐ government-issued identification for listed individuals
☐ tax identification document
☐ other: [Describe]

7. Certification

I certify that the information provided in this Beneficial Ownership Certification Form is true, complete, and accurate to the best of my knowledge.

I understand that this form may be relied upon for verification, compliance, onboarding, account review, or other lawful business purposes.

8. Authorized Signer Information

Authorized Signer Name: [Full Name]
Title: [Title]
Relationship to Entity: [Owner / Officer / Manager / Authorized Representative]
Phone Number: [Phone Number]
Email Address: [Email Address]

9. Signature

Authorized Signature: __________________________
Name: [Full Name]
Title: [Title]
Date: [Date]

10. Internal Review Notes

For internal use, if applicable:

Reviewed By: [Name]
Review Date: [Date]
Comments: [Notes]