KYC Self-Declaration Form Template

Company/Service Provider: [Company Name]
Customer Name: [Customer Legal Name]
Customer ID / Account No. (Optional): [ID]
Date: [Date]
Customer Type: ☐ Individual ☐ Business/Entity

1. Customer Details

1.1 Individual (if applicable): Full name: [] | DOB: [] | Country of residence: [] | Address: [].
1.2 Business (if applicable): Legal name: [] | Registration no.: [] | Country/state: [] | Registered address: [].
1.3 Contact: Email/phone: [__].

2. Declarations (Select and Complete)

2.1 Accuracy: I declare that the information provided to [Company Name] is true, accurate, and complete to the best of my knowledge.
2.2 Authority: If I am signing on behalf of a business, I confirm I am authorized to act for the business.
2.3 Beneficial Ownership (Businesses):
☐ The business has disclosed all beneficial owners/controllers as required.
☐ The business has no beneficial owners above [__]% (or as defined by applicable rules) and the controlling persons have been disclosed.

2.4 Sanctions/PEP: To the best of my knowledge:

• I/the customer is not a sanctioned person/entity: ☐ Yes ☐ No ☐ Unknown (explain).

• No beneficial owner/controller is sanctioned: ☐ Yes ☐ No ☐ Unknown (explain).

• I/the customer is not a politically exposed person (PEP), and no disclosed owner/controller is a PEP: ☐ Yes ☐ No ☐ Unknown (explain).

2.5 Source of Funds (Optional): The primary source of funds is: ☐ salary ☐ business revenue ☐ investments ☐ loan ☐ other: [].
2.6 Update Obligation: I agree to notify [Company Name] within [] days of any material changes (name, address, ownership, control, or other key details).

3. Attachments (Optional)

3.1 ☐ ID document(s)
3.2 ☐ Proof of address
3.3 ☐ Registry extract/incorporation document (business)
3.4 ☐ Ownership chart/cap table (business)
3.5 ☐ Other: [List]

4. Internal Use (Optional)

4.1 Completed review: ☐ Approved ☐ Pending ☐ Rejected
4.2 Reviewer: [Name/Title] | Date: [Date] | Notes: [__]

Signatures

Customer / Authorized Representative: [Full Name]
Title (If Business): [Title]
Date: [Date]
Signature: ___________________________