KYC Self-Declaration Form Template

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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).

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: ___________________________

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KYC Self-Declaration Form Template

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KYC Self-Declaration Form Template — quick answers

Reviewed July 2026 Free download, PDF & DOCX

What is a KYC self-declaration form?

A KYC Self-Declaration Form is a document where a customer confirms key facts about their identity and, for businesses, ownership/control details. It’s often used alongside document checks and screening to support customer due diligence and create a clear audit trail.

What does a customer declare?

Typical declarations include: that information is accurate, that the customer is acting for themselves (or disclosing beneficial owners), and that they are not a sanctioned person/entity. This template includes a PEP/sanctions declaration and an update obligation.

Is this enough for KYC?

Usually not by itself. Most programs require additional verification (documents, databases, screening). This template is designed as a supporting record, not a standalone compliance solution.

How should it be used?

Use it during onboarding or periodic reviews, and keep it with other KYC evidence. This template includes optional attachments and an internal reviewer section if you want it signed off.

What should you avoid collecting?

Avoid collecting unnecessary sensitive data. This template uses “last 4 digits” fields and encourages minimal data collection and secure storage.

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