Certification Regarding Beneficial Owner (s) and Controlling


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Certification Regarding Beneficial Owner (s) and Controlling Person of Legal Entity Customers
1. General Instructions
What is this form?
To help the government fight financial crime, federal regulation requires certain financial institutions to obtain, verify, and record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who ultimately own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes.
Who must complete this form?
This form must be completed by the person opening a new account on behalf of a legal entity with any of the following U.S. financial institutions: (i) a bank or credit union; (ii) a broker or dealer in securities; (iii) a mutual fund; (iv) a futures commission merchant; or (v) an introducing broker in commodities. In some cases, a financial institution may request beneficial ownership information from existing customers. For the purposes of this form, a legal entity includes a corporation, limited liability company, or other entity that is created by a filing of a public document with a Secretary of State or similar office, a general partnership, and any similar business entity formed in the United States or a foreign country. Legal entity does not include sole proprietorships, unincorporated associations, or natural persons opening accounts on their own behalf.
What information do I have to provide?
This form requires you to provide the name, address, date of birth and social security number (or passport number or other similar information, in the case of Non-U.S. Persons) for the following individuals (i.e., the beneficial owners):
I. Each individual, if any, who owns, directly or indirectly, 25 percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a corporation);
II. An individual with significant responsibility for managing the legal entity customer (e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President or Treasurer).
Amegy Bank will ask to see a copy of a driver’s license or other identifying document for each beneficial owner listed on this form.

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Amegy Bank, a division of ZB, N.A. Member FDIC

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Beneficial Ownership Certification
Persons opening an account on behalf of a legal entity must provide the following information:

Name of Natural Person Opening Account / Loan Request

Title of Natural Person Opening Account / Loan Request

Name of Legal Entity for Which the Account is Being Opened

Type of Legal Entity

Address of Legal Entity

Control Prong
Complete the following information for one individual with significant responsibility for managing the legal entity listed above, such as:
• An executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or

• Any other individual who regularly performs similar functions.

(If appropriate, an individual listed under the section above may also be listed in this section.)

Name/Title

Date of Birth

Address (Residential / Physical Address)

For U.S. Persons: Social Security Number1

ID Type ID Number

State/Country of Issuance

Date of Issuance

Expiration Date

Ownership Prong
Complete the following information for each individual, if any, who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above:
(If no individual meets this definition, please write “Not Applicable.”)

Owner #1 Name

Date of Birth

Address (Residential / Physical Address)

For U.S. Persons: Ownership Social Security Number1 Percentage

ID Type ID Number

State/Country of Issuance

Date of Issuance

Expiration Date

1 In lieu of a Social Security Number or passport number, Non-U.S. Persons may also provide an Individual Taxpayer Identification Number (ITIN), an alien identification card number, or number and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard.

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Amegy Bank, a division of ZB, N.A. Member FDIC

Owner #2 Name
ID Type ID Number

Date of Birth

Address (Residential / Physical Address)

For U.S. Persons: Ownership Social Security Number1 Percentage

State/Country of Issuance

Date of Issuance

Expiration Date

Owner #3 Name
ID Type ID Number

Date of Birth

Address (Residential / Physical Address)

For U.S. Persons: Ownership Social Security Number1 Percentage

State/Country of Issuance

Date of Issuance

Expiration Date

Owner #4 Name
ID Type ID Number

Date of Birth

Address (Residential / Physical Address)

For U.S. Persons: Ownership Social Security Number1 Percentage

State/Country of Issuance

Date of Issuance

Expiration Date

1 In lieu of a Social Security Number or passport number, Non-U.S. Persons may also provide an Individual Taxpayer Identification Number (ITIN), an alien identification card number, or number and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard.

I, __________________________________ (name of natural person opening account), hereby certify, to the best of
my knowledge, that the information provided above is complete and correct. In addition, the above-listed legal entity hereby agrees to promptly notify the bank upon any change in the information provided above.

Signature: ___________________________________ Date: _________________

REV 5/2/18

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Amegy Bank, a division of ZB, N.A. Member FDIC

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Certification Regarding Beneficial Owner (s) and Controlling