BOI Filing Questionnaire FinCEN Beneficial Ownership Information Collection Form – Section 1: Reporting Company Information Reporting Company Information Legal Name of the Reporting Company * Trade Name or DBA (Doing Business As) Name * Principal Place of Business Address – Street * Principal Place of Business Address – City * Principal Place of Business Address – State * Principal Place of Business Address – ZIP Code * State or Jurisdiction of Formation * Entity Type * Corporation Limited Liability Company (LLC) Partnership Trust Other (Specify) Employer Identification Number (EIN) or Taxpayer Identification Number (TIN) * Beneficial Owner Information (Complete for Each Beneficial Owner) First Name * Middle Name (if applicable) Last Name * Date of Birth * Social Security Number (SSN) or TIN (If no SSN) * Citizenship: * U.S. Citizen Non-U.S. Citizen (Specify Country of Citizenship) Specify Country of Citizenship Complete Residential Address * Title or Role within the Reporting Company * Ownership Percentage * Ownership Type * Direct Ownership Indirect Ownership Total Ownership Control or Authority Held (Check All That Apply): * Significant responsibility for control or direction of the company Serves as a senior officer Other If Other (Specify) Driver’s License or State ID Number Passport Number (if applicable) If Other (Specify) Upload the documents mentioned above * Drop a file here or click to upload Choose File Maximum file size: 516MB Applicant Information (Person Filing the Report) First Name * Middle Name (If applicable) Last Name * Date of Birth * Social Security Number (SSN) or TIN (If no SSN) * Citizenship * U.S. Citizen Non-U.S. Citizen Specify Country of Citizenship Applicant’s Street Address * Applicant’s City * Applicant’s State & Zip * Email Address * Phone Number * Relationship to Reporting Company * Employee Attorney Accountant Other If other (Specify) Driver’s License or State ID Number Passport Number (if applicable) If other (Specify) Upload the documents mentioned above * Drop a file here or click to upload Choose File Maximum file size: 516MB Document Submission and Verification Supporting Documents for Reporting Company Articles of Incorporation Operating Agreement Partnership Agreement Trust Documents Other If Other (Specify) Upload the Copy of Beneficial’s Driver’s License or State ID, Copy of Passport and Other Proof of Identity * Drop a file here or click to upload Choose File Maximum file size: 516MB Upload the Copy of Applicant’s Driver’s License or State ID, Copy of Passport and Other Proof of Identity * Drop a file here or click to upload Choose File Maximum file size: 516MB Additional Notes or Comments Certification and Signature I certify that the information provided is accurate and complete to the best of my knowledge. * Signature signature keyboard Clear Date Full Name of Applicant * Required Attachments Check Mark all the boxes and uploaded the documents below * Copies of all identity verification documents (Driver’s License, Passport, etc.) Documentation for entity formation (e.g., Articles of Incorporation, Partnership Agreement) Proof of ownership percentages (e.g., stock certificates, membership agreements) Upload all the documents mentioned above in the check box * Drop a file here or click to upload Choose File Maximum file size: 516MB Submit If you are human, leave this field blank.
