Beneficial Ownership Information Report

Appendix—Beneficial Ownership Information (BOI) Report Summary of Data Fields

Note: Lines that must be filled in for a report to be accepted are identified with the * symbol next to the line number. Italicized text provides a description and/or explanation of lines and response options for purposes of this PRA notice.

Filing Information

1. * Type of filing (check only one box for lines 1a-1d)

   1. Initial report (check if reporting for the first time: if this box is checked, proceed to line 2)

   2. Correct prior report (check to amend information that was inaccurate and/or incomplete when reported in a prior report; if this box is checked, then you must fill out lines 1e-1h (Reporting Company information associated with most recent report))

   3. Update prior report (check to report a change in beneficial ownership information; if this box is checked, then you must fill out lines 1e-1h (Reporting Company information associated with most recent report))

   4. Newly exempt entity (check if company previously filed a report and now qualifies for an exemption to the definition of Reporting Company; if this box is checked, then you must fill out lines 1e-1h (Reporting Company information associated with most recent report) and no other lines in the report)

Reporting Company information associated with most recent report, if any:
(when the type of filing is “Correct prior report” (line 1b), “Update prior report” (line 1c), or “Newly exempt entity” (line 1d), lines 1e-1h must be completed in order to link the new filing to the previous filing)

5. Legal name

6. Tax identification type (select one from list of options)

• EIN (Employer Identification Number)

• SSN/ITIN (Social Security Number / Individual Taxpayer Identification Number)

• Foreign

1. Tax identification number

2. Country/Jurisdiction (if foreign tax ID only) (select from list of countries/jurisdictions)

1. Date prepared (auto-filled when form is finalized) (line 2 populates automatically with the date when the filer selects “Finalize” on the form)

Part I. Reporting Company Information

3. Request to receive FinCEN Identifier (FinCEN ID) (check the box to receive a FinCEN ID)

4. Foreign pooled investment vehicle (check the box if Reporting Company is a foreign pooled investment vehicle)

Full legal name and alternate name(s):

5. * Reporting Company legal name

6. Alternate name (e.g., trade name, DBA) (multiple alternate names may be reported)

Form of identification:

7. * Tax identification type (select one from list of options)

• EIN (Employer Identification Number)

• SSN/ITIN (Social Security Number / Individual Taxpayer Identification Number)

• Foreign

8. * Tax identification number

9. Country/Jurisdiction (if foreign tax ID only) (select from list of countries/jurisdictions)

Jurisdiction of formation or first registration:

10. * a. Country/Jurisdiction of formation (select from list of countries/jurisdictions, including the United States, each U.S. Territory,¹ and all foreign countries. If United States is selected, complete lines 10b, 10c, or 10d as applicable; if a U.S. Territory is selected, line 10b populates automatically with the selected U.S. Territory; if a foreign country is selected, complete lines 10e, 10f, or 10g as applicable.)

Domestic Reporting Company:

2. State of formation (select from list of U.S. States; if a U.S. Territory was selected in line 10a, line 10b populates automatically with the selected U.S. Territory)

3. Tribal jurisdiction of formation (select from list of Tribes and “Other Tribe”)

4. Name of the other Tribe (enter name of the other Tribe not included in list for line 10c, only available if “Other Tribe” selected in line 10c)

Foreign Reporting Company:

2. State of first registration (select from list of U.S. States and U.S. Territories)

3. Tribal jurisdiction of first registration (select from list of Tribes and “Other Tribe”)

4. Name of the other Tribe (enter name of the other Tribe not included in list for line 10f, only available if “Other Tribe” selected in line 10f)

Current U.S. address (street address):

11. * Address (number, street, and apt. or suite no.)

12. * City

13. * U.S. or U.S. Territory (select U.S.; or U.S. Territory from list of U.S. Territories)

14. * State (select from list of U.S. States; if a U.S. Territory was selected in line 13, line 14 populates automatically with the selected U.S. Territory)

15. * ZIP Code

16. Existing Reporting Company (check if Reporting Company was created or registered before January 1, 2024) (if this box is checked, then Company Applicant information is not required, proceed to Part III)

Part II. Company Applicant Information (report up to two Company Applicants, lines 17-32 are repeated for each Company Applicant; if Existing Reporting Company was checked in line 16, Company Applicant information is not required, proceed to Part III.)

Company Applicant FinCEN ID:

17. FinCEN ID (if FinCEN Identifier is not provided, information about the Company Applicant must be provided in the lines below)

Full legal name and date of birth:

18. * Individual’s last name

19. * First name

20. Middle name (required if the Company Applicant has a middle name)

21. Suffix (required if the Company Applicant’s name has a suffix)

22. * Date of birth

Current address (street address):

23. * Address type (check the appropriate box for lines 23a or 23b)

    1. Business address

    2. Residential address

24. *Address (number, street, and apt. or suite no.)

25. * City

26. * Country/Jurisdiction (select from list of countries/jurisdictions)

27. * State (select from list when United States, Canada, or Mexico was selected in line 26; if a U.S. Territory was selected in line 26, line 27 populates automatically with the selected U.S. Territory; if a foreign country was selected in line 26, line 27 remains empty)

28. * ZIP/Foreign postal code

Form of identification and issuing jurisdiction:

29. * Identifying document type (select one from list of lines 29a-29d)

1. State-issued driver’s license

2. State/local/Tribe-issued ID

3. U.S. passport

4. Foreign passport (may only be provided if individual does not possess document type listed in line 29a, 29b, or 29c.)

30. * Identifying document number

31. * Identifying document issuing jurisdiction (select country/jurisdiction in line 31a and complete lines 31b-31d if applicable)

1. Country/Jurisdiction (select from list of countries/jurisdictions)

b. State (select from list when the United States was selected in line 31a and the identifying document is issued by a State; if a U.S. Territory was selected in line 31a, line 31b populates automatically with the selected U.S. Territory; if a foreign country was selected in line 31a, line 31b remains empty)

c. Local/Tribal (select from list when the United States was selected in line 31a and the identifying document is issued by a local jurisdiction or Tribe; if local jurisdiction or Tribe is not included in list, select “Other” and go to line 31d; if a U.S. territory or foreign country was selected in line 31a, line 31c remains empty)

d. Other local/Tribal name (only available if “Other” selected in line 31c; enter name of local jurisdiction or Tribe that was not included in the list for line 31c)

32. * Identifying document image (attach image of identifying document referred to in lines 30-32) (instructions on upload process will be provided here)

Part III. Beneficial Owner Information (multiple Beneficial Owners may be reported, lines 33-49 are repeated for each Beneficial Owner)

33. Parent/Guardian information instead of minor child (check if the Beneficial Owner is a minor child and the parent/guardian information is provided instead)

Beneficial Owner FinCEN ID:

34. FinCEN ID (if FinCEN Identifier is not provided, information about the Beneficial Owner must be provided in the lines below)

Exempt entity:

35. Exempt entity (check the box when an exempt entity is being reported in lieu of a Beneficial Owner’s information; if checked, provide the legal name of the exempt entity in line 36, and lines 37-39 are grayed out)

Full legal name and date of birth:

36. * Individual’s last name (or entity’s legal name if line 35 box is checked)

37. * First name

38. Middle name (required if the Beneficial Owner has a middle name)

39. Suffix (required if the Beneficial Owner’s name has a suffix)

40. * Date of birth

Residential address (street address):

41. * Address (number, street, and apt. or suite no.)

42. * City

43. * Country/Jurisdiction (select from list of countries/jurisdictions)

44. * State (select from list when United States, Canada, or Mexico was selected in line 43; if a U.S. Territory was selected in line 43, line 44 populates automatically with the selected U.S. Territory; if a foreign country was selected in line 43, line 44 remains empty)

45. * ZIP/Foreign postal code

Form of identification and issuing jurisdiction:

46. * Identifying document type (select one from list of lines 46a-46d)

1. State-issued driver’s license

2. State/local/Tribe-issued ID

3. U.S. passport

4. Foreign passport (may only be provided if individual does not possess document type listed in line 46a, 46b, or 46c)

47. * Identifying document number

48. * Identifying document issuing jurisdiction (select country/jurisdiction in line 48a and complete lines 48b-48d if applicable)

1. Country/Jurisdiction (select from list of countries/jurisdictions)

2. State (select from list when the United States was selected in line 48a and the identifying document is issued by a State; if a U.S. Territory was selected in line 48a, line 48b populates automatically with the selected U.S. Territory; if a foreign country was selected in line 48a, line 48b remains empty)

c. Local/Tribal (select from list when the United States was selected in line 48a and the identifying document is issued by a local jurisdiction or Tribe (if local jurisdiction or Tribe is not included in the list, select “Other” and go to line 48d); if a U.S. Territory or foreign country was selected in line 48a, line 48c remains empty)

d. Other local/Tribal name (only available if “Other” selected in line 48c; enter name of local jurisdiction or Tribe that was not included in list for line 48c)

49. * Identifying document image (attach image of identifying document referred to in in lines 46-48) (instructions on upload process will be provided here)

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Summary of Data Fields for the Potential Second Implementation: Part III (Beneficial Owner Information)

Part III. Beneficial Owner Information (multiple Beneficial Owners may be reported, lines 33-49 are repeated for each Beneficial Owner)

33. Parent/Guardian information instead of minor child (check if the Beneficial Owner is a minor child and the parent/guardian information is provided instead)

Beneficial Owner FinCEN ID:

33. FinCEN ID (if FinCEN Identifier is not provided, information about the Beneficial Owner must be provided in the lines below)

Exempt entity:

33. Exempt entity (check the box when an exempt entity is being reported in lieu of a Beneficial Owner’s information; if checked, provide the legal name of the exempt entity in line 36, and lines 37-39 are grayed out)

Full legal name and date of birth:

33. * Individual’s last name (or entity’s legal name if line 35 box is checked)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values²)

33. * First name

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. Middle name (required if the Beneficial Owner has a middle name)

34. Suffix (required if the Beneficial Owner’s name has a suffix)

35. * Date of birth

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

Residential address (street address):

33. * Address (number, street, and apt. or suite no.)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * City

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * Country/Jurisdiction (select from list of countries/jurisdictions)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * State (select from list when United States, Canada, or Mexico was selected in line 43; if a U.S. Territory was selected in line 43, line 44 populates automatically with the selected U.S. Territory; if a foreign country was selected in line 43, line 44 remains empty)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * ZIP/Foreign postal code

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

Form of identification and issuing jurisdiction:

33. * Identifying document type (select one from list of lines 46a-46d)

5. State-issued driver’s license

6. State/local/Tribe-issued ID

7. U.S. passport

8. Foreign passport (may only be provided if individual does not possess document type listed in line 46a, 46b, or 46c)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * Identifying document number

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

33. * Identifying document issuing jurisdiction (select country/jurisdiction in line 48a and complete lines 48b-48d if applicable)

2. Country/Jurisdiction (select from list of countries/jurisdictions)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

2. State (select from list when the United States was selected in line 48a and the identifying document is issued by a State; if a U.S. Territory was selected in line 48a, line 48b populates automatically with the selected U.S. Territory; if a foreign country was selected in line 48a, line 48b remains empty)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

c. Local/Tribal (select from list when the United States was selected in line 48a and the identifying document is issued by a local jurisdiction or Tribe (if local jurisdiction or Tribe is not included in the list, select “Other” and go to line 48d); if a U.S. Territory or foreign country was selected in line 48a, line 48c remains empty)

26. (if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

d. Other local/Tribal name (only available if “Other” selected in line 48c; enter name of local jurisdiction or Tribe that was not included in list for line 48c)

33. * Identifying document image (attach image of identifying document referred to in in lines 46-48) (instructions on upload process will be provided here)(if you are not able to obtain this information about the Beneficial Owner, select the appropriate reason from the drop-down list of values)

1 U.S. Territories are considered part of the United States for purposes of determining the reporting obligations of domestic and foreign Reporting Companies. However, per ISO standard 3166-1, U.S. Territories are listed as jurisdictions separate from the United States for database management purposes.

2 FinCEN is considering several drop-down options, including (but not limited to): “Cannot Contact BO”; “BO Unresponsive”; “BO Refused to Provide”; and “Third Party Refused to Provide.”

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