Beneficial Ownership Information Request

Beneficial Ownership Information (BOI) Request: Summary of Data Fields by Authorized Recipient

Note: Data fields that must be filled in to start a search are identified with the * symbol next to the data field. Italicized text provides a description and/or explanation of lines and response options for purposes of this PRA notice.

1. Financial institutions

Proposed data fields and certification:

Search for Beneficial Ownership Information

*Reporting company legal name

*Reporting company tax identification number type (select one from list of options)

• EIN (Employer Identification Number)

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

• Foreign (if “foreign” is selected, a drop down menu for “country/jurisdiction” populates automatically; select from list of countries/jurisdictions)

*Reporting company tax identification number

*Certification

I certify on behalf of the financial institution making this request that: (1) this information is requested to facilitate the financial institution’s compliance with customer due diligence requirements under applicable law, as defined in 31 CFR 1010.955(b)(4)(i); (2) the financial institution has obtained and documented the consent of the reporting company to request this information from FinCEN; and (3) the financial institution has fulfilled all other requirements of 31 CFR 1010.955(d)(2).

[Select “I agree”]

2. State, local, and Tribal law enforcement agencies

Proposed data fields and certification:

New Justification

*Agency Reference (agency’s internal reference name for BOI request)

*Court authorization description (description of the information the court has authorized the agency to seek)

*Name of court of competent jurisdiction

*Date of court authorization (mm/dd/yyyy)

Checkbox Request is being conducted on behalf of another person in the same agency (select this checkbox if the BOI request is made on behalf of another person in the same agency; provide the following information if this checkbox is selected: *first name of requester; middle name of requester; *last name of requester; title; city; *country/jurisdiction; state; ZIP/foreign postal code)

*Certification

I certify that a court of competent jurisdiction has authorized my agency to seek this information in a criminal or civil investigation and that the requested information is relevant to the criminal or civil investigation.

[Select “I agree”]

3. State regulatory agencies

Proposed data fields and certification:

Search Beneficial Ownership Information Requested by Financial Institutions

To begin a search, provide a Financial Institution Name or Financial Institutiton Employer Identification Number (EIN). To further refine your search, you may enter a Reporting Company Legal Name, Reporting Company Tax Identification Number, and/or a date range in which the financial institution searched for beneficial ownership information.

Financial Institution

Financial Institution EIN (Employer Identification Number)

Reporting Company Legal Name

Reporting Company Tax Identification Number

Start Date (mm/dd/yyyy) (start of date range of financial institution search for beneficial ownership information)

End Date (mm/dd/yyyy) (end of date range of financial institution search for beneficial ownership information)

*Certification

I certify that my agency is authorized by law to assess, supervise, enforce, or otherwise determine the compliance of a relevant financial institution with customer due diligence requirements under applicable law, as defined in 31 CFR 1010.955(b)(4)(i), and that my agency will use the requested information solely for such purposes.

[Select “I agree”]