Credit Card Processing Application

CERTIFICATE OF BENEFICIAL OWNER(S)

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 own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute the crimes. By signing this Application, I attest that I have accurately provided the name, address, date of birth, and Social Security Number (SSN) for the following individuals (i.e. the beneficial owners):

i) Each individual, if any, who owns directly or indirectly, twenty-five (25) percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns twenty-five (25) percent or more of the shares of a corporation); and

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).

The number of individuals that satisfy this definition of “beneficial owner” may vary. Under section (i), depending on the factual circumstances, up to four individuals (but as few as zero) may need to be identified. Regardless of the number of individuals under each section (i), you must provide the identifying information of one individual under section (ii). It is possible that in some circumstances the same individual must be identified under both sections (e.g., the President of Acme, Inc. who also holds a 30% equity interest). Thus, a completed form will contain the identifying information of at least one individual (under section (ii)), and up to five individuals (i.e., one individual under section (ii) and four twenty-five (25) percent equity holders under section (i)).

Date*

Name*

First Last

Title*

Signature*

CIP / LIST OF BENEFICIAL OWNERS HOLDING AN INTEREST OF 25% OR GREATER

Owner / Officer #1

SS Number

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

% of Equity Ownership

Owner / Officer #2

SS Number

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

% of Equity Ownership

Owner / Officer #3

SS Number

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

% of Equity Ownership

Owner / Officer #4

SS Number

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

% of Equity Ownership

IDENTIFY A SINGLE INDIVIDUAL WHO HAS A SIGNIFICANT RESPONSIBILITY TO CONTROL A MERCHANT

Name

First Last

Title

SS Number

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Step 1 of 3

Business Information

Owner / Principal Information

Trade & Bank References

Relevant Questions

Required Documentation

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