FinCEN BOIR Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastEmail *Phone *Type of filing: *Initial reportCorrect prior reportUpdate prior reportNewly exempt entityIs this for a foreign pooled investment vehicle? *YesNoTax identification typeEINSSN/ITINForeignEIN or SSN/ITIN *Country/Jurisdiction (if foreign tax ID only) *Country of formation or first registration.State of Formation *Tribal jurisdiction of formation (if applicable)Name of the other tribe (if applicable)Address of Entity *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeU.S. or U.S. Territory *Date of birth *Residential Address of Company Applicant *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany applicant's country of residence *Form of identification *State/Local/Tribe-Issued IDU.S. PassportForeign PassportOne form of identification will be needed. *Email a jpeg or pdf file of your identification type*Identifying document number *Country of identifying document issuing jurisdiction *State of identifying document issuing jurisdiction *Local/Tribal of identifying document issuing jurisdiction (if applicable)Have you emailed a jpeg or pdf copy of your identification type? *YesNoPlease email to [email protected] A copy of your FEIN and State LLC Filing documents are required. Have you email these to us? *YesNoPlease email to [email protected]Is the beneficial owner a minor? If yes, submit the parent/guardian information below. *YesNoIf you have a FinCEN ID as a beneficial owner, please provide it below.Is the beneficial owner an exempt entity? *YesNoExempt Entities are; Securities Reporting Issuer, Governmental Authority, Bank, Credit Union, Depository Institution Holding Company, Money Services Business, Broker/Dealer in Securities, Securities Exchange or Clearing Agency, Other Exchange Act Registered Entity, Investment Company or Investment Adviser, Venture Capital Fund Adviser, Insurance Company, State-Licensed Insurance Provider, Commodity Exchange Act Registered Entity, Accounting Firm, Public Utility, Financial Market Utility, Pooled Investment Vehicle, Tax-Exempt Entity, Entity Assisting a Tax-Exempt Entity, Large Operating Company (20 full-time employees or more or $5,000,000 in gross sales), Subsidiary of certain Exempt Entities or an Inactive Entity.Beneficial Owner #1 – Entity's legal name (if an entity) *Beneficial Owner #1 *FirstLastBeneficial Owner #1 – Date of birth *Beneficial Owner #1 Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBeneficial Owner #1 – Country/Jurisdiction *Additional Beneficial Owners This section is for additional beneficial owners. If there are more than three beneficial owners, please contact us. Beneficial Owner #2 – Entity's legal name (if an entity)Beneficial Owner #2 NameFirstLastBeneficial Owner #2 – Date of birthBeneficial Owner #2 AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBeneficial Owner #2 – Entity's legal name (if an entity)Beneficial Owner #3 Name FirstLastBeneficial Owner #2 – Country/JurisdictionBeneficial Owner #3 – Date of birthBeneficial Owner #3 Address Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBeneficial Owner #3 – Country/JurisdictionConsent *I am aware of and consent to the privacy policy at InvestingTE.com which is located at https://investingte.com/tos/privacy-policy/.SMS Opt-In *By checking this box, I agree to receive texts from InvestingTE.com at this mobile number. Message and data rates may apply. Text STOP to unsubscribe from messages at any time. See https://investingte.com/tos/ to see our company’s terms of service and privacy policy.I do not opt-in to receive texts related to any correspondence for my order.Submit
