FinCEN BOIR Intake Form

Name

First

Middle

Last

Email

Phone

Type of filing:

Initial report
Correct prior report
Update prior report
Newly exempt entity

Is this for a foreign pooled investment vehicle?

Yes
No

Tax identification type

EIN
SSN/ITIN
Foreign

EIN 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 1

Address Line 2

City

State

Zip Code

U.S. or U.S. Territory

Date of birth

Residential Address of Company Applicant

Address Line 1

Address Line 2

City

State

Zip Code

Company applicant's country of residence

Form of identification

State/Local/Tribe-Issued ID
U.S. Passport
Foreign Passport

One 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?

Yes
No

Please email to [email protected]

A copy of your FEIN and State LLC Filing documents are required. Have you email these to us?

Yes
No

Please email to [email protected]

Is the beneficial owner a minor? If yes, submit the parent/guardian information below.

Yes
No

If you have a FinCEN ID as a beneficial owner, please provide it below.

Is the beneficial owner an exempt entity?

Yes
No

Exempt 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

First

Last

Beneficial Owner #1 – Date of birth

Beneficial Owner #1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Beneficial 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 Name

First

Last

Beneficial Owner #2 – Date of birth

Beneficial Owner #2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Beneficial Owner #2 – Entity's legal name (if an entity)

Beneficial Owner #3 Name

First

Last

Beneficial Owner #2 – Country/Jurisdiction

Beneficial Owner #3 – Date of birth

Beneficial Owner #3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Beneficial Owner #3 – Country/Jurisdiction

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FinCEN BOIR Intake Form

Additional Beneficial Owners

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