FinCEN Beneficial Ownership Information Intake Form

Beneficial Owner Information

Who is providing this information? (your name)(Required)

First Last

Phone

Name of Company?

Company EIN (tax id no)*

Beneficial Owner/Director Information

Beneficial Owner/Director Name**

Residential Address

Best Contact Information (phone/or email) ***

Use the plus symbol to add rows

*If you do not know your entity’s Taxpayer Employer Identification Number (EIN), please contact us at 904.737.4600 ext. 120 so we can assist you in finding or creating an EIN.

**We will need a digital copy or photocopy of the driver’s license, a U.S. passport, or a foreign passport for each Beneficial Owner/Director.

***This information enables us to directly contact an owner/director if missing information is needed to complete your filing.

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