FinCEN Beneficial Ownership Information Intake Form

Beneficial Owner Information

This field is for validation purposes and should be left unchanged.

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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