Customer Identification Form

Customer Identification Form

This Customer Identification Form (the "Form") is executed as of Month: DD: YYYY: by and between Customer Name: and Institution Name: .

RECITALS

WHEREAS, Customer seeks to establish a relationship with Institution and, in connection with that relationship, Institution requires reliable identification data and documentation to satisfy its legal and regulatory obligations; and

WHEREAS, Customer will supply the information and documentation requested in this Form and authorizes Institution to verify such information in accordance with applicable laws and Institution's policies; and

WHEREAS, the parties intend that the information provided by Customer may be relied upon by Institution and its agents for identity verification, recordkeeping, and reporting obligations.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. Definitions

For purposes of this Form, "Customer" means the person or entity identified in this Form, and "Institution" means the entity identified in this Form. "Identification Data" means the personal or corporate information and documentary evidence provided by Customer for identity verification and beneficial ownership determination.

2. Customer Information

Month: DD: YYYY:

3. Entity Type

Individual    Corporation    Partnership    Trust    Sole Proprietor    Other

4. Beneficial Owner(s)

If Customer is an entity, list each beneficial owner who directly or indirectly owns 25% or more of the entity or who otherwise exercises substantial control. Provide full legal name, date of birth, SSN/TIN, residential address, and percent ownership. If none, state "None."

Month: DD: YYYY:

5. Identification Documents Provided

Customer represents that the following original or certified documents have been provided to Institution for verification purposes (check all that apply and provide identifying details):

Passport    Driver's License    State ID    National ID    Corporate/Organizational Documents    Other

6. Certification and Authorization

Customer certifies, under penalty of perjury where applicable, that the information and documentation provided in and with this Form are true, complete and accurate. Customer further authorizes Institution and its agents to obtain, verify and retain such information from third parties, to perform identity verification and screening against government lists, and to disclose Identification Data to affiliates, service providers, and governmental authorities as required or permitted by law. Customer agrees to promptly notify Institution of any material change to the information provided.

By checking this box and signing below, Customer certifies the foregoing statements and consents to the specified verifications and disclosures.

7. Use and Retention of Data

Institution will retain Identification Data and copies of certificates or documents in accordance with its record retention policies and applicable law. Institution may use the data in connection with account opening, ongoing due diligence, monitoring, compliance, and legal obligations.

8. Representations, Warranties and Indemnity

Customer represents and warrants that it is authorized to provide the Identification Data and documents. Customer agrees to indemnify and hold harmless Institution and its agents from any loss, liability or expense (including reasonable attorneys' fees) arising from Customer's breach of any representation or warranty in this Form or from Customer's failure to provide accurate information.

9. Notices

10. Amendments; Waiver; Counterparts

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party granting the waiver. This Form may be executed in counterparts, each of which shall be deemed an original and all of which taken together shall constitute one instrument.

Governing Law; Entire Agreement; Severability

Governing Law: This Form shall be governed by and construed in accordance with the laws of the jurisdiction specified below. The parties consent to the exclusive jurisdiction of the courts of that jurisdiction for disputes arising from this Form.

Entire Agreement: This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior discussions and agreements.

Severability: If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

Notices Regarding False Statements

Customer acknowledges that making material false statements or omissions on this Form may be unlawful and may subject Customer to civil or criminal penalties under applicable law.

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