CTA - BOI Information Form - Montero Corporate Services

BOI Information Form

Form Completed By*
Submitter Email Address*
Submitter Phone*
Referred by*
Bill to:*
Bill to email address:*
Bill to Address*
Street Address Address Line 2 City State ZIP Code
Type of Filing*
- Initial Report
- Correct Prior Report
- Update Prior Report
Information About Entity (Reporting Company)
This is information about the entity which we are filing the report for.
Reporting Company (Entity) Name*
Name must match as reflected with the Secretary of State
Alternate Name (e.g. trade name, DBA)
Formation State*
Reporting Company Address*
Street Address Address Line 2 City State ZIP Code
Must be street address - PO Box is not allowed
Type of Company*
IRS Tax ID number (EIN or SSN) (No Dash)*
Reporting Company Formation Date Information*
- Created or registered BEFORE January 1, 2024
- Created or registered AFTER January 1, 2024
Entity Formation Date*
Date Format: MM slash DD slash YYYY

Date Articles were filed with State
Upload Formation Document*
Articles of Incorporation - Certificate of Formation, etc...
Information About Beneficial Owner(s)
Enter Number of Beneficial Owners*
For purposes of the BOI rule, a “beneficial owner” is any individual who, directly or indirectly,exercises substantial control over a reporting company or owns or controls at least 25% of theownership interests of a reporting company. Note that even though the rule refers to these individuals as beneficial owners , many individuals who are considered beneficial owners under theBOI rule are likely to have no material ownership interest at all, but they will need to be identified as beneficial owners by virtue of exercising substantial control.
Beneficial Owner 1 FinCEN ID Number (if applicable)
If you have a FinCEN ID you DO NOT have to complete the rest of the Beneficial Owner 1 questions
Beneficial Owner 1 Full Legal Name*
First Middle Last Suffix
Beneficial Owner 1 Date of Birth*
Date Format: MM slash DD slash YYYY
Beneficial Owner 1 Residential Address (Business Addresses Not Accepted)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Beneficial Owner 1 ID Type and Unique Identifying Number (ID)*
1) A non-expired passport issued to the individual by the U.S. government; 2) A non-expired identification documented issued to the individual by a State, local government, or Indian tribe; 3) A non-expired driver’s license issued to the individual by a State; or 4) A non-expired passport issued by a foreign government to the individual if the individual does not possess any of the above documents
Beneficial Owner 1 ID Issuing Jurisdiction*
Beneficial Owner 1 ID Image - Upload*
Upload a scanned image of the chosen ID
Beneficial Owner 2 FinCEN ID Number (if applicable)
If you have a FinCEN ID you DO NOT have to complete the rest of the Beneficial Owner 2 questions
Beneficial Owner 2 Full Legal Name*
First Middle Last Suffix
Beneficial Owner 2 Date of Birth*
Date Format: MM slash DD slash YYYY
Beneficial Owner 2 Residential Address (Business Addresses Not Accepted)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Beneficial Owner 2 ID Type and Unique Identifying Number (ID)
1) A non-expired passport issued to the individual by the U.S. government; 2) A non-expired identification documented issued to the individual by a State, local government, or Indian tribe; 3) A non-expired driver’s license issued to the individual by a State; or 4) A non-expired passport issued by a foreign government to the individual if the individual does not possess any of the above documents
Beneficial Owner 2 ID Issuing Jurisdiction*
Beneficial Owner 2 ID Image - Upload*
Upload a scanned image of the chosen ID
Beneficial Owner 3 FinCEN ID Number (if applicable)
If you have a FinCEN ID you DO NOT have to complete the rest of the Beneficial Owner 3 questions
Beneficial Owner 3 Full Legal Name*
First Middle Last Suffix
Beneficial Owner 3 Date of Birth*
Date Format: MM slash DD slash YYYY
Beneficial Owner 3 Residential Address (Business Addresses Not Accepted)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Beneficial Owner 3 ID Type and Unique Identifying Number (ID)*
1) A non-expired passport issued to the individual by the U.S. government; 2) A non-expired identification documented issued to the individual by a State, local government, or Indian tribe; 3) A non-expired driver’s license issued to the individual by a State; or 4) A non-expired passport issued by a foreign government to the individual if the individual does not possess any of the above documents
Beneficial Owner 3 ID Issuing Jurisdiction*
Beneficial Owner 3 ID Image - Upload*
Upload a scanned image of the chosen ID
Beneficial Owner 4 FinCEN ID Number (if applicable)
If you have a FinCEN ID you DO NOT have to complete the rest of the Beneficial Owner 4 questions
Beneficial Owner 4 Full Legal Name*
First Middle Last Suffix
Beneficial Owner 4 Date of Birth*
Date Format: MM slash DD slash YYYY
Beneficial Owner 4 Residential Address (Business Addresses Not Accepted)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Beneficial Owner 4 ID Type and Unique Identifying Number (ID)*
1) A non-expired passport issued to the individual by the U.S. government; 2) A non-expired identification documented issued to the individual by a State, local government, or Indian tribe; 3) A non-expired driver’s license issued to the individual by a State; or 4) A non-expired passport issued by a foreign government to the individual if the individual does not possess any of the above documents
Beneficial Owner 4 ID Issuing Jurisdiction*
Beneficial Owner 4 ID Image - Upload*
Upload a scanned image of the chosen ID
Notes

Montero Corporate Services

Entity Questionnaires

BOI Information Form

Information About Entity (Reporting Company)

Information About Beneficial Owner(s)