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Beneficial Ownership — Entities
Use this form to provide information for all “Beneficial Owners” (as defined below) of an entity. These individuals will not have any
authority or be able to take any action on this account unless they are also listed as Authorized Individuals on this account.
This form must be signed by an Authorized Individual in Section 3.
For purposes of this form, “Beneficial Owners” are defined as:
• Corporations and Unincorporated Associations — ALL principals, officers, directors, and any individuals or entities who own 25% or more
of the entity.
• Partnerships — Individuals who own/control 25% or more of the assets/voting power, including, but not limited to, Limited Partners.
• LLCs — ALL managing members and any member who owns/controls 25% or more of the entity.
If there are more than two Beneficial Owners of the entity, please make a copy of this page.
LL Beneficial Owners of this entity have been previously listed as Authorized Individuals on the account. You do not need to
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complete the beneficial owner sections below. You agree to notify Fidelity if or when someone else ever owns 25% or more of the
entity, and/or if or when additional Beneficial Owners are introduced in the future. Skip to Section 3.
here are no Beneficial Owners of this entity. No single individual/entity owns 25% or more of the entity AND ALL officers, principals,
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directors, and/or Managing Members have been previously listed on the account as Authorized Individuals. You do not need to
complete the beneficial owner sections below. You agree to notify Fidelity if or when someone ever owns 25% or more of the entity,
and/or if or when Beneficial Owners are introduced in the future. Skip to Section 3.
here are Beneficial Owners who have not yet been listed as Authorized Individuals on this account and their information is
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included below. You agree to notify Fidelity if or when someone else ever owns 25% or more of the entity, and/or if or when additional
Beneficial Owners are introduced in the future.
1. Beneficial Owner
Enter full name as evidenced
by a government-issued, unexpired document (e.g., driver’s
license, passport, permanent
resident card).
If this Beneficial Owner is a
trust or another entity, enter full
entity name as evidenced by the
relevant formation document
(e.g., trust document, partnership agreement, corporate
resolution). Additional information and documentation will be
required when the Beneficial
Owner is a trust or entity.
First Name
Middle Name
Last Name
Entity Name
Date of Birth MM DD YYYY
State/Country Where Organized
Social Security or Taxpayer ID Number
SSN OR
TIN
Fidelity Account Number
Residential Address This is your legal address used for tax reporting.
Address
City
State/Province
ZIP/Postal Code
Country
Citizenship
Indicate your
citizenship status.
U.S. citizen
Foreign citizen Information in this box must be completed.
Permanent U.S. resident
Non-permanent U.S. resident
Country of Citizenship
Check one and attach
a copy of a valid and
unexpired government ID
showing number and photo.
To claim non-U.S. tax status,
also complete and submit an
IRS Form W-8BEN.
Nonresident of U.S.
Country of Tax Residency Only applicable to nonresidents of the U.S.
City, State/Province, and Country of Birth
Passport
Employment Authorization Document
DHS Permanent Resident Card
Foreign National Identity Document
Form continues on next page.
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Page 1 of 2
029550101
2. Additional Beneficial Owner
Enter full name as evidenced
by a government-issued,
unexpired document (e.g.,
driver’s license, passport,
permanent resident card).
If this Beneficial Owner is
a trust or another entity,
enter full entity name as
evidenced by the relevant
formation document (e.g.,
trust document, partnership
agreement, corporate resolution). Additional information
and documentation will be
required when the Beneficial
Owner is a trust or entity.
First Name
Middle Name
Last Name
Entity Name
State/Country Where Organized
Date of Birth MM DD YYYY
Social Security or Taxpayer ID Number
SSN OR
TIN
Residential Address This is your legal address used for tax reporting.
Address
City
State/Province
ZIP/Postal Code
Country
Citizenship
Indicate your
citizenship status.
U.S. citizen
Foreign citizen Information in this box must be completed.
Permanent U.S. resident
Non-permanent U.S. resident
Country of Citizenship
Check one and attach
a copy of a valid and
unexpired government ID
showing number and photo.
To claim non-U.S. tax status,
also complete and submit an
IRS Form W-8BEN.
Nonresident of U.S.
Country of Tax Residency Only applicable to nonresidents of the U.S.
City, State/Province, and Country of Birth
Passport
Employment Authorization Document
DHS Permanent Resident Card
Foreign National Identity Document
3. Signature and Date
Form cannot be processed without signature and date.
By signing below, you certify and acknowledge the following:
•T
o help the government fight money laundering and the funding
of terrorism, federal law requires Fidelity to obtain your name,
date of birth, address, and a government-issued ID number
before opening your account, and to verify the information. In
certain circumstances, Fidelity may obtain and verify comparable
information for any person authorized to make transactions in an
account or beneficial owners of certain entities. Further documentation is required for certain entities such as trusts, estates,
corporations, partnerships, and other organizations. Your account
may be restricted or closed if Fidelity cannot obtain and verify
this information. Fidelity will not be responsible for any losses or
damages (including, but not limited to, lost opportunities) that
may result if your account is restricted or closed.
• All information or documentation provided by you is true and
accurate.
• You are authorized to provide this information on behalf of the
entity, and you affirm that you are authorized to make the representations made herein.
• The Social Security number(s) and/or the TIN(s) provided on this
form is/are correct (or you are waiting for a number to be issued).
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
SIGN
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE X
DATE
MM-DD-YYYY
X
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 628538.2.0 (11/16)
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