FinCEN Buyer Data Collection Form FinCEN Buyer Data Collection Form Section 1 – Buyer Information (Individual) Full Legal Name: * Social Security Number: * (Last 4 digits) Current Residential Address: City/State/Zip: Citizenship: Driver’s License or Passport Number: * Issuing State/Country: * Phone Number: * Email Address: * Ownership Percentage: Section 2 – Buyer Information (Entity, if applicable) Legal Entity Name: Type of Entity: LLC Corporate Trust OtherOther If Trust: Irrevocable Revocable State of Formation: Business Address: City/State/Zip: EIN: Registered Agent Name: Section 3 – Beneficial Owner Information (If Entity Buyer) Provide information for each individual who owns 25% or more OR exercises substantial control. Full Legal Name: Date of Birth: Residential Address: City/State/Zip: Citizenship: Driver’s License or Passport Number: * Issuing State/Country: * Ownership Percentage: Relationship to the Transferee Entity: I.E. Owner/LLC Member Corporate Officer Manager Attorney Accountant If Trust: What is the Relationship to the Transferee Trust? Trustee Attorney Beneficiary Date of Birth: * If Trust: What is the Date of Formation of Trust? If Signing Individual: Authorization Capacity: Name of Employer, Principal, or Partnership: Other Description: Section 4 – Payment Information Total Consideration Paid: (in US Dollars) Payment Amount: Payment Method: If Foreign Payment Method Please Write Currency Code: Account No: Financial Institution Legal Name: Check If True for This Payment: Payment is NOT from a Financial Institution Account Payment Associated with all Recorded Transferees in Section 2 All Payors Are All Recorded Transferees in Section 2 Name All Payors Involved with this Payment: Certification I acknowledge on behalf of the buyer/transferee that: * No funds have been or will be transferred or paid outside of the control of the Settlement Agent/Reporting Person who is facilitating the acquisition of the Property. Funds have been or will be transferred between the parties outside of the control of the Settlement Agent/Reporting Person who is facilitating the acquisition of the Property. I hereby certify that the information provided in this FinCEN Buyer Seller Data Collection Form is true, correct, and complete to the best of my knowledge and belief. I understand that this information is being collected for compliance with applicable federal reporting requirements, including those administered by the Financial Crimes Enforcement Network (FinCEN), and may be reported to governmental authorities as required by law. I agree to indemnify, defend, and hold harmless settlement agent or other reporting person against any and all losses, liabilities, damages, claims, fines, causes of action related to the reporting of information contained in this form to FinCen under this regulation. I acknowledge that providing false, fictitious, or fraudulent information may subject me to civil and/or criminal penalties under applicable federal law. I agree to promptly notify the reporting party of any material changes to the information provided prior to closing. Buyer Signature: signature keyboard Clear Date Captcha Submit If you are human, leave this field blank.
