FinCEN Seller Data Collection Form FinCEN Seller Data Collection Form Section 1 – Seller Information (Individual) Full Legal Name: * Date of Birth: * 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: * Section 2 – Seller Information (Entity, if applicable) Legal Entity Name: Type of Entity LLC Corporate Trust OtherOther State of Formation: Business Address: City/State/Zip: EIN: Registered Agent Name: Certification I hereby certify that the information provided in this FinCEN 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. Seller Signature: * signature keyboard Clear Date Captcha Submit If you are human, leave this field blank.
