Flaster Greenberg Corporate Transparency Act Questionnaire

Corporate Transparency Act Questionnaire
Completed on behalf of:*
Client Name (the “Client” or the “Company”)
By:*
Name of person completing form
Its:*
Title of person completing form
As of:*

MonthDayYear
Date
This Questionnaire is being distributed to Client by Flaster/Greenberg P.C. ("Flaster") to enable Flaster to complete the filings required by the Corporate Transparency Act (the "Act") with the Financial Crimes Enforcement Network ("FinCEN") division of the United States Department of the Treasury. Every entity formed or authorized to do business by filing a document with a state's Secretary of State (or equivalent) must comply with the Act.

Flaster will rely upon the information provided in this Questionnaire, including Client's representation that such information is accurate and complete, when completing the filings required by the Act.

ACCORDINGLY, THE CLIENT IS OBLIGATED TO READ THIS QUESTIONNAIRE CAREFULLY AND TO ANSWER THE ITEMS CONTAINED HEREIN COMPLETELYAND ACCURATELY.

ALL INFORMATION CONTAINED IN THIS QUESTIONNAIRE WILL BE TREATED CONFIDENTIALLY

REPORTING COMPANY INFORMATION
This information is required to be disclosed to FinCEN about the Company.¹
Full Legal Name:*
Registered Trade Names, if any:*
Current Business Address:*
Jurisdiction:*
State or Foreign Country of Formation
Unique Identifier Type (typically EIN):*
Unique Identifier Number:*
Primary Flaster Greenberg Attorney:*
The undersigned confirms the accuracy and completeness of the information provided in this Questionnaire.
Company Name*
Signature*
By*
Its*
¹ 31 CFR 1010.380(b1i) and 31 CFR 1010.380(c); See also: https://www.fincen.gov/boi-faqs#C_1.

BENEFICIAL OWNER INFORMATION
Please provide the requested information for each "Beneficial Owner" of the Company.

A Beneficial Owner² of a reporting company is any individual who, directly or indirectly:
- Exercises "substantial control" over a reporting company; or
- Owns or controls at least 25% of the ownership interests of a reporting company.
Substantial Control³ can be exercised in four ways:
- Being a senior officer such as president, chief financial officer, general counsel, chief executive office, chief operating officer, or any other officer who performs a similar function;
- Having authority to appoint or remove certain officers or a majority of directors (or similar body);
- Being an important decision-maker for the reporting company; or
- Having any other form of substantial control over the reporting company.
Two checklists are below to help determine beneficial ownership of the Company.
YOU MUST COMPLETE BOTH CHECKLISTS AND CERTIFY THE ACCURACY OF YOUR ANSWERS
² 31 CFR 1010.380(d); See also: https://www.fincen.gov/boi-faqs#A_1.

³ 31 CFR 1010.380(d)(i): see also: https://www.fincen.gov/boi-faqs#D_2.

15. Does your company have any other instrument, contract, arrangement, understanding, relationship, or mechanism to establish ownership?*

YesNo
The undersigned confirms the accuracy and completeness of the information provided.
Company Name*
Signature*
By*
Its*
⁴ See: https://fincenid.fincen.gov/landing

Senior Officers
List all individuals that (i) hold the title of or (ii) exercise the traditional functions of:
- President
- Chief Executive Officer
- Chief Operating Officer
- Chief Financial Officer
- General Counsel
- Any other officer
If an owner has applied for and received a FinCEN ID, please enter only their name and FinCEN ID. If they have not, please list all information requested.

Senior Officers

Rows	Legal Name	Title	Date of Birth	Residential Address	Form of ID (Typically Driver's License or Passport)	Government/FinCEN Number
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Upload Image of ID for each senior officer listed above

Cancelof

Appointment Power
List all individuals that hold the power to appoint any officers identified as senior officers or a majority of the board of directors or similar body, if applicable. If an entity holds such appointment power, repeat the Substantial Control and Ownership Interest Checklists as applicable, for each such entity and list those individuals here.

If an owner has applied for and received a FinCEN ID, please enter only their name and FinCEN ID. If they have not, please list all information requested.

Appointment Power

Rows	Legal Name	Date of Birth	Residential Address	Form of ID (Typically Driver's License or Passport)	Government/FinCEN Number
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Upload Image of ID for each person with appointment powers listed above

Cancelof

Decision Makers
List any individual that directs, determines or has substantial influence overimportant decisions regarding the:
1. Nature, scope, or attributes of the business;
2. Selection or termination of business lines or ventures;
3. Selection or limitation of geographic focus;
4. Finances, including:
  1. The entry into sales, mortgages, or other transfers of principal assets;
  2. Major expenditures or investments;
  3. Issuances of equity or incurrence of significant debt;
  4. Approval of operating budgets and compensation or incentive schemes;
5. Structure of the Company, including:
  1. Reorganization, dissolution, or merger;
  2. Amendment to any governing documents of the Company;
6. Any other form of substantial control exercised in a unique way as pertains to the Company.
If an entity holds such decision-making power, repeat the Substantial Control and Ownership Interest Checklists as applicable, for each such entity and list those individuals here.

If an owner has applied for and received a FinCEN ID, please enter only their name and FinCEN ID. If they have not, please list all information requested.

Decision Makers

Rows	Legal Name	Date of Birth	Residential Address	Form of ID (Typically Driver's License or Passport)	Government/FinCEN ID Number
#1
#2
#3
#4
#5
#6
#7

Upload Image of ID for each decision maker listed above

Cancelof

Direct Ownership of Company Interest
List any individual that personally owns or controls 25% or more of the Company’s equity as described in Q7.

List any individual that owns or controls 25% or more of the Company’s non-equity ownership interests described in Q8-Q15.

List any individual that owns or controls 25% or more of the Company’s equity or non-equity ownership interests by repeating the Substantial Control and Ownership Interest Checklists, as applicable, for each such entity.

If an owner has applied for and received a FinCEN ID, please enter only thier name and FinCEN ID. If they have not, please list all information requested.

By way of example, if the Company is 100% owned by HoldCo, any person that is a Beneficial Owner of Holdco must be listed, either through ownership of interests in HoldCo or the exercise of Substantial Control over HoldCo. However, if the Company is 50% owned by HoldCo and Person A owns 25% of HoldCo, the ownership interest in the Company by Person A is calculated by multiplying 50% by 25% to yield a 12.5% ownership interest in the Company, meaning Person A need not be listed as a Beneficial Owner.⁵

If an owner has applied for and received a FinCEN ID, please enter only thier name and FinCEN ID. If they have not, please list all information requested.

Direct Ownership

Rows	Legal Name	Date of Birth	Residential Address	Form of ID (Typically Driver's License or Passport)	Government/FinCEN ID Number
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Upload Image of ID for each direct owner listed above

Cancelof
⁵See generally: https://www.fincen.gov/boi-faqs#D_1 and https://www.fincen.gov/sites/default/files/shared/BOI_Small_Compliance_Guide.v1.1-FINAL.pdf

You have reached the end of the Corporate Transparancy Act Questionaiire. You can go back and review and/or edit your responses before submitting.

If you would like a copy of this completed questionaiire emailed to you, please enter the address you would like it sent to below.

If you are sure your answers are complete and correct please submit the form by clicking on the green SUBMIT button below.

Thank you.
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REPORTING COMPANY INFORMATION