Initial Report Input Form

Initial Report Input Form for Reporting Company formed before 1/1/2024
Important Instructions - Read before proceeding
• Only 25% or greater owners are considered Beneficial Owners who must be reported on this form. The actual amount of ownership does not need to be disclosed.  Refer to Resource Material Section at www.BoirAgent.com for information about non-equity Beneficial Owners that may apply to your entity.

• There are four (4) Beneficial Owner sections. After the first section, these sections can be left blank if not needed. If additional sections are needed, please email service@BoirAgent.com.

• Make sure you have access to a PDF or JPG formatted file that contains your current identifying document(s). Do not use expired or inaccurate identifying documents.

• Data fields marked with an * must be filled or an error message will be produced. Missing information can then be entered and the form re-submitted.

• You do not need to provide a Beneficial Owner social security number, unless there is a single Beneficial Owner who uses this number for their Reporting Company.

• Complete the form in full. Partial submissions are not accepted and cannot be saved.

• The submission button is located at the very bottom of the form.

• Submitted forms are reviewed within one business day. Any errors are communicated to the client by email, using the email address provided with the form. If the form is error free, the information provided will be filed with FinCEN within one business day.

• Upon filing of the information, BoirAgent emails an invoice to the client with instructions for making an ACH payment directly to BoirAgent’s checking account. To keep the cost of our service as affordable as possible, we do not accept credit card payments. This email contains the FinCEN submission tracking ID, providing proof of filing. Upon receipt of payment, the client will be emailed the full confirmation report, which includes the BOIR ID, Submission Tracking ID and Reporting Company FinCEN ID (if this option was selected by client). A PDF copy of the official filing is also provided. All client information is retained by BoirAgent on a secure platform. Clients who subscribe to BoirAgent’s Compliance program can request copies of this material at any time at no additional cost.
Information Entry Section
Request to receive FinCEN Identifier (FinCEN ID) - Highly recommended; no additional cost.

Click circle to apply for FinCEN ID
Full legal name of Reporting Company:*
Alternate name (trade name, DBA, etc.)
Form of identification*
Tax Identification Number without spaces or dashes*
Reporting Company's Current U.S. Address
Street Address

Street Address Line 2

CityState

Zip Code
Email for designated Reporting Company contact for monthly compliance email service. May be a Beneficial Owner. Email address not filed with FinCEN report*
example@example.com
1st Benefecial Owner Information

25% or greater ownership or power/influence over business activity
Parent/Guardian information instead of minor child

Check if Beneficial Owner is minor child and parent/guardian info is provided instead
1st Beneficial Owner's full name and date of birth:
Legal Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Residential address:

1st Beneficial Owner
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Beneficial Owner email for monthly compliance email service. Not filed with FinCEN report.*
example@example.com
Form of identfication and issuing jurisdiction

1st Beneficial Owner
Identifying document type*
Identifying document number*
Driver's license issued by this state*
1st Beneficial Owner identifying document image (driver's license or U.S. Passport)*

Cancelof
2nd Beneficial Owner Information (leave blank if not needed)

25% or greater ownership or power/influence over business activity
Parent/Guardian information instead of minor child

Check if Beneficial Owner is minor child and parent/guardian info is provided instead
2nd Beneficial Owner's full name and date of birth:
Legal Name

First NameLast Name
Date of birth

MonthDayYear
Date
Residential address:

2nd Beneficial Owner
Address

Street Address

Street Address Line 2

CityState

Zip Code
2nd Beneficial Owner email for monthly compliance email service. Not filed with FinCEN report.
example@example.com
Form of identfication and issuing jurisdiction

2nd Beneficial Owner
Identifying document type
Identifying document number
Driver's license issued by this state
2nd Beneficial Owner identifying document image (driver's license or U.S. Passport)

Cancelof
3rd Beneficial Owner Information (leave blank if not needed)

25% or greater ownership or power/influence over business activity
Parent/Guardian information instead of minor child

Check if Beneficial Owner is minor child and parent/guardian info is provided instead
3rd Beneficial Owner's full name and date of birth:
Legal Name

First NameLast Name
Date of birth

MonthDayYear
Date
Residential address:

3rd Beneficial Owner
Address

Street Address

Street Address Line 2

CityState

Zip Code
3rd Beneficial Owner email for monthly compliance email service. Not filed with FinCEN report.
example@example.com
3rd Beneficial Owner identifying document image (driver's license or U.S. Passport)

Cancelof
4th Beneficial Owner Information (leave blank if not needed)

25% or greater ownership or power/influence over business activity
Parent/Guardian information instead of minor child

Check if Beneficial Owner is minor child and parent/guardian info is provided instead
4th Beneficial Owner's full name and date of birth:
Legal Name

First NameLast Name
Date of birth

MonthDayYear
Date
Residential address:

4th Beneficial Owner
Address

Street Address

Street Address Line 2

CityState

Zip Code
4th Beneficial Owner email for monthly compliance email service. Not filed with FinCEN report.
example@example.com
4th Beneficial Owner identifying document image (driver's license or U.S. Passport)

Cancelof
Submission of this form indicates that the BoirAgent Disclaimer/Authoirzation document (presented on the BoirAgent website, www.BoirAgent.com) has been reviewed, acknowledged and accepted by the Reporting Company and all Beneficial Owners.
Should be Empty:

Initial Report Input Form for Reporting Company formed before 1/1/2024

Important Instructions - Read before proceeding

Information Entry Section

Reporting Company's Current U.S. Address

1st Benefecial Owner Information

1st Beneficial Owner's full name and date of birth:

Residential address:

Form of identfication and issuing jurisdiction

2nd Beneficial Owner Information (leave blank if not needed)

2nd Beneficial Owner's full name and date of birth:

Residential address:

Form of identfication and issuing jurisdiction

3rd Beneficial Owner Information (leave blank if not needed)

3rd Beneficial Owner's full name and date of birth:

Residential address:

4th Beneficial Owner Information (leave blank if not needed)

4th Beneficial Owner's full name and date of birth:

Residential address:

Submission of this form indicates that the BoirAgent Disclaimer/Authoirzation document (presented on the BoirAgent website, www.BoirAgent.com) has been reviewed, acknowledged and accepted by the Reporting Company and all Beneficial Owners.