BO1 BENEFICIAL OWNERSHIP (BO) DECLARATION FORM

THE ABOVE-MENTIONED ENTITY HAS THE FOLLOWING BENEFICIAL OWNERS [Please see Part c (2) (e)]

Rows	1	2	3	4	5	6	7	8
BENEFICIAL OWNER # 1
BENEFICIAL OWNER # 2
BENEFICIAL OWNER # 3
BENEFICIAL OWNER # 4

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE COMPLETE PART B FOR EACH BENEFICIAL OWNER]
1. BENEFICIAL OWNER # 1 PARTICULARS
1.1 NAME

First NameSurname
1.2 ANY PREVIOUS NAME (E.G., MAIDEN NAME):
1.3 DATE OF BIRTH (DD-MM-YYYY):

DayMonthYear
Date
1.4 PLACE OF BIRTH:
1.5 NATIONALITY:
1.6 RESIDENTIAL ADDRESS

Street Address

Street Address Line 2

City and CountryState

Zip Code
1.7 BUSINESS ADDRESS

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
1.8 TAX IDENTIFICATION NUMBER (TIN). (IF APPLICABLE):
1.9 TELEPHONE / MOBILE NUMBER:
Format: (000) 000-0000.
1.10 EMAIL ADDRESS:
example@example.com
1.11 PRIMARY IDENTIFICATION TYPE:
i.e. Identity Document, Passport etc.
1.12 PRIMARY IDENTIFICATION NUMBER:
1.13 IDENTIFICATION ISSUING COUNTRY / STATE/REGION:
1.14 PLACE OF WORK AND POSITION HELD:

1.15 DATE BENEFICIAL OWNERSHIP COMMENCED

Rows	D	D	M	M	Y	Y	Y	Y
Date

1.16 DATE BENEFICIAL OWNERSHIP CEASED

Rows	D	D	M	M	Y	Y	Y	Y
Date

MEMBERS DECLARATION
1.17 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
1.17 (a) NAME OF DIRECTOR / SHAREHOLDER / MEMBER / BENEFICIAL OWNER:
Full Name i.e. John Johnson

1.17 (b)SIGNATURE DATE (DDMMYYYY)

Rows	D	D	M	M	Y	Y	Y	Y
Date

ACCOUNTABLE INSTITUTIONS DECLARATION
1.18 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
1.18 (a) NAME OF ACCOUNTABLE INSTITUTION:
1.18 (b) NAME OF AUTHORIZED STAFF:
1.18 (c) POSITION:

1.18 (d) SIGNATURE DATE (DDMMYYYY)

Rows	D	D	M	M	Y	Y	Y	Y
Date

(NB: IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN)

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]
2. BENEFICIAL OWNER # 2 PARTICULARS
2.1 NAME:

First NameSurname
2.2 ANY PREVIOUS NAME (E.G., MAIDEN NAME):
2.3 DATE OF BIRTH (DD-MM-YYYY):

DayMonthYear
Date
2.4 PLACE OF BIRTH:
2.5 NATIONALITY:
2.6 RESIDENTIAL ADDRESS (INCLUDING ERF, STREET NAME, CITY, STATE AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
2.7 BUSINESS ADDRESS (INCLUDING ERF, STREET NAME, CITY AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
2.8 TAX IDENTIFICATION NUMBER (TIN). (IF APPLICABLE):
2.9 TELEPHONE/MOBILE NUMBER:
Format: (000) 000-0000.
2.10 EMAIL ADDRESS:
example@example.com
2.11 PRIMARY IDENTIFICATION TYPE:
2.12 PRIMARY IDENTIFICATION NUMBER:
2.13 IDENTIFICATION ISSUING COUNTRY / STATE / REGION:
2.14 PLACE OF WORK AND POSITION HELD:

MEMBERS DECLARATION
2.17 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
2.17 (a) NAME OF DIRECTOR / SHAREHOLDER / MEMBER / BENEFICIAL OWNER:
Full Name

ACCOUNTABLE INSTITUTIONS DECLARATION
2.18 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
2.18 (a) NAME OF ACCOUNTABLE INSTITUTION:
2.18 (b) NAME OF AUTHORIZED STAFF:
2.18 (c) POSITION:

NB: IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]
3. BENEFICIAL OWNER # 3 PARTICULARS
3.1 NAME:

First NameSurname
3.2 ANY PREVIOUS NAME (E.G., MAIDEN NAME):
3.3 DATE OF BIRTH (DD-MM-YYYY):

DayMonthYear
Date
3.4 PLACE OF BIRTH:
3.5 NATIONALITY:
3.6 RESIDENTIAL ADDRESS (INCLUDING ERF, STREET NAME, CITY, STATE AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
3.7 BUSINESS ADDRESS (INCLUDING ERF, STREET NAME, CITY AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
3.8 TAX IDENTIFICATION NUMBER (TIN). (IF APPLICABLE):
3.9 TELEPHONE / MOBILE NUMBER:
Format: (000) 000-0000.
3.10 EMAIL ADDRESS:
example@example.com
3.11 PRIMARY IDENTIFICATION TYPE:
3.12 PRIMARY IDENTIFICATION NUMBER:
3.13 IDENTIFICATION ISSUING COUNTRY / STATE/REGION:
3.14 PLACE OF WORK AND POSITION HELD:

MEMBERS DECLARATION
3.17 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
3.17 (a) NAME OF DIRECTOR / SHAREHOLDER / MEMBER/BENEFICIAL OWNER:

ACCOUNTABLE INSTITUTIONS DECLARATION
3.18. I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
3.18 (a)NAME OF ACCOUNTABLE INSTITUTION:
3.18 (b) NAME OF AUTHORIZED STAFF:
3.18 (c) POSITION:

NB: IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]
4. BENEFICIAL OWNER # 4 PARTICULARS
4.1 Name

First NameSurname
4.2. ANY PREVIOUS NAME (E.G., MAIDEN NAME):
4.3 DATE OF BIRTH (DD-MM-YYYY):

MonthDayYear
Date
4.4 PLACE OF BIRTH:
4.5 NATIONALITY:
4.6 RESIDENTIAL ADDRESS (INCLUDING ERF, STREET NAME, CITY, STATE AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
4.7 BUSINESS ADDRESS (INCLUDING ERF, STREET NAME, CITY AND COUNTRY)

Street Address

Street Address Line 2

City and CountryState / Province

Postal / Zip Code
4.8 TAX IDENTIFICATION NUMBER (TIN). (IF APPLICABLE):
4.9 TELEPHONE / MOBILE NUMBER:
Format: (000) 000-0000.
4.10 EMAIL ADDRESS:
example@example.com
4.11 PRIMARY IDENTIFICATION TYPE:
4.12 PRIMARY IDENTIFICATION NUMBER:
4.13 IDENTIFICATION ISSUING COUNTRY / STATE / REGION:
4.14 PLACE OF WORK AND POSITION HELD:

MEMBERS DECLARATION
4.17 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
4.17 (a) NAME OF DIRECTOR / SHAREHOLDER / MEMBER / BENEFICIAL OWNER:

ACCOUNTABLE INSTITUTIONS DECLARATION
4.18 I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
4.18 (a) NAME OF ACCOUNTABLE INSTITUTION:
4.18 (b) NAME OF AUTHORIZED STAFF:
4.18 (c) POSITION:

NB: IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.

COMPLETION
NB: UPON COMPLETION, THE FORM MUST BE DOWNLOADED AND SIGNED BEFORE SUBMISSION TO BIPA.
Payment Instructions - Manual EFT
This is a paid compliance service.

To complete and recieve completed forms, please make payment via Electronic Funds Transfer (EFT) using the details below:

Bank: First National Bank of Namibia Limited
Account Name: CC Automate
Account Number: 64279056864
Branch : Grove Mall
Branch Code : 280679
Payment Reference: BO1 – [Full CC Name and Registration Number]

After making payment, upload your Proof of Payment in the section below.

Important:
• Your form will NOT be processed until payment is confirmed.
• Documents will only be generated and released after EFT approval.
• Incorrect or missing references may delay processing.
Upload Proof Of Payment (EFT) - Upload a screenshot or PDF of your EFT confirmation.Ensure the payment reference matches:BO1 – [Full CC Name]*

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BO1 BENEFICIAL OWNERSHIP (BO) DECLARATION FORM

1. INSTRUCTIONS

PART A - ENTITY PARTICULARS

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE COMPLETE PART B FOR EACH BENEFICIAL OWNER]

1. BENEFICIAL OWNER # 1 PARTICULARS

MEMBERS DECLARATION

ACCOUNTABLE INSTITUTIONS DECLARATION

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]

2. BENEFICIAL OWNER # 2 PARTICULARS

MEMBERS DECLARATION

ACCOUNTABLE INSTITUTIONS DECLARATION

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]

3. BENEFICIAL OWNER # 3 PARTICULARS

MEMBERS DECLARATION

ACCOUNTABLE INSTITUTIONS DECLARATION

PART B - BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]

4. BENEFICIAL OWNER # 4 PARTICULARS

MEMBERS DECLARATION

ACCOUNTABLE INSTITUTIONS DECLARATION

COMPLETION

Payment Instructions - Manual EFT