Illustrative Customer Due Diligence Templates Page 9
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25EP 200 IG 2
FORM A
(Identification and
verification of
beneficial owners)
Form A: Beneficial Owners
For each beneficial owner that the client has, please complete the following form. Certain clients do not
need to fill up this form. Please refer to Annex 1 for a list of these clients.
If an ACRA search profile of the shareholders have been obtained, it is not necessary to verify the identity
of the shareholders/partners further. A shareholder may be a beneficial owner if the shareholder
ultimately owns or controls more than 25% of shares in the company.
Identification
BENEFICIAL OWNER
Full legal name(s),
Unique
both official and any
identification
aliases:
number:
Contact number(s):
Occupation:
Nationality:
Date of birth:
Residential street
address:
Information regarding
the nature of beneficial
ownership and the
ownership and control
structure of the client:
*If the beneficial owner is a PEP, Form D must be completed in addition to this form.
Client/Agent’s Declaration
I declare that the information provided in these forms is true and correct. I am aware that I may be subject
to prosecution and criminal sanctions under written law if I am found to have made any false statement
which I know to be false or which I do not believe to be true, or if I have intentionally suppressed any
material fact.
Name of client/agent:
Identity/passport number:
Date:
Signature:
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