CTA Intake Form | CTA Compliance Help

REPORTING COMPANY FULL LEGAL NAME (Please double-check your Secretary of State filing to be sure the name is "exactly" correct.)

D.B.A. NAMES (Please provide any alternative names or "doing business as" names.)

TAX IDENTIFICATION NUMBER or EIN (No dash is required. Please double-check to be sure it is correct.)

COUNTRY (U.S. is the default. Please indicate if your entity is domiciled in a foreign jurisdiction.)

STATE OF FORMATION (In which U.S. State was your entity formed?)

BUSINESS STREET ADDRESS (A P.O. Box is not acceptable.)

BUSINESS CITY, STATE & ZIP CODE

WAS YOUR ENTITY IN EXISTENCE PRIOR TO JANUARY 1, 2024?

If your entity was not in existence prior to January 1, 2024, please provide the formation date.

NUMBER OF BENEFICIAL OWNERS?

Beneficial Owners are any person who owns or controls 25% or more of the equity of the entity...And also any person that exercises substantial control like an officer (I.E. CEO, CFO, President, Vice President, Secretary or Comptroller or General Legal Counsel.) Please note that controlling either the interest or operations through an entity like a trust or other business may require additional disclosure.

LAST NAME

FIRST NAME

MIDDLE NAME(S)

DATE OF BIRTH (Format Month/Day/Year - 01/01/2001)

STREET ADDRESS (P.O. Boxes are not allowed.)

CITY

COUNTRY IF NOT THE UNITED STATES

STATE

ZIP CODE (First Five Digits only)

IDENTIFYING DOCUMENT NUMBER (I.E. Your driver's license number or passport number.)

UPLOAD IDENTIFYING DOCUMENT IMAGE (Passport, Driver's License, Gov't I.D. in jpeg or pdf.)

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