Final Annexure Beneficial Owner Declaration Form

Annexure IV

Beneficial Ownership Declaration

Name:

Account Number:

We hereby declare that following persons owns 15% / 25% (*Refer notes A & B) or more interest in the ___________________________ entity

Sr. No.	Name and Address of Beneficial Owners	Beneficial Owner Type (Refer Note C)	DOB	Unique No. of an identification document (PAN / Voter ID/ Aadhaar card etc.)*	Nationality	% of interest/ownership in the entity

*Note: In absence of PAN/ Voter ID/ Aadhar No. please submit an acceptable Proof of Identity. Indicative list is as under:

1. Passport
2. Driving License
3. Photo Ration Card
4. Photo ID card issued by Government Department / Statutory Regulatory Authorities.

If the beneficial owner exercises control through other means like voting rights, agreements, arrangement etc. this may be please specified.

Authorised Signatory/ies (i) ___________________________ Signature ....................

Authorised Signatory/ies (ii) ___________________________ Signature ....................

(Refer note D for Signature requirement)

# Notes

A:- Controlling ownership interest means:

Ownership of/entitlement to more than 25 % of share capital of the juridical person, where the juridical person is a company;
Ownership of/entitlement to more than 15% of the capital or profits of the juridical person where the juridical person is a partnership; or,
Ownership of/entitlement to more than 15% of the property or capital or profits of the juridical person where the juridical person is an unincorporated association or body of individuals.

B:- Beneficial Ownership Declaration is not required for the following entities

C:- Beneficial Ownership Declaration to provide details of following

In case of Partnership Firm/ LLP :- natural persons / partners
In case of Trust :- Trustees / Settlor / Protector / Beneficiary
In case of Foundation :- Founder managers / Directors/ Beneficiary
In case of Society :- Members/ authorised signatories/ Beneficiary
In case of Club :- Members/ authorised signatories/ Beneficiary
In case of association: - Members/ authorised signatories/ Beneficiary
In case of Pvt Ltd companies and Unlisted Public Ltd Companies :- Share holder/ Directors / Other Beneficiaries
In case of Foreign Entity :- Share/ holder/ Director / Other Beneficiaries

D:- Signature on Declaration form

In case of Partnership Firm/ LLP /Trust /Foundation Society ,Club: - Any two Authorised Signatories as per Mode of Operations should sign
In case of association: - All Authorised Signatories should sign
In case of Pvt Ltd companies and Unlisted Public Ltd Companies: - Any two Directors or Company Secretary should sign
In case of Foreign Entity: - All Authorised Signatories should sign