Beneficial Ownership Information Form Step 1: 2025 Beneficial Ownership Information FormLEGAL INFORMATIONLegal Name of Entity(Required)Entity EIN / Tax ID Number(Required)Legal Entity StructureLIMITED LIABILITY COMPANY (LLC)SOLE PROPRIETORCORPORATIONS-CORPORATIONPERSONAL SERVICE CORPORATIONNON-PROFIT ORGANIZATIONESTATECHURCH ORGANIZATIONTrade name or DBANumber of membersPlease enter a number from 0 to 100.In which state is the entity active?(Required)Select a stateAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces Europe, Canada, Africa and Middle EastArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRepublic of Marshall IslandsRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingBENIFICIAL MEMBER INFORMATIONFirst Name(Required) First Middle Name (optional) First Last Name(Required) Last Name Suffix Name (optional)Please SelectDDSMDPhDJRSRIIIIIIIVVVITitle(Required)Please SelectCEOExecutorOwnerManaging MemberManaging Member / OwnerPresidentOtherDrivers License Number(Required)Please Upload Picture of Drivers License Front(Required)Max. file size: 100 MB.CORPORATE ADDRESS (PO Boxes are not authorized)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you want to receive your mail at another address? YES NO Mailing Address(Required) Mailing Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code COMMUNICATIONPhone Number(Required)Email address(Required) (Required) I agree to the terms & conditions and authorize this payment to Entity Assistance Division. I hearby certify that the information above is correct and that I am authorized to conduct this transaction.(Required) I agree to receive email updates, newsletters & SMS.Payment InformationBOI Filing(Required) Price: Credit Card(Required)