CONSUMER CFG BENEFICIAL OWNERSHIP ATTESTATION

BENEFICIAL OWNERSHIP ATTESTATION

To help the government fight financial crime, regulation requires financial institutions obtain, verify and record information that

identifies each person who opens an account, including ownership of that account. The information you are providing will be used

for that purpose. Certain industries can be abused to disguise involvement in terrorist financing, money laundering, tax evasion,

corruption, fraud and other financial crimes. Requiring this information helps law enforcement investigate and prosecute these

crimes.

This form must be completed by the person opening a new account (includes deposit account opening, credit requests, new

services and applicable maintenance requests) on behalf of a business with a US financial institution.

This form requires you to provide the name, address, date of birth and Social Security number (or passport number or other

similar information, in the case of foreign persons) for the following:

? Each individual, if any, who owns, directly or indirectly, 25 percent or more equity interest in the business customer

(20 percent for lending requests).

? An individual with significant responsibility for managing the business customer (e.g., a Chief Executive Officer, Chief

Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President or Treasurer). It is

possible that in some circumstances the same individual might be identified under both sections./ (e.g., An individual with 25

percent ownership may also be the CEO; therefore, he/she would be listed in the ownership and significant controller sections.)

Note: Federal regulation requires banks to request information from or pertaining to existing customers as part of periodic

reviews. Citizens Bank may request information for individual(s) with 10 percent or more ownership to satisfy due diligence

requirements.

Persons opening an account or providing details on behalf of a business customer must provide the following information:

Name and Title of Natural Person attesting to the information below:

_________________________________________________________________________________________________

Name of Business:

_________________________________________________________________________________________________

Business EIN/Tax ID:

_________________________________________________________________________________________________

As the individual opening an account or providing information on behalf of a business, I, _________________________________

(name of natural person), hereby certify to the best of my knowledge that the information provided is complete and correct. The

authorized individual/entity agrees to notify the financial institution of any change in such information.

Signature:___________________________________________________ Date:___________________________

Intermediary: If a business (non-individual) is an owner of the business for which this account is being established, it is

defined as an intermediary and the following information must be provided:

Intermediary Business Name

Address (street, city, state, zip, country)

Percent of Ownership of Business Customer

Intermediary Business Name

Address (street, city, state, zip, country)

Percent of Ownership of Business Customer

Intermediary Business Name

Address (street, city, state, zip, country)

Percent of Ownership of Business Customer

Name of Business Customer: ____________________________

Individual(s), if any, who directly or indirectly (through an intermediary) own(s) 25 percent (20 percent for lending) or

more of the equity interest in the business listed above:

If no individual meets the definition, please check here:

Individual Name

Date of Birth

Street Address

Is Individual an NRA*? Yes

No

TIN Type and Number

Primary ID Type**

Street Address Line 2

City

Primary ID Number

Percent of Ownership

Primary ID Issue Date

Primary ID Expiration Date

Individual Name

Street Address

Is Individual an NRA*? Yes

No

TIN Type and Number

Primary ID Type**

City

Primary ID Number

Primary ID Issue Date

Primary ID Expiration Date

Individual Name

Street Address

No

TIN Type and Number

Primary ID Type**

City

Primary ID Number

Country

State

Country

ZIP/Postal Code

Percent of Ownership

Primary ID Issue Date

Primary ID Expiration Date

Individual Name

Street Address

Is Individual an NRA*? Yes

No

TIN Type and Number

Primary ID Type**

State

Street Address Line 2

Primary ID State/Country/Province

Date of Birth

Country

ZIP/Postal Code

Percent of Ownership

Is Individual an NRA*? Yes

State

Street Address Line 2

Primary ID State/Country/Province

Date of Birth

Country

ZIP/Postal Code

Primary ID State/Country/Province

Date of Birth

State

Street Address Line 2

City

Primary ID Number

ZIP/Postal Code

Primary ID State/Country/Province

Percent of Ownership

Primary ID Issue Date

Primary ID Expiration Date

Significant Controller: Required information for one individual with significant responsibility for managing the business

listed above.

If significant controller is also a beneficial owner and the information is provided above, list name only and note

¡®information provided above.¡¯

Individual Name

Date of Birth

Street Address

Is Individual an NRA*? Yes

TIN Type and Number

Primary ID Type**

No

Street Address Line 2

City

Primary ID Number

State

Country

ZIP/Postal Code

Primary ID State/Country/Province

Primary ID Issue Date

Primary ID Expiration Date

*NRA ¡ª

? Non-Resident Alien: A permanent resident of a country other than the US. Foreign address of the individual required.

**Primary ID Type ¡ª a government-issued document evidencing nationality or residence and bearing a photograph or similar

safeguard. Examples include unexpired: (i) federal- or state-issued ID, (ii) passport, or (iii) permanent resident/green card.

963557_MS19_Attestation

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