Client Due Diligence

Client Due Diligence Form

Complete the form below to confirm your company's eligibility to use CT Payer.

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To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify, and record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., beneficial owners) helps law enforcement investigate and prosecute these crimes.

Contact Information

Name *

Title *

Email *

Phone

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Banking Information

To be used for account funding. Funds coming from an account other than what is listed here will be subject to a hold and return.

Bank Name *

Account Number (Last 4 Digits) *

Name as Registered on Bank Account *

(Must be in name of client)

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Program Information

Describe who will receive payments and for what purpose. *

Describe how payees will be advised of any possible study related payments. *

Describe the process that will be used to verify the identities of payees *

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Certification of Beneficial Owner(s)

The information contained in this certification is sought pursuant to Section 1020.230 of Title 31 of the United States Code of Federal Regulations (31 CFR 1020.230). The OMB control number for this information collection is 1506-0070.

Controlling Interest: (Executive Officer or Senior Manager)

The following information is required for one individual with significant responsibility for managing the legal entity listed above such as a CEO, CFO, COO, Managing Member, General Partner, President, Vice President, Treasurer or another individual who regularly performs similar functions.

Name *

Title *

Residential/Business Address *

who Describe (if

Date of Birth *

SSN/Passport # *

Equity Interest: (25% or more)

The following information is required for any individuals, who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed on page 2. If an owner is a legal entity, provide ownership information for that legal entity as well.

Does any individual or legal entity owner meet this definition?

Name & Position/Title (if applicable) *

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a second individual or legal entity owner meet this definition?

Name & Position/Title (if applicable) *

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a third individual or legal entity owner meet this definition?

Name & Position/Title (if applicable) *

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a fourth individual or legal entity owner meet this definition?

Name & Position/Title (if applicable) *

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Is the legal entity company listed on page 2 a subsidiary of another company? *

Parent Company Name

Parent Company Address

Ultimate Beneficial Owner(s)

List any individuals who ultimately own 25 percent or more of the equity interests of the legal entity listed on page 2, even if they aren't listed on official documents.

Does any individual meet this definition? *

Ultimate Beneficial Owner #1 (25% or more)

Name *

Title (if applicable)

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a second individual meet this definition? *

Ultimate Beneficial Owner #2 (25% or more)

Name & Position/Title (if applicable) *

Title (if applicable)

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a third individual meet this definition? *

Ultimate Beneficial Owner #3 (25% or more)

Name *

Title (if applicable)

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Does a fourth individual meet this definition? *

Ultimate Beneficial Owner #4 (25% or more)

Name *

Position/Title (if applicable)

Residential/Business Address *

Date of Birth *

SSN/Passport # *

Attestation *

I hereby certify, to the best of my knowledge, that the beneficial ownership information provided above is complete and correct.

Customer Verification

It is recommended that the following documents be provided with the submission of your completed due diligence form to expedite the approval process. Please be advised that additional documentation may be requested during the course of due diligence.

1) For an individual: Unexpired government-issued identification evidencing nationality or residence and bearing a photograph or similar safeguard, such as a driver's license or passport.

2) For a person other than an individual (such as a corporation, partnership or trust): Documents showing the existence of the entity, such as a certificate of incorporation, certified articles of incorporation, a government-issued business licence, a partnership agreement or trust instrument.

Supporting Documents

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Save and Resume Later

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Email *

Contact Information

Company Information

Banking Information

Program Information

Certification of Beneficial Owner(s)

Controlling Interest: (Executive Officer or Senior Manager)

Equity Interest: (25% or more)

Ultimate Beneficial Owner(s)

Ultimate Beneficial Owner #1 (25% or more)

Ultimate Beneficial Owner #2 (25% or more)

Ultimate Beneficial Owner #3 (25% or more)

Ultimate Beneficial Owner #4 (25% or more)

Customer Verification

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