Text extracted via OCR from the original document. May contain errors from the scanning process.
EFTA01425965
Deutsche Bank
Wealth Management
Certification Regarding Beneficial Owners Of Lega
Entity Customers
I. General instructions
What is this form?
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., the
beneficial owners) helps law enforcement investigate
and prosecute these crimes.
Who has to complete this form?
This form must be completed by the person opening a new account on behalf of
a legal entity with any of the following U.S.
financial institutions: (i) a bank or credit union; (ii) a broker or dealer
in securities; (iii) a mutual fund; (iv) a futures commission
merchant; or (v) an introducing broker in commodities.
For the purposes of this form, a legal entity includes a corporation,
limited liability company, or other entity that is created
by a filing of a public document with a Secretary of State or similar
office, a general partnership, and any similar business
entity formed in the United States or a foreign country. Legal entity does
not include sole proprietorships, unincorporated
associations, or natural persons opening accounts on their own behalf.
What information do I have to provide?
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 Non-U.S. Persons) for the following
individuals (i.e., the beneficial owners):
• Each individual, if any, who owns, directly or indirectly, 25 percent or
more of the equity interests ofthe legal entity customer
(e.g., each natural person that owns 25 percent or more ofthe shares of a
corporation); and
• An individual with significant responsibility for managing the legal
entity customer (e.g., a Chief Executive Officer,
Chief Financial Officer, Chief Operating Officer, Managing Member, Genera!
Partner, President Vice President, orTreasurer).
The number of individuals that satisfy this definition of "beneficial owner"
may vary. Under section (i), depending on the
factual circumstances, up to four individuals (but as few as zero) may need
to be identified. Regardless of the number
of individuals identified under section (i), you must provide the
identifying information of one individual under section
EFTA01425966
(ii). It is possible that in some circumstances the same individual might be
identified under both sections (e.g., the President
of Acme. Inc. who also holds a 30% equity interest). Thus, a completed form
will contain the identifying information of at least
one individual (under section (ii)). and up to five individuals (i.e., one
individual under section (ii) and four 25 percent equity
holders under section (i)).
The financial institution may also ask to see a copy of a driver's license
or other identifying document for each beneficial
owner listed on this form.
WM189666 026619.051818
Page 1 of 2
II. Certification of beneficial owner(s)
Persons opening an account on behalf of a legal entity must provide the
following information:
a. Name and Title of Natural Person Opening Account:
Darren K. Indyke, Treasurer
b. Name of Legal Entity. Type of Legal Entity, and Address of Legal Entity
for Which the Account is Being Opened:
Gratitude America, Ltd., a U.S. Virgin Islands not-for-profit corporation
and 501(c)(3) private foundation
6100 Red Hook Quarter, B3
St. Thomas, USVI 00802
I
c. The following information for each individual, if any. 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 above;
Name
Date of Birth
Legal Address
For U.S. Persons:
Social Security
Number
For Non-U.S. Persons:
(See footnote i for alternatives
to Social Security Number)
Not Applicable
For Non-U.S. Persons, in addition to a Social Security Number or a Passport
Number with Country of Issuance, an alien identification card number, or
number
and country of issuance of any other government-issued document evidencing
nationality or residence and bearing a photograph or similar safeguard should
be provided.
(If no individual meets this definition, please write "Not Applicable.')
d. The following information for one individual with significant
responsibility for managing the legal entity listed above,
such as:
• An executive officer or senior manager (e.g.. Chief Executive Officer,
Chief Financial Officer. Chief Operating Officer.
Managing Member. General Partner. President, Vice President. Treasurer); or
EFTA01425967
• Any other individual who regularly performs similar functions.
(If appropriate, an individual listed under section (c) above may also be
listed in this section (d)).
Name
Date of Birth
Legal Address
For U.S. Persons:
Social Security
Number
For Non-U.S. Persons;
(See footnote 1 for alternatives
to Social Security Number)
Darren K. Indyke
' For Non-U.S. Persons, in addition to a Social Security Number or a
Passport Number with Countiv of Issuance, an alien identification card
number, or number
and country of issuance of any other government-issued document evidencing
nationality or residence and bearing a photograph or similar safeguard should
be provided.
Darren K. Indyke
(name of natural person opening the account), hereby certify, to the best of
my knowledge, that the information provided above is complete and correct.
Signature VeriGcmipni
August 15, 2018
7
7
Signature
Date
Nam
Title:
Date:
02018 Deutsche Bank AG. All rights reserved. WM189666 026819.051318
Legal Entity Identifier (Optional)
/r
EFTA01425968