Name of Legal Entity for Which the Account is Being Opened: 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:(If no individual meets this definition, please write Applicable.”) “Not Name Date of Birth Address For Foreign Persons: For U.S. Persons: Passport Number and Social Security Country of Issuance, or Number other similar identification number 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., Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or Any individual who regularly performs similar functions. (If appropriate, an individual listed section (c) above may also be listed in this section (d)). Name Date of Address For U.S. Persons: For Foreign Persons: Passport Number and Social Security Country of Issuance, or Number other similar identification number1 I, (name hereby certify, to the best of my of person opening account), knowledge, that the information provided above is complete and correct. Signature: Date: CHECKLIST FOR BENEFIT OR TRAGEDY ACCOUNTS
Name of Legal Entity for Which the Account is Being Opened: 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:(If no individual meets this definition, please write “Not Applicable.”) Name Date of Birth Address For U.S. Persons: Social Security Number For Foreign Persons: Passport Number and Country of Issuance, or other similar identification number 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., Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or Any individual who regularly performs similar functions. (If appropriate, an individual listed section (c) above may also be listed in this section (d)). Name Date of Address For U.S. Persons: Social Security Number For Foreign Persons: Passport Number and Country of Issuance, or other similar identification number1 I, (name of person opening account), hereby certify, to the best of my knowledge, that the information provided above is complete and correct. Signature: Date: CHECKLIST FOR BENEFIT OR TRAGEDY ACCOUNTS
DueHO2LG020516.docx