Beneficial Owner Information Report (BOI) REQUIRED INFORMATION TO COMPLETE YOUR BENEFICIAL OWNER INFORMATION REPORT (BOI) Is your Company Exempt? (check all boxes that apply Is your Company a Corporation or LLC? Is your Company publically traded? Does your company employ more than 20 employees in the US? Last year, did your company report taxable and domestic revenue of greater than $5M? Does your company have a business office in the US? Filing Type: Initial Report Update Prior Report Previously Filed, now Newly Exempt Company Information Name / Federal ID (EIN):* Primary Contact / Phone:* Contact Email:* List Any DBA's: Business Address Address (No PO):* City / State / Zip:* --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Formation Jurisdiction City / State / Zip:* --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ` Date Formed:* Company Applicant Primary Company contact -- This is ONLY for Companies formed after 1/1/2024. If formed prior to 1/1/2024 skip to Beneficial Owners section below. Full Name / DOB:* Address:* City / State / Zip:* --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers License or Passport:* Upload ID: Beneficial Owner: ONLY report individuals who excersize substancial control over a reporting company (CEO, CFO, President, etc. or an important decision maker) OR an individual who owns or controls at least 25% of the company. Name / Control / DOB:* Address:* City / State / Zip:* --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers License or Passport:* Upload ID: Additional Beneficial Owner: Name / Control / DOB: Address: City / State / Zip: --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers License or Passport:* Upload ID: Additional Beneficial Owner: Name / Control / DOB: Address: City / State / Zip: --- Select State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers License or Passport:* Upload ID: Authorization: Company Name:* (Company) authorizes API Processing - Licensing, Inc. (API) to file its' initial filing report required as part of the Corporate Transparency Act (CTA) dated January 1, 2024. The company has provided certain information to API to file the Beneficial Owner Information (BOI) to the Financial Crimes Enforcement Network (FINCEN). API will rely solely on the information provided by Company; API will not conduct any investigation or fact-finding to complete the report. Company understands that any future changes made to the Company, i.e., ownership, address changes, or name changes will require a separate filing which is not part of this initial filing and would be subject to additional fees by API. Your Signature: Authorized Name / Date:* Submit Information
