Name: Lippitt O’Keefe, PLLC
Address: 370 E. Maple Road, Third Floor,, Birmingham, MI, 48009

Beneficial Owner Reporting Form

Lippitt O'Keefe Beneficial Owner Reporting

Please complete the information below so that we may assist you in complying with the new beneficial owner reporting requirements set forth by the US federal government.

Email
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What is the full name of your company?
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What is the trade name or "doing business as" (DBA) name of your company? Please answer "N/A" if your company does not have a DBA.
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What is your company's EIN?
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Which State is your company organized in?
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What is the address of the principal place of your business in the United States?
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Under federal statutes, a "beneficial owner" is any individual who, directly or indirectly exercises substantial control over the company or who owns or controls at least 25 percent of the ownership interests of the company. How many beneficial owners does your company have?
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Please provide the full legal name for Beneficial Owner #1
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Please provide a photo of the driver's license or US Passport for Beneficial Owner #1
Does the driver's license or passport photo uploaded show the true birthdate and current residential address for Beneficial Owner #1? If not, please provide that information in this section.
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Please provide the full legal name for Beneficial Owner #2
Please provide a photo of the driver's license or US Passport for Beneficial Owner #2. If not applicable, please skip this question
Does the driver's license or passport photo uploaded show the true birthdate and current residential address for Beneficial Owner #2? If not, please provide that information in this section.
Please provide the full legal name for Beneficial Owner #3
Please provide a photo of the driver's license or US Passport for Beneficial Owner #3. If not applicable, please skip this question.
Does the driver's license or passport photo uploaded show the true birthdate and current residential address for Beneficial Owner #3? If not, please provide that information in this section.
If your company has more than three (3) beneficial owners, please send an email indicating as such to locompliant@gmail.com.
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Please confirm that you have reviewed your responses and that they are true, correct and complete.
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Please confirm that you would like Lippitt O'Keefe or one of its agents to file your Beneficial Owner Information with the United States Federal Government.
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