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Crypto Exchange Customer KYC Form
Individual · Standard · Crypto-assets, Onboarded remotely · EU AMLR

1. Personal details

Full legal name (all first names and surnames)*Art 22(1)(a)(i)
Other names you have used (former names, aliases)
Date of birth*Art 22(1)(a)(ii)
DD / MM / YYYY
Place of birth (city and country)*Art 22(1)(a)(ii)
Nationality (list every nationality you hold)*Art 22(1)(a)(iii)
National identification number or passport number, with issuing country*Art 22(1)(a)(iii)
Residential address*Art 22(1)(a)(iv)
Country of residence*Art 22(1)(a)(iv)
Select a country ▾
Copy of your passport or national identity card (front and back)*Art 22(6)
Upload passport or national ID card, front and back
Email address*
Phone number

2. Management and authority

Person completing this form for the customer: full name, role and date of birth*Art 20(1)(i)
Proof of authority (power of attorney or board resolution), if acting for someone elseArt 20(1)(i)
Upload a file (PDF, JPG or PNG)

3. Occupation and business

Employment status*Art 20(1)(e), 25(e)
EmployedSelf-employedBusiness ownerRetiredStudentNot workingOther
Occupation, employer or business name, and sectorArt 25(e)

4. Purpose and expected activity

Why do you want to open this relationship, and what will you use it for?*Art 20(1)(c), 25(a)
Which products or services will you use?*Art 25(a)
Current or business accountDomestic paymentsInternational paymentsCurrency exchangeCardsLendingSavings or investmentsCrypto-assetsOther
Expected value of transactions per month (EUR or equivalent)*Art 25(b)
Under 10,00010,000 to 50,00050,000 to 250,000250,000 to 1,000,000Over 1,000,000
Expected number of transactions per monthArt 25(b)
Under 1010 to 5050 to 250Over 250
Main countries you will send money to or receive it from*Art 25(d)
Will you carry out transactions on behalf of, or for the benefit of, anyone else?*Art 20(1)(h)
No, only for myself or this organisationYes, explain below

5. Source of funds and wealth

Where will the money for this relationship come from?*Art 25(c)
Salary or pensionBusiness incomeSavingsInvestmentsSale of property or assetsInheritance or giftLoanDonations or grantsOther
Bank and country of the account the funds will come from

6. Crypto-assets

Wallet addresses you will send from or receive to, and whether each is self-hosted or held at an exchange*Art 40
How did you acquire your crypto-assets?*Art 25(c)
Bought on an exchangeMining or stakingPayment for goods or servicesTrading profitsOther
Exchanges or service providers you use
Do you use privacy coins, mixers or other tools that hide transaction history?*Art 79
NoYes, explain below

7. Politically exposed persons

Do you, or does any beneficial owner, director or authorised signatory, hold a prominent public function now or in the last 12 months?*Art 20(1)(g), 42, 45
NoYes, give details below
Is any of them a family member or known close associate of such a person?*Art 46
NoYes, give details below
If yes: name, position, country and dates in officeArt 42

8. Sanctions and other declarations

Are you, or is any beneficial owner, director or related company, named on a sanctions list (UN, EU, UK or US)?*Art 20(1)(d)
NoYes, explain below
Do you do business in, with, or through comprehensively sanctioned countries or regions?*
NoYes, explain below

9. Tax residency

Countries of tax residence
Tax identification numberArt 22(1)(a)(iv), (b)(iii)
Are you a US person for tax purposes?
NoYes

10. Documents to provide

Proof of address dated in the last 3 months (utility bill or bank statement)
Upload a file (PDF, JPG or PNG)
A selfie or short video, or an electronic ID at substantial or high assurance*Art 22(6)(b)
Upload a file (PDF, JPG or PNG)

11. Declaration and signature

I confirm the information in this form is true and complete, and I will tell you promptly if it changes.*Art 26
I agree
I understand my information will be used to meet anti-money laundering obligations and kept for at least 5 years after the relationship ends.*Art 77
I agree
Name, position and signature*
Date*
DD / MM / YYYY

12. For internal use

Screening: sanctions, PEP and adverse media for the customer, beneficial owners and directors (date and result)*Art 20(1)(d), (g)
Customer risk rating and reason*
LowMediumHigh
Next review date*Art 26(2)
DD / MM / YYYY
Reviewed by (name and date)*

About this template

A KYC form for customers of a crypto-asset exchange or wallet. It adds wallet addresses, how the customer acquired their crypto-assets and the use of privacy coins or mixers.

When to use it

Use it to onboard retail users of a crypto-asset service provider.

Core requirements covered

9 of 9 core requirements of EU AMLR.

  • Identify and verify the customer✓
  • Verify identity from a document or eID✓
  • Purpose and intended nature✓
  • Targeted financial sanctions✓
  • Nature of the customer's business✓
  • Ongoing monitoring✓
  • Politically exposed persons✓
  • On behalf of someone else✓
  • Authority of the person acting✓

Edit it before you use it

Every question can be removed, reworded, reordered or made optional in the editor. You can add your own questions and fields too.

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