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US CIP Customer Identification Form
Individual · Standard · US BSA / FinCEN

1. Personal details

Full legal name (all first names and surnames)*1020.220(a)(2)(i)
Other names you have used (former names, aliases)
Date of birth*1020.220(a)(2)(i)
DD / MM / YYYY
Place of birth (city and country)*
Nationality (list every nationality you hold)*
National identification number or passport number, with issuing country*1020.220(a)(2)(i)
Residential address*1020.220(a)(2)(i)
Country of residence*
Select a country ▾
Copy of your passport or national identity card (front and back)*1020.220(a)(2)(ii)
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*
Proof of authority (power of attorney or board resolution), if acting for someone else
Upload a file (PDF, JPG or PNG)

3. Occupation and business

Employment status*
EmployedSelf-employedBusiness ownerRetiredStudentNot workingOther
Occupation, employer or business name, and sector

4. Purpose and expected activity

Why do you want to open this relationship, and what will you use it for?*1020.210
Which products or services will you use?*
Current or business accountDomestic paymentsInternational paymentsCurrency exchangeCardsLendingSavings or investmentsCrypto-assetsOther
Expected value of transactions per month (EUR or equivalent)*
Under 10,00010,000 to 50,00050,000 to 250,000250,000 to 1,000,000Over 1,000,000
Expected number of transactions per month
Under 1010 to 5050 to 250Over 250
Main countries you will send money to or receive it from*
Will you carry out transactions on behalf of, or for the benefit of, anyone else?*
No, only for myself or this organisationYes, explain below

5. Source of funds and wealth

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

6. 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?*1010.620
NoYes, give details below
Is any of them a family member or known close associate of such a person?*
NoYes, give details below
If yes: name, position, country and dates in office

7. 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)?*OFAC
NoYes, explain below
Do you do business in, with, or through comprehensively sanctioned countries or regions?*
NoYes, explain below

8. Tax residency

Countries of tax residence
Tax identification number1020.220(a)(2)(i)
Are you a US person for tax purposes?
NoYes

9. Documents to provide

Proof of address dated in the last 3 months (utility bill or bank statement)
Upload a file (PDF, JPG or PNG)

10. Declaration and signature

I confirm the information in this form is true and complete, and I will tell you promptly if it changes.*
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.*
I agree
Name, position and signature*
Date*
DD / MM / YYYY

11. For internal use

Screening: sanctions, PEP and adverse media for the customer, beneficial owners and directors (date and result)*OFAC
Customer risk rating and reason*1020.210
LowMediumHigh
Next review date*1020.210
DD / MM / YYYY
Reviewed by (name and date)*

About this template

A customer identification program form under the US Bank Secrecy Act. It collects name, date of birth, address and identification number, and records how identity was verified.

When to use it

Use it to open accounts for individuals at a US bank, broker-dealer or their fintech partners.

Core requirements covered

5 of 5 core requirements of US BSA / FinCEN.

  • CIP: name, date of birth, address, ID number✓
  • CIP: verify identity✓
  • Nature and purpose of the relationship✓
  • OFAC sanctions✓
  • Customer risk profile and monitoring✓

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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