A. Identifying Information
B. Control Parties
a. List all individual(s) by their full legal name (in First Middle Last Name Order) with significant responsibility to control, manage or direct the counterparty:
b. Signatory for the counterparty: If Bilateral Agreements are used, the counterparty must ensure that the signer’s full legal name, title and date fields are clearly populated on the agreement.
C. Legal Entity Ownership
a. Please list each legal entity, if any who directly owns 25% or more of the equity interest of the counterparty (If no entity meets this definition, please right “Not Applicable:
D. Individual Ownership
a. Please list each individual, if any, who, directly or indirectly owns 25% or more of the equity interests of the counterparty (If no individual meets this definition, please write “Not Applicable”):
b. Provide the full legal name of the individual including middle name. Please note failure to provide full legal name may delay the onboarding process.
1. NEW EMPIRE CENTRAL CAPITAL FUND MANAGER reserve the right to require further information if deemed necessary
2. If applicable, an executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or any other individual who regularly performs similar functions.)
3. Individual with authority to act for the counterparty, NEW EMPIRE CENTRAL CAPITAL FUND MANAGER reserves the right to request a corporate or LLC resolution designating the individual’s authority to act, if applicable.
4. Through any contract, arrangement, understanding, relationship or otherwise
5. See FN 4
E. OFAC Sanctioned Countries
a. Please specify whether the counterparty is owned in the aggregate, directly or indirectly 50% or more by one or more OFAC blocked persons
b. Please specify whether the counterparty, its ultimate parent, or subsidiaries has a business relationship with any of the below listed countries. If none apply, please state "Not Applicable". If any of the countries apply, please explain the details of the business relationship. Additionally, please provide the approximate percentage of revenue derived from the country relative to the total revenue.
c. Please specify to which entity(ies) your responses apply
F. Proof of Identity Please attach a copy of your current Passport or Driver’s license
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