B01 – Beneficial Ownership Declaration Form (DOCX)
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BO
BENEFICIAL OWNERSHIP (BO) DECLARATION FORM
IN ACCORDANCE WITH THE COMPANIES AMENDMENT ACT NO.4 OF 2023, CLOSE CORPORATION AMENDMENT ACT NO. 5 OF 2023 & FINANCIAL INTELLIGENCE ACT 2012
PLEASE READ THE INSTRUCTIONS BELOW (PART C) AND TICK APPROPRIATELY
COMPLETE FORM WITH BLACK INK IN BLOCK LETTERS – NO ABBREVIATIONS
PART A – ENTITY PARTICULARS
• PURPOSE OF BENEFICIAL OWNERSHIP INFORMATION SUBMISSION (PLEASE TICK)
REGISTRATION OF NEW COMPANY
REGISTRATION OF NEW CLOSE CORPORATION
SUBMISSION OF ANNUAL RETURNS / DUTY
COMPANY/CLOSE CORPORATION UPDATES / BO UPDATES
• ENTITY INFORMATION
I. FULL LEGAL NAME OF ENTITY:
II. TIN OF ENTITY (IF ANY):
III. ENTITY REGISTRATION NUMBER (IF ANY):
IV. COUNTRY OF INCORPORATION:
• TYPE OF ENTITY (PLEASE TICK AGAINST THE CORRECT BOX)
PUBLIC COMPANY (LTD)
PRIVATE COMPANY (PTY (LTD))
SECTION 21 COMPANY (NGO)
FOREIGN ENTITY
CLOSE CORPORATION
• BENEFICIAL OWNERS (SEE INSTRUCTIONS ON PAGE 4)
THE ABOVE-MENTIONED ENTITY HAS THE FOLLOWING BENEFICIAL OWNERS [Please see Part C (2) (e)]
NAME OF BENEFICIAL OWNER
TYPE OF BENEFICIAL OWNERSHIP
(TICK ALL APPLICABLE COLUMN FOR EACH BENEFICIAL OWNER)
1
2
3
4
5
6
7
8
PART B – BENEFICIAL OWNER PARTICULARS [IF MORE THAN ONE BENEFICIAL OWNER, PLEASE PRINT AND COMPLETE PART B FOR EACH BENEFICIAL OWNER]
• BENEFICIAL OWNER PARTICULARS
• FIRST NAME:
II. SURNAME:
III. ANY PREVIOUS NAME (E.G., MAIDEN NAME):
IV. DATE OF BIRTH (DD-MM-YYYY):
V. PLACE OF BIRTH:
VI. NATIONALITY:
VII. RESIDENTIAL ADDRESS (INCLUDING ERF, STREET NAME, CITY,
STATE AND COUNTRY))
VIII. BUSINESS ADDRESS (INCLUDING ERF, STREET NAME,
CITY AND COUNTRY)
X. TAX IDENTIFICATION NUMBER (TIN). (IF APPLICABLE):
XI. TELEPHONE/MOBILE NUMBER:
XII. EMAIL ADDRESS:
XIII. PRIMARY IDENTIFICATION TYPE (SEE INSTRUCTIONS):
XIV. PRIMARY IDENTIFICATION NUMBER (SEE INSTRUCTIONS):
XV. IDENTIFICATION ISSUING COUNTRY/ STATE/REGION:
XVI. PLACE OF WORK AND POSITION HELD:
2. DATE BENEFICIAL OWNERSHIP COMMENCED
D
D
M
M
Y
Y
Y
Y
3. DATE BENEFICIAL OWNERSHIP CEASED
DECLARATION
1. I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
NAME OF DIRECTOR/SHAREHOLDER/MEMBER/BENEFICIAL OWNER: ______________________________________________________
[DELETE WHERE NOT APPLICABLE]
SIGNATURE: DATE (DDMMYYYY):
2. I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL INFORMATION PROVIDED IN THE ABOVE BENEFICIAL OWNERSHIP DECLARATION IS ACCURATE AND RELIABLE.
NAME OF ACCOUNTABLE INSTITUTION:
POSITION:
*IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.
NAME OF ACCOUNTABLE INSTITUTION:
POSITION:
*IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.
NAME OF AUTHORIZED STAFF:
NAME OF AUTHORIZED STAFF:
DATE (DDMMYYYY):
DATE (DDMMYYYY):
SIGNATURE:
SIGNATURE:
OFFICIAL USE ONLY [TO BE COMPLETED BY BIPA OFFICIAL]
NAME OF REGISTRATION OFFICER:
OFFICIAL USE ONLY [TO BE COMPLETED BY BIPA OFFICIAL]
NAME OF REGISTRATION OFFICER:
SIGNATURE:
SIGNATURE:
DATE (DDMMYYY):
DATE (DDMMYYY):
Part C (COMPLETION NOTES)
• INSTRUCTIONS
• Complete all relevant sections in block letters.
• Complete the form in black ink only.
• Any information that is not originally in the Latin alphabet, please use a recognised transliteration into the Latin alphabet.
• Spell out all words - No abbreviations.
• ALL mandatory fields must be completed.
• Attach certified or notarised proof of identity copy not older than 6 months for each Beneficial Owner.
• Attach proof of Registration with Accountable Institution/ FIC.
• EXPLANATORY NOTES
• What is this form?
This form is the Beneficial Ownership Declaration Form used for the purpose of collecting beneficial ownership information on legal persons registered or to be registered with BIPA. The form consists of 3 Sections, Section A consist of Company information and the type of beneficial ownership, Section B consist of Beneficial Owner’s particular and the attestation and Section C consists of the completion notes.
• Who should complete this form?
All existing companies and close corporations or companies and close corporations that are to be registered with BIPA must complete this form.
• When should this form be submitted to BIPA?
The Beneficial Ownership Declaration form must be submitted to BIPA at:
• registration of a company or close corporation;
• the end of the company or close corporation’s financial year end together with the annual returns; and
• within seven (7) days after a material change to the beneficial ownership of a company or close corporation
• Who is a Beneficial Owner?
Beneficial owner is the natural person (s) who ultimately owns or controls company or close corporations or the natural person on whose behalf a transaction is being conducted. It also includes those natural persons who exercise ultimate effective control over a legal person. Only a natural person can be an ultimate beneficial owner, and more than one natural person be the ultimate beneficial owner of a given legal person.
• Type of Beneficial Ownership.
FOR EACH BENEFICIAL OWNER, PLEASE TICK ALL APPLICABLE COLUMN TO INDICATE THE TYPE OF BENEFICIAL OWNERSHIP (NATURE OF INTEREST) [See Part B]
The following are the type of beneficial ownership:(All Potential Beneficial Owners should be tested against all categories (1-8)
• A natural person who directly or indirectly or through a trust, other legal person or other legal arrangements holds 25 percent or more of the shares, voting rights or other ownership interest in the legal person;
• A natural person who holds the position of a senior managing in the legal person;(Only select when category 1 is not applicable,)
• A natural person or through a trust, other legal person or other legal arrangements who jointly exercise direct or indirect control over the legal person;
• A natural person who directly or indirectly controls several legal persons and holds a combination of 25 percent or more of shares, voting right or ownership interest in the legal persons;
• A natural person who has the right, directly or indirectly, to appoint or remove a majority of the board of directors of the legal person;
• A natural person who has the power to materially influence the decision-making or policy of the legal person;
• A natural person who derives substantive economic benefits, including dividends, rights to profit, enjoyment of assets of the legal person or ability to use significant assets of the legal person, even if the person has no other formal link to the legal person; or
• A natural person who has influence or ultimate control over the legal person through any other means.
• Who is an Accountable Institution?
An Accountable Institution is a:
• Legal practitioner who acts on behalf of a client to create, operate or manage a legal person;
• Accountants and Auditors who act on behalf of a client to create, operate or manage a legal person;
• Company Service Providers who do the following:
• Acting as a formation agent of legal persons (Companies and Close Corporations)
• Acting as (or arranging for another person to act as) a director of a company
• Acting as a secretary of a company
• Acting as (or arranging for another person to act as) a nominee shareholder for another person
• Provide a registered office, business address or office accommodation, correspondence or administrative address of a company
• What are the consequences for late submission or non-submission of the Beneficial Ownership form?
• The Registrar will issue a written directive instructing the entity to submit the Beneficial Ownership information.
• If an entity or person fails to comply with the Directive, the Registrar shall impose a financial penalty
not exceeding N$ 50 000 and a financial penalty not exceeding N$ 1000 for every day of non-compliance.
• The Registrar shall list the entity on an inactive list and thereafter deregister the entity six months after the date the entity was listed.
• What are the consequences for providing false or misleading BO information, withholding BO information and making false entry into the BO registry?
Conviction to a fine not exceeding N$ 10 000 000.00 or imprisonment for a period not exceeding 10 years or conviction to both a fine and imprisonment.