3. Your Information
First Name [Estate/Minor] M.I. Last Name
Social Security or Taxpayer ID Number Email
Date of Birth MM DD YYYY Daytime Phone Extension
Residential Address (where you live) This is your legal address used for tax reporting.
Street Address
City State ZIP
Mailing Address May be a P.O. box, drop box, or c/o location
Same as legal / residential address Default if no other information indicated below.
Mailing Address
City State ZIP
Citizenship
I am a U.S. Citizen Skip to “Income Source.”
Indicate your
citizenship status.
I am a Foreign Citizen. Information in this box must be completed.
Permanent U.S. resident Non-permanent U.S. resident Non-resident of U.S.
Country of Citizenship Country of Tax Residency
City, State/Province, and Country of Birth
Check one and attach DHS Permanent Resident Card Employment Authorization Document Passport
copy of government ID
showing number and U.S. driver’s license Foreign national identity document
photo. To claim non-U.S. ID Number Country of Issuance, If Not U.S. State, If Driver’s License
tax status, also complete
and submit an IRS Form
W-8BEN.
Income Source
Check one and Employed: Self-employed:
provide information. Occupation Employer Leave blank if self-employed.
Industry regulations
require us to ask for
this information. Employer Address
City State/Province ZIP/Postal Code Country
Retired: Not employed:
Source of Income Pension, investments, spouse, etc.
Account owner must sign and date at the end of section 8. Your Information continues on next page.