[LII note: The following content was originally published as an image, which can be viewed at https://www.ecfr.gov/graphics/er28se17.007.gif. We extracted the text from a machine-readable version at https://www.fdic.gov/regulations/laws/rules/8000-1400.html#fdic8000fraappendixa.]
Name Date of Birth Address (Residential or Business Street Address) For U.S. Persons: Social Security Number For Foreign Persons: Passport Number and Country of Issuance, or other similar identification number1
       
       
       
       

(If no individual meets this definition, please write "Not Applicable.")

d.  The following information for one individual with significant responsibility for managing the legal entity listed above, such as:

|B Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Vice President, Treasurer); or

|B functions.

(If appropriate, an individual listed under section (c) above may also be listed in this section (d)).

[LII note: end substituted content]