Accredited Investor Questionnaire

# Investor Suitability Questionnaire ## Investment Opportunity **Issuing Company:** ___________ (the "**Company**") **Type of Securities:** ___________ This Questionnaire is being distributed to certain individuals and entities which may be offered the opportunity to purchase the above-described securities (the "**Securities**") of the Company. The purpose of this Questionnaire is to assure the Company that all such offers and purchases will meet the standards imposed by the Securities Act of 1933, as amended (the "**Act**\"), and applicable state securities laws. All answers will be kept confidential. However, by signing this Questionnaire, the undersigned agrees that this information may be provided by the Company to its legal and financial advisors, and the Company and such advisors may rely on the information set forth in this Questionnaire for purposes of complying with all applicable securities laws. **The undersigned represents that the information contained herein is complete and accurate and will notify the Company of any material change prior to investment.** ## Section A — Accredited Investor Certification (Individual) The undersigned makes one of the following representations regarding its income, net worth, status as a "family client" of a "family office," and/or certain professional certifications or designations **and has checked the applicable representation**: ___________ The undersigned's income[^1] during each of the last two years exceeded $200,000 or, if the undersigned is married or has a spousal equivalent[^2], the joint income of the undersigned and the undersigned's spouse or spousal equivalent, as applicable, during each of the last two years exceeded $300,000, and the undersigned reasonably expects the undersigned's income, from all sources during this year, will exceed $200,000 or, if the undersigned is married or has a spousal equivalent, the joint income of the undersigned and the undersigned's spouse or spousal equivalent, as applicable, from all sources during this year will exceed $300,000. ___________ The undersigned's net worth[^3], including the net worth of the undersigned's spouse or spousal equivalent, as applicable, is in excess of $1,000,000 (excluding the value of the undersigned's primary residence). ___________ The undersigned is a holder in good standing of one or more of the following certifications or designations administered by the Financial Industry Regulatory Authority, Inc. (FINRA): the Licensed General Securities Representative (Series 7), Licensed Investment Adviser Representative (Series 65), or Licensed Private Securities Offerings Representative (Series 82). ___________ The undersigned is a "family client," as defined in rule 202(a)(11)(G)-1 under the Investment Advisers Act of 1940, as amended (the "**Advisers Act**"), of a family office as defined in rule 202(a)(11)(G)-1 under the Advisers Act, (i) with assets under management in excess of $5,000,000, (ii) that is not formed for the specific purpose of acquiring the securities offered, and (iii) whose prospective investment is directed by a person who has such knowledge and experience in financial and business matters that such family office is capable of evaluating the merits and risks of the prospective investment. ___________ The undersigned cannot make any of the representations set forth above. --- ## Section B — Accredited Investor Certification (Entity) The undersigned makes one of the following representations regarding its net worth and certain related matters **and has checked the applicable representation**: ___________ The undersigned is a trust with total assets in excess of $5,000,000 whose purchase is directed by a person with such knowledge and experience in financial and business matters that such person is capable of evaluating the merits and risks of the prospective investment. ___________ The undersigned is a bank, an investment adviser registered pursuant to Section 203 of the Advisers Act or registered pursuant to the laws of a state, any investment adviser relying on the exemption from registering with the SEC under Section 203(l) or (m) of the Advisers Act, an insurance company, an investment company registered under the United States Investment Company Act of 1940, as amended, a broker or dealer registered pursuant to Section 15 of the United States Securities Exchange Act of 1934, as amended, a business development company, a Small Business Investment Company licensed by the United States Small Business Administration, a Rural Business Investment Company as defined in Section 384A of the Consolidated Farm and Rural Development Act, as amended, a plan with total assets in excess of $5,000,000 established and maintained by a state for the benefit of its employees, or a private business development company as defined in Section 202(a)(22) of the Advisers Act. ___________ The undersigned is an employee benefit plan and either all investment decisions are made by a bank, savings and loan association, insurance company, or registered investment advisor, or the undersigned has total assets in excess of $5,000,000, or if such plan is a self-directed plan, investment decisions are made solely by persons who are accredited investors.