The information collected in this document is required by the Securities and Exchange Commission (“SEC”) for certain Regulation D offerings under the Securities Act of 1933. The purpose of the document is to collect information from potential investors to determine an investor’s financial status and experience, for compliance with Regulation D.
Investor Questionnaire This questionnaire should be filled out by potential investors to determine whether they meet various federal and state requirements to invest in a nonpublic offering. This questionnaire contains two (2) sections. The first section is to be completed by all investors and collects basic information. The second section is to be completed by accredited investors only and requires them to disclose their current investments and financial standing. This questionnaire is ideal for individuals or small businesses that want to determine the viability of investors for a nonpublic offering. Investor Questionnaire The information provided will be used to determine whether you meet the standards for participation in a nonpublic offering under Section 4(2) of the Securities Act of 1933 and various state securities laws. The information you provide will be treated confidentially. However, you agree that the information may be released to appropriate parties as provided by law. Section 1. General Information — to be completed by all potential investors For Trusts, Corporate, or Company potential investors, the following questions should be completed with regard to the individuals making the investment decision. 1. Name: ________________________________ 2. Address: Business: ________________________________________ Residence: _______________________________________ 3. Contact Information: Business Phone: _______________________________ Mobile Phone: _________________________________ Home Phone: _________________________________ E-mail: _______________________________________ 4. Personal Information (to be completed by individual investors): Date of Birth: ______________________________ Marital Status (please circle one): Married Divorced Single Widowed Social Security Number: _________________________________ 5. Employment Information: Employer: _______________________________________ Nature/Type of Business: ______________________________ Position Held: _______________________________________ Dates Employed: _____________________________________ 6. Business Entity Information (to be completed by investors who are a business entity): Date of organization or incorporation: _____________________ T.I.N. and /or E.I.N. of Business: ________________________________ State of Business: ________________________________ Legal form of entity (please circle one): Corporation General Partnership Limited Partnership Limited Liability Corporation 7. Trust Information (to be completed by investors who are a Trust) Revocable Trust (If the trust does not have $5 million in assets or if the trust was specifically formed for the purpose of this investment, identify each grantor, and indicate under what circumstances the trust is revocable by the grantor. Also, indicate the category that describes how each such grantor is qualified as an Accredited Investor): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (Continue on a separate piece of paper, if necessary.) Other type of Trust (indicate type of trust and, for trusts other than pension trusts, name the grantors and beneficiaries): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (Continue on a separate piece of paper, if necessary.) Section 2. Accredited Investor- to be completed by accredited investors © Copyright 2011 Docstoc Inc. 3 I certify that I meet the Accredited Investor condition(s), as defined by Rule 501 of Regulation D of the Securities Act of 1933, set forth below by initialing the applicable box. ______ A bank as defined in section 3(a)(2) of the Act, or any savings and loan association or other institution as defined in section 3(a)(5)(A) of the Act whether acting in its individual or fiduciary capacity; any broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934. _______ An insurance company as defined in section 2(a)(13) of the Act. _______ An investment company registered under the Investment Company Act of 1940 or a business development company as defined in section 2(a)(48) of that Act. _______ A Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1958. _______ A plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000. _______ An employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, if the investment decision is made by a plan fiduciary, as defined in section 3(21) of such act, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are accredited investors. _______ A private business development company as defined in section 202(a)(22) of the Investment Advisers Act of 1940. _______ An organization described in section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000. _______ A director, executive officer, or general partner of the issuer of the securities being offered or sold, or any director, executive officer, or general partner of a general partner of that issuer. _______ A natural person whose individual net worth, or joint net worth with that person's spouse, at the time of his purchase exceeds $1,000,000. _______ A natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year. © Copyright 2011 Docstoc Inc. 4 _______ A trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii). _______ An entity in which all of the equity owners are accredited investors as defined by Rule 501 of Regulation D of the Securities Act of 1933. The undersigned hereby certifies that the above and foregoing answers are true and complete to the best of his or her knowledge, information, and belief. Date: __________________________ By: ______________________________________ Printed Name: _____________________________ © Copyright 2011 Docstoc Inc. 5
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