Private Equity Investments Checklist _____________________________________________
The information in this checklist must be provided to SELF DIRECTED IRA SERVICES, INC, prior to the purchase of a Private Equity Investment for your IRA.
1.) Direction of Investment Form – Be sure to complete all applicable sections, and sign the form as the Accountholder. (Copy of form attached). 2.) Funding Authorization Form – This form instructs SELF DIRECTED IRA SERVICES, INC., on how you want the payment to be made (wire or check), how it is to be sent (regular mail, overnight), and to what address. 3.) Account Holder Representation Form– Must be completed for each investment. 4.) Subscription Document, Purchase Agreement, Investment Agreement, or Shareholder Agreement (as provided to you by the Investment Provider) - Please sign as the Accountholder, and provide all pages of the document. If these documents are not applicable, please provide the operating agreement, limited partnership agreement, etc., and sign as the Accountholder. The owner/buyer registration should be listed as “SELF DIRECTED IRA SERVICES, INC., Custodian, FBO Accountholder Name, IRA #”. 5.) Private Placement Memorandum or other offering documents related to the investment. - These should be provided by the Investment Provider. 6.) Copy of the filed Articles of Incorporation, Certificate of Limited Partnership, Articles of Organization, or other corporate filings. - These should be provided by the Investment Provider. 7.) Private Investment Issuer Representation Form – This form should be completed and signed by the Investment Provider. (Copy of form attached).
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Direction of Investment – IRA
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To: Self Directed IRA Services (IRA Custodian) C/O Horizon Bank, 522 Congress Ave, STE 100 Austin, TX 78701 Type of IRA: ___Traditional ___Roth ___SEP ___SIMPLE
I_____________________________________________________________, do hereby certify that I am the accountholder or grantor of self-directed IRA #_____________ and in accordance therewith I am given the right to direct the investment of my account balance. I understand that I must comply with the IRA plan agreement’s written policy regarding self-direction. My social security number is _____________________.
I hereby direct the custodian/trustee to sell and/or liquidate the following assets in my account at the indicated terms, if any: 1) 2) 3) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
I hereby direct the custodian/trustee to purchase the following assets for my account at the indicated terms, if any: 1) 2) 3) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
I understand that my self-direction investment account shall be charged or credited as appropriate with the net earnings, gains, losses and expenses as well as appreciations or depreciations in market value of assets attributable to such account. I also understand that my account will be charged with any costs or expenses attributable to the establishment and/or maintenance of my self-directed investment account. I understand that the custodian/trustee shall not be responsible or liable for any loss or expense which may arise or result from compliance with any directions I may give. I understand the IRA custodian/trustee will have a reasonable amount of time to complete my instructions. I understand my election shall remain in effect until such time as I specifically revoke it.
Signed this ______ day of __________________, _________. (month) (year) Signature of Accountholder______________________________________________________________ The custodian/trustee acknowledges receipt of this direction of investment this _____day of __________________, _________. (month) (year). Signature of Custodian/Trustee_____________________________________________________________
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Funding Authorization Form
(If funding an investment, use this form in conjunction with our Direction of Investment form) ____________________________________________________________________________________________________
Accountholder Name_____________________________________________ IRA #________________ Name of Investment being funded___________________________________ Amount $______________
Funding is to be made by (choose one option below):
Check ____ Regular Mail_____ Overnight ______
Wire____ Bank Name______ __________________________ Bank Phone #______________________________ ABA/Routing #_____________________________
Payee Name:______________________________ For credit to:_______________________________ Address: _________________________________ Account#__________________________________ Address:_________________________________ City:____________________________________ State:______ Zip:_____________ Domestic Wire Fee - $25 International Wire Fee - $50
Funding Authorization/Signature I agree to release, indemnify, and hold harmless Self Directed IRA Services, Inc. from any claims arising out of the payment authorized by this form. This includes, but is not limited to, claims that this payment is not legal, diversified, prudent, or proper. Self Directed IRA Services, Inc. will not be responsible to take any action should the investment become subject to default, including fraud, insolvency, bankruptcy, or other court order or legal process. Account Holder Printed Name________________________________________________ Account Holder Signature ___________________________________________________Date____________
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Account Holder Representation Form
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Accountholder Name_____________________________________________ IRA #________________ Name of Investment being funded___________________________________ Amount $______________
Account Holder MUST check ONE of the following options: 1) __________ By checking this option, I represent that I am not an officer of director of the offering entity and/or borrower of any affiliate thereof, and I am not related to any officer of director of the offering entity and/or borrower or any affiliate thereof. I also represent that my ownership of this entity, (combined with any family member or disqualified person) will be less than 50%.
2) __________ By checking this option, I represent and disclose that I am an officer or director of the offering entity and/or borrower of its affiliate, or that I am related to an officer or director of the offering entity and/or borrower or its affiliate. The nature of the relationship and the combined percentage of the entity owned by my IRA Account, any family member, or disqualified person is as follows:
Nature of Relationship:________________________________ Percentage Owned:____% (Please Note: If the number you place in this field is less than 50%, a legal opinion will be required before Self Directed IRA Services can process your investment. If the number is 50% or greater, the investment cannot be processed by Self Directed IRA Services, Inc.
____________________________________________ Account Holder Signature
_____________ Date
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PRIVATE INVESTMENT ISSUER REPRESENTATION LETTER
This form must be completed and signed by the Issuer/General Partner/Managing Member/Officer or Trustee of the Issuing Investment prior to any funds being invested. ________________________________________________________________________________________________________
1. The Issuer of the investment indemnifies SDIRA Services from any and all legal or financial damages, costs, etc that may result from legal actions involving the Investment or Issuer to the extent attributable to the fraud, gross negligence, or willful misconduct of the Issuer or the breach of this agreement for the diminution in value, lost profits, or other investment losses. Issuer represents that the debt instrument/certificate/ownership interest will be payable or registered to the IRA plan as follows: Self Directed IRA Services, Inc. Custodian FBO Accountholder Name, IRA #_______________ 522 Congress Ave, STE 100 Austin, TX 78701
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TAX ID 26-2637994
3. 4. 5. 6. Issuer agrees to forward to SDIRA Services, the original debt instrument, original stock certificate, LP/LLC certificate, or any other written purchase confirmation in the event that certificates are not issued. Issuer agrees to inform SDIRA Services promptly of any significant change in its legal structure, if it becomes insolvent, or of pending litigation seeking damages greater than $1,000,000. IRA investors will be provided with all offering documents (Subscription Documents, Prospectus, Private Placement Memorandum, LP Agreement, Operating Agreement, sample copy of debt instrument) with regard to the debt investment. Issuer agrees to send all income associated with the investment directly to SDIRA Services, in a timely manner. Issuer agrees that under no circumstances will the Issuer distribute principal monies or assets directly to SDIRA Services Account Holders. Issuer hereby indemnifies SDIRA Services and takes full responsibility for any tax, legal, or penalty damages associated with the direct distribution of monies or assets by the Issuer to the Account Holder. Issuer agrees that upon request from SDIRA Services, the debt instrument/certificate/ownership interest will be reregistered to a successor custodian or the account holder individually. Issuer agrees that SDIRA Services has not endorsed or approved the Investment or Issuer and will make no representation to the contrary. Issuer also acknowledges that SDIRA Services acceptance of said investment solely indicates that it meets SDIRA Service’s existing systems and procedures and in no way can be construed to be either an endorsement or evaluation of merit of any kind or acknowledgement that the investment complies with any sanction, legal authority, or regulatory statue. All correspondence including tax forms (if applicable), K-1’s (if applicable), financial statements, voting information, or any other documentation will be directly sent by the Issuer to the Account Holder’s home address, and not to SDIRA Services. Issuer agrees to notify SDIRA Services and Account Holders of any address change, name change dissolution, or bankruptcy of the Investment, in writing. Issuer agrees to not use SDIRA Service’s name in advertising, printed or web-based material, or any other form of communication without the express written consent of SDIRA Services. Issuer will not distribute SDIRA Service’s Applications or other marketing documents to protential clients without the express written consent of SDIRA Services. If applicable, IRA investors have been made aware that the investment may generate Unrelated Business Taxable Income (UBTI). If UBTI, is generated, the Issuer represents that UBTI information will be included on IRS form 1065 (Schedule K-1) and provided to the IRA investor each year.
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________________________________________________________________________________________________________ Issuer Signature:___________________________________________________Date:_______________ Printed Name of Signor:_____________________________________________ Title:_______________________ Investment Name:__________________________________________________ Investment Address: _______________________________________________ _______________________________________________
Type of Investment: _____ Unsecured Note _____Preferred Stock
_____Secured Note
_____Debenture
_____Bond
_____Common Stock
_____Limited Partnership
_____Limited Liability Company
_____ Unit Investment Trust
_____Other (please list)_______________________________________
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