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Back to Forms for 'Limited Liability Partnerships'.


INVESTOR QUESTIONNAIRE

INVESTOR QUESTIONNAIRE

 

Name of Subscriber: ________________________________________________

The offer and sale of limited partnership interests (the ''Interests'') in _____________________________________________________ (the ''Partnership''), are not being registered under the Securities Act of 1933, as amended (the ''Act'') or qualified under state securities laws, in reliance upon exemptions from such registration and qualification requirements for transactions not involving any public offering. Information supplied through this Questionnaire will be used to ensure compliance with the requirements of such exemptions.

 

The undersigned Subscriber represents and warrants to the Partnership and the General Partner that:

 

(a) The information contained herein is complete and accurate and may be relied upon by the Partnership and the General Partners; and

 

(b) Subscriber will notify the General Partner immediately of any material change in any of such information occurring prior to the acceptance or rejection of the Subscriber's subscription for an Interest.

 

INSTRUCTIONS:

 

Part I of this Questionnaire concerns investors who are "accredited," as that term is defined and construed pursuant to Regulation D under the Securities Act of 1933. If you qualify under any of the categories listed in Part I, you are not required to fill out Part II of this Questionnaire. If you do not qualify under any of the categories listed in Part I, you must fill out Part II.

 

IF THE INVESTOR IS A PARTNERSHIP, PLEASE ATTACH AN EXECUTED COPY OF THE PARTNERSHIP AGREEMENT AND ALL AMENDMENTS THERETO.

IF THE INVESTOR IS A CORPORATION, PLEASE ATTACH A COPY OF THE ARTICLES OF INCORPORATION AND A BOARD OF DIRECTORS RESOLUTION (CERTIFIED BY THE SECRETARY OF THE CORPORATION) AUTHORIZING THIS INVESTMENT.

IF THE INVESTOR IS A TRUST, PLEASE ATTACH A COPY OF THE TRUST AGREEMENT AND ALL AMENDMENTS THERETO.

 

PART I: ACCREDITED INVESTORS

 

1. FOR INDIVIDUAL INVESTORS ONLY:

 

Initial ________ a. I certify that I have an individual net worth, or my spouse and I have a combined net worth, in excess of $1,000,000. For purposes of this Questionnaire, ''net worth'' means the excess of total assets at fair market value, (including principal residence, home furnishing, and automobiles) over total liabilities.

or

 

Initial ________ b. I certify that I had individual income, exclusive of any income attributable to my spouse, of more than $200,000 in the two calendar years preceding the calendar year in which this Questionnaire is submitted, and I reasonably expect to have an individual income in excess of $200,000 during the current calendar year. or

 

Initial ________ c. I certify that my spouse and I had joint in come of more than $300,000 in the two calendar years preceding the calendar year in

which this Questionnaire is submitted, and reasonably expect to have joint income in excess of $300,000 during the current calendar year.

 

2. FOR CORPORATIONS. BUSINESS TRUSTS, OR PARTNERSHIPS:

 

Initial ________ d. Subscriber certifies that it was not formed for the specific purpose of acquiring the Interests and that Subscriber has total assets in excess of $5,000,000.

or

 

Initial ________ e. Subscriber certifies that all of its equity owners are accredited investors under either 1(a) above (i.e., $1,000,000 net worth) or 1(b) or 1(c) above (i.e., $200,000 individual or $300,000 joint income). Please list below the names of all equity owners and the manner in which they qualify* (check applicable category )

Check the Applicable Column

 

                                                                                                         $200,000 (individual)

                                                                         $1,000,000                 or $300,000  (joint)

       Names of All Equity Owners                        Net Worth                  Minimum Income

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

 

3. FOR TRUSTS:

 

Initial ________ f. The undersigned financial institution certifies that it is (i) a bank, savings and loan association, or other regulated financial institution; (ii) acting in its fiduciary capacity as trustee;  and (iii) subscribing for the purchase of the Interests on behalf of the subscribing trust.

or

 

Initial ________ g. The undersigned certifies that the subscribing trust has total assets in excess of $5,000,000, and that the person making the investment decision on behalf of the trust has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of an investment in the Interests.

or

 

Initial ________ h. The undersigned certifies that it is a revocable

trust that may be amended or revoked at any time by the grantors thereof, and all of the grantors are accredited investors under either 1(a) above (i.e., $1,000,000 net worth) or 1(b) or 1(c) above (i.e., $200,000 individual or $300,000 joint income). Please list below the names of all grantors.

Check the Applicable Column

 

                                                                                                         $200,000 (individual)

                                                                         $1,000,000                 or $300,000  (joint)

       Names of All Grantors                                  Net Worth                  Minimum Income

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

 

FOR EMPLOYEE BENEFIT PLANS (INCLUDING KEOGH PLANS):

 

Initial ________ i. The undersigned is an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended ("ERISA''), and the decision to invest in the Partnership was made by a plan fiduciary (as defined in Section 3 (21) of ERISA), which is either a bank, savings and loan association, insurance company, or registered investment adviser. Please state the name of such plan fiduciary: or

 

Initial ________ j. The undersigned is an employee benefit plan within the meaning of ERISA and has total assets in excess of $5,000,000.

or

1

 

Initial ________ k. The undersigned is an employee benefit plan within the meaning of ERISA, the plan is self directed, and the investment decision is being made by a plan participant who is an accredited investor under either 1(a) above (i.e., $1,000,000 net worth) or 1(b) or 1(c) above (i.e., $200,000 individual or $300,000 joint income). Please list below the names of all such participants.

Check the Applicable Column

 

                                                                                                         $200,000 (individual)

                                                                         $1,000,000                 or $300,000  (joint)

       Names of All Participants                             Net Worth                  Minimum Income

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

______________________________         _______________      _________________

 

 

5. FOR INDIVIDUAL RETIREMENT ACCOUNTS:

 

Initial ________ 1. The undersigned hereby certifies that the beneficiary thereof is an accredited investor under either (a) above (i.e., $1,000,000 net worth) or (b) or (c) above (i.e., $200,000 individual or $300,000 joint income).

 

6. FOR 501(c)(3) ORGANIZATIONS:

 

Initial ________ m. The undersigned hereby certifies that it is an

organization described in section 501(c)(3) of the Internal Revenue Code of 1986, as amended, not formed for the specific purpose of acquiring the Interests, with total assets in excess of $5,000,000.

 

PART II: NON-ACCREDITED INVESTORS

 

1. Name of Person Making Investment Decision: ____________________________

 

Date of Birth: ________________                            U.S. Citizen: Yes ____  No ____

 

College:______________________________________________________________

Degree: _______________ Year: _________________

 

Graduate School: _______________________________________________________

Degree: _______________ Year: _________________

 

Social Security or Federal ID No(s): _______________________________________

____________________________________________________________________

 

2. Nature of Business: __________________________________________________

 

Position and Duties: ___________________________________________________

 

Please set forth other prior occupations or duties during the past five years:

___________________________________________________________________

___________________________________________________________________

 

Year of Anticipated Retirement: _______________________

 

3. Please list investments made during the past five years: ____________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

_________________________ (to include Year, Nature of Investment, Amount ($))

4. (a) I consider myself to have such knowledge and experience in financial and business matters to enable me to evaluate the merits and risks of an investment in the Company. Yes ____  No ____

 

(b) If the answer to 4(a) is ''yes,'' please set forth below (or in an attachment) the basis for your answer (e.g., investment or business experience, profession, past review of other investment offerings, etc.) ________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

 

(c) If the answer to 4(a) is ''no,'' please list the name, business address and telephone number of the person who is your purchaser representative ____________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

 

 

5. My income from all sources was, now is, or is expected to be:

 

            Year                                                             Gross Income

 

[19 _ (Two Years Ago)]                             $____________________

 (Actual)

 

[19 _ (One Year Ago)]                               $____________________

(Actual)

 

 

[19 _ (This Year )]                                      $____________________

(Estimated)

1

6. (a) My personal net worth (including the net worth of my spouse, if any) is now estimated at: $___________________________

 

(b) My personal net worth (exclusive of homes, home furnishings and automobiles) is now estimated at: $___________________________

 

(c) My estimated liquid assets equal: $___________________________

 

(d) My estimated non-liquid assets equal: $_______________________

 

Dated: _____________ 19______

 

Signature for Individual Subscriber

 

______________________________

Signature

 

______________________________

Print Name of Subscriber

 

_____________________________

Signature of joint Subscriber (if any)

 

_______________________________

Print Name of joint Subscriber (if any)

 

 

Signature For Partnership Trust, Corporation or Other Entity

 

______________________________

Print Name of Subscriber

 

______________________________

Signature

 

______________________________

Print Name of Signing

 

______________________________

Title

 



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