Accredited Investor Form

Below is a list of the Accredited Investor criteria. You can extract and print this form and use it to identify whether your investor is accredited or non-accredited. If investors don’t meet any of the conditions listed below, they are non-accredited.

The Subscriber further represents and warrants as indicated below by the Subscriber’s initials:

1. A: Individual: (Please initial one or more of the following statements)
   1. _____I certify that I am an accredited investor because I have had individual income (exclusive of any income earned by my spouse) of more than $200,000 in each of the most recent two years, and I reasonably expect to have an individual income in excess of $200,000 for the current year.
   2. _____I certify that I am an accredited investor because I have had joint income with my spouse in excess of $300,000 in each of the last two years and reasonably expect to have joint income in excess of $300,000 for the current year.
   3. _____I certify that I am an accredited investor because I have an individual net worth or my spouse and I have a joint net worth in excess of $1,000,000.
   4. I am a director or executive officer of ______________.

1. B: Partnerships, Limited Liability Companies, trusts, or other entities:(Please initial one of the following statements). The Subscriber hereby certifies that it is an accredited investor because it is:
   1. _____an employee benefit plans whose total assets exceed $5,000,000;
   2. _____an employee benefit plan whose investment decisions are made by a plan fiduciary, which is either a bank, savings, and loan association, or an insurance company (as defined in Section 2(13) of the Securities Act) or an investment adviser registered as such under the Investment Advisers Act of 1940;
   3. _____a self-directed employee benefit plan, including an Individual Retirement Account, with investment decisions made solely by persons who are accredited investors;
   4. _____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 Shares/units with total assets in excess of $5,000,000;
   5. _____a Limited Liability Company, partnership or similar business trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Shares/units and whose purchase is directed by a sophisticated person as described in Rule 506(c)(2)(ii) of Regulation D and who has such knowledge and experience in financial and business matters that he is capable of evaluating the risks and merits of an investment in the Shares/units;
   6. _____a trust, not formed for the specific purpose of acquiring the Shares/units with total assets exceeding $5,000,000, whose purchase is directed by a person who 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 Shares/units or
   7. _____an entity (including a revocable grantor trust but other than a conventional trust) in which each of the equity owners qualifies as an accredited investor.

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