Offeree Suitability Questionnaire (Page 2 of 2) in pdf

QUESTIONS 5, 6 AND 7 ARE INTENDED TO DETERMINE WHETHER OR NOT

YOU QUALIFY AS AN ACCREDITED INVESTOR PURSUANT TO SEC

REGULATION D UNDER THE ACT.

5. Is your net worth in excess of $1,000,000? (For purposes of this question, you may include

your spouse's net worth and may not include the value of your personal residence)

Yes _________ No __________

6. Was your individual income during the past two years in excess of $200,000 or was your

joint income with your spouse during the past two years in excess of $300,000 and do you

have a reasonable expectation of reaching the same income level in the current year?

Yes _________ No __________

8. What was your Federal tax bracket for your last fiscal year (i.e., the taxable rate imposed

upon the last dollar of taxable income reported in your most recent federal tax return)?

___________%

9. Approximately what percentage of your net worth is readily convertible into cash?

_____%

10. Please briefly describe principal positions held during the last ten years or since

Graduation from college (whichever is less), which will demonstrate your related experience

in financial and business matters:

________________________________________________________________________

12. Investment experience:

(a) Please indicate the frequency of your investment in non-marketable securities:

( ) often; ( ) occasionally; ( ) seldom; ( ) never.

(b) Please indicate the frequency of your investment in Limited liability companies:

( ) often; ( ) more than once; ( ) never.

I/we represent and warrant that the above information supplied by me, or us, is true and

correct in all respects.

IN WITNESS WHEREOF, I/we have executed this Questionnaire this _____ day of

________________, 2013.

________________________________________

(Signature of Offeree)

Offeree Suitability Questionnaire Page 2