Declaration Of Accredited / Expert / Institutional Investor Status (Page 3 of 3) in pdf

Declaration Of Accredited / Expert / Institutional Investor Status Page 3

ACCREDITED INVESTOR QUALIFICATION

& VERIFICATION REQUIREMENTS

FOR REG D, RULE 506(c) OFFERINGS



A bank, insurance company, or registered investment adviser must sign this Qualification

Statement on our behalf of the Investor, or



You must provide Documentation that the plan has total assets in excess of Five Million

Dollars ($5,000,000).

Signature(s)

IN WITNESS WHEREOF, I/we hereby attest, under penalty of perjury, that the following

representations are true and correct, signed this _______ day of ________________, 20______, at

_________________________________________________[City and State].

___________________________________________________

Signature of Individual, Owner, Manager,

Officer or Member

___________________________________________________

Printed Name (and Title if a Legal Entity)

___________________________________________________

Company Name (if applicable)

___________________________________________________

Signature of Individual, Owner, Manager,

Officer or Member

___________________________________________________

Printed Name (and Title if a Legal Entity)

___________________________________________________

Company Name (if applicable)

Please complete additional form if more than 2 signatures are required.

Page 3 of 3

Declaration Of Accredited / Expert / Institutional Investor Status Page 3