Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Date Phone 501 Primary Contact / Legal Name *FirstLastEntity Name (if investing via LLC, Trust, LP, etc.)Tax ID / SSN / EINEmail AddressPhone NumberMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTarget Investment Amount ($)Type of InvestorIndividual / JointRevocable Trust / Irrevocable TrustLLC / C-Corp / S-Corp / PartnershipIRA / Retirement PlanOtherAccreditation Status Qualification (Rule 501 of Regulation D)Income: Earned individual income exceeding $200,000 (or $300,000 joint income with a spouse) in each of the two most recent years, with a reasonable expectation of reaching the same level in the current year.Net Worth: Individual or joint net worth exceeds $1,000,000 (excluding the value of your primary residence).Professional Credentials: Hold in good standing a Series 7, Series 65, or Series 82 license.Entity Assets: Entity with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered.Equity Ownership: Entity in which all of the equity owners are accredited investors.Rule 506(c) Verification MethodThird-Party Verification Letter (Recommended): I will provide a verification letter from a licensed CPA, licensed Attorney, SEC-registered Investment Adviser, or registered Broker-Dealer dated within the last 90 days.Third-Party Verification Service: I request to be verified via a digital verification provider (e.g., VerifyInvestor, Parallel Markets) via a secure upload link.Document Review: I will provide financial documentation directly (e.g., W-2s, tax returns, bank/brokerage statements, credit reports) to support the income or net worth threshold.Acknowledgments (By signing below, I certify that...)The information provided above is true, complete, and accurate.I understand that investment acceptance is contingent upon successful accreditation verification under SEC Rule 506(c).I agree to provide necessary supporting documentation or authorization to complete the verification process.Printed NameDateSubmit
