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Form #966Investor Questionnaire
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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)
                                                                      Â
$1,000,000Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â or $300,000Â (joint)
      Names of All Equity Owners        Â
           Net Worth               Minimum Income
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
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;Â 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)
                                                                      Â
$1,000,000Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â or $300,000Â (joint)
      Names of All Grantors                              Net
Worth               Minimum Income
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
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)
                                                                      Â
$1,000,000Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â or $300,000Â (joint)
      Names of All Participants                         Net
Worth               Minimum Income
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
______________________________Â Â Â Â Â Â Â Â _______________Â Â Â Â Â _________________
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
$5,000,000.
PART II:
NON-ACCREDITED INVESTORS
1. Name of Person Making Investment
Decision: ____________________________
Date of Birth: ________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â U.S.
Citizen: Yes ____Â No ____
College:______________________________________________________________
Degree: _______________ Year:
_________________
Graduate School:
_______________________________________________________
Degree: _______________ Year:
_________________
Social Security or Federal ID No(s):
_______________________________________
____________________________________________________________________
2. Nature of Business:
__________________________________________________
Position and Duties:
___________________________________________________
Please set forth other prior
occupations or duties during the past five years:
___________________________________________________________________
___________________________________________________________________
Year of Anticipated Retirement:
_______________________
3. Please list investments made
during the past five years: ____________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_________________________ (to include
Year, Nature of Investment, Amount ($))
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 ____Â 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)]Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â $____________________
 (Actual)
[19 _ (One Year Ago)]Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â $____________________
(Actual)
[19 _ (This Year )]Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â $____________________
(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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