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I am filling out this form as a

Personal Identification Information

We need to know which company you represent. Please complete accurately with the most current information to the best of your knowledge.

Marital Status

Business Identification Information

We need to know which company you represent. Please complete accurately with the most current information to the best of your knowledge.

Personal Financial Information

This is your own personal financial history, make sure NOT to fill out these fields with your business's information. Please complete accurately with the most current information to the best of your knowledge.

Personal Risk Declarations

This is your own personal risk history. Please complete accurately with the most current information to the best of your knowledge.

A. Are there any outstanding judgements against you?
B. Have you declared bankruptcy within the last 4 years?
C. Have you had any property foreclosed or given title in lieu thereof in the last 4 years?
D. Are you currently a party to a lawsuit?
E. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure or judgement in the last 4 years?
F. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation or loan guarantee?
G. Are you obligated to pay alimony, child support, or separate maintenance?
H. Have you been convicted of a felony in the past 10 years?
I. Are you a United States Citizen?
J. Are you a permanent resident alien?

Business Risk Declarations

This is your Business's risk history. Please complete accurately with the most current information to the best of your knowledge.

K. Neither my business nor any principal of my business has declared bankruptcy in the last 4 years.
L. Neither my business nor any principal of my business is a party to any lawsuit.
M. My business has never defaulted on any loan or debt.
N. No principal of my business has had a property foreclosed within the past 4 years.
O. The business or its principals has never been denied a license, certification, or lost its ability to legally conduct business nor been suspended or administratively limited in its ability to conduct business.

Issuer Personal Disclosures

To be completed by each Owner/Member (natural person or entity) holding 20% or more of the company.

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