Investment Investor Form

INVESTMENT INVESTOR FORM

This Investment Investor Form (the Agreement) is submitted to indicate the undersigned's election to participate in the investment offering identified below and to provide required certifications and information. The undersigned represents, warrants, and certifies the accuracy of all information provided herein and acknowledges the representations, acknowledgements, and restrictions set forth in this Form.

1. Investor Information

Investor Name:

Individual    Corporation    Limited Liability Company    Trust    Partnership    Other

Date of Birth (if individual):

2. Investment Details

Effective Investment Date:

3. Payment Instructions

Payment Method: Wire Transfer    ACH    Check    Other

4. Accreditation, KYC and Tax Certifications

Certification of Accredited Investor Status (check all that apply):
Individual or joint net worth with spouse or partner in excess of $1,000,000 (excluding primary residence).
Individual income in excess of $200,000 in each of the two most recent years (or $300,000 with spouse/partner) with reasonable expectation of same in current year.
Entity with total assets in excess of $5,000,000 or all equity owners are accredited investors.
Other qualifying criteria as defined under applicable securities law.

Anti-Money Laundering and Know Your Customer: The investor certifies that the investor and any beneficial owners are not subject to sanctions, are not a politically exposed person unless disclosed, and will provide identification and documentary evidence upon request to satisfy applicable anti-money laundering and KYC requirements.

Tax Status: The investor represents its tax status and agrees to provide any required tax forms or certifications upon request. The investor further certifies that it has disclosed all relevant tax residency information for applicable reporting obligations.

5. Representations, Warranties, and Acknowledgements

By signing below, the investor represents and warrants that: (a) the investor has full power, authority and legal capacity to execute and deliver this Form and to perform its obligations hereunder; (b) the information provided is true, complete and correct as of the date signed; (c) the investor is acquiring the interest for investment for its own account and not with a view to distribution in violation of applicable securities laws; and (d) the investor understands that the investment involves a high degree of risk, including the risk of complete loss of capital, limited liquidity, and transfer restrictions.

The investor acknowledges receipt of any offering materials furnished and agrees that the issuer and its agents may rely on the representations contained herein in accepting the investor's subscription. The investor agrees to indemnify and hold harmless the issuer, its affiliates, and their respective officers, directors and agents from any losses arising from any misrepresentation or breach of the representations and warranties made in this Form.

Transfer Restrictions: The investor understands that any interest purchased is restricted and may not be resold or transferred except in compliance with applicable securities laws and any contractual transfer restrictions applicable to the offering.

Electronic Communications and Consent: The investor consents to receive communications, notices and documents electronically unless the investor elects to receive paper copies in writing. Consent to electronic delivery does not alter any substantive rights under applicable law.

6. Additional Information

List of documents provided (identification, proof of address, accreditation documents, etc.):

7. Certifications

The undersigned certifies under penalty of perjury that the information provided in this Form is true, correct, and complete, and that the undersigned will promptly notify the Issuer of any change in circumstances that would render any representation herein untrue or incomplete. The undersigned authorizes verification of any information provided and agrees to provide additional documentation upon request.

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