Legal Investor Questionnaire

LEGAL INVESTOR QUESTIONNAIRE

This Legal Investor Questionnaire (the Questionnaire) is executed on by Investor Name: with Principal Address: and Issuer Name: .

RECITALS

WHEREAS, the Issuer is offering or intends to offer certain securities or interests and requires information concerning prospective investors to determine suitability, compliance with applicable securities laws, and the Issuer's offering restrictions; and

WHEREAS, the Investor acknowledges that the Issuer may rely on the representations, warranties and covenants set forth in this Questionnaire for regulatory compliance, investor qualification and other corporate purposes; and

WHEREAS, the parties wish to record the Investor's status, ownership, source of funds, and other matters required by the Issuer in connection with the contemplated transaction.

NOW, THEREFORE, in consideration of the Issuer's review and reliance, the Investor makes the following statements, representations and certifications to the Issuer.

1. INVESTOR INFORMATION

2. ENTITY TYPE & FORMATION

Entity Type (select all that apply): Individual Corporation LLC Partnership Trust Other

3. ACCREDITED INVESTOR STATUS

The Investor represents and warrants under penalty of perjury that the Investor qualifies as an Accredited Investor under applicable law by meeting one or more of the following categories (check all that apply) and provide supporting details where requested:

Individual with annual income in excess of $200,000 in each of the two most recent years (or $300,000 combined with spouse) and a reasonable expectation of the same income level in the current year.
Individual or joint net worth exceeding $1,000,000, excluding primary residence.
Entity with total assets in excess of $5,000,000, or an entity in which all equity owners are accredited.
Other category qualifying under applicable securities law (describe below).

4. FINANCIAL INFORMATION & SOURCE OF FUNDS

5. BENEFICIAL OWNERS / CONTROL PERSONS

Provide the full legal name, title/relationship to Investor, percentage ownership or control, and country of citizenship for each beneficial owner or individual exercising control over the Investor. Attach additional pages if necessary.

6. INVESTMENT OBJECTIVES & EXPERIENCE

Investment Objective (select all applicable): Growth Income Speculation Capital Preservation

7. RISK ACKNOWLEDGMENT

The Investor acknowledges that any investment in the Issuer may involve a substantial risk of loss, that the Investor can bear such loss without undue hardship, and that the Investor has reviewed and understands all offering materials and financial projections provided by the Issuer. The Investor further acknowledges that no federal or state authority has approved or disapproved the offering, and that the Investor has had the opportunity to ask questions and receive answers.

8. REPRESENTATIONS, WARRANTIES AND COVENANTS

The Investor represents and warrants to the Issuer that: (a) the information contained in this Questionnaire is true, complete and correct as of the date hereof; (b) the Investor will notify the Issuer promptly of any material change in facts, circumstances or status; (c) the Investor's acquisition of securities is for investment purposes only and not with a view to distribution or resale; (d) the Investor is not subject to any law, order or agreement that would prohibit or limit the Investor's performance of its obligations herein; and (e) the Investor will comply with all applicable laws in connection with any investment.

The Investor further covenants to deliver, upon request, supporting documentation reasonably necessary for the Issuer to verify the Investor's representations, including but not limited to financial statements, tax returns, trust documents, organizational documents and identification records.

9. CONFIDENTIALITY; USE OF INFORMATION

The Issuer will treat the information provided in this Questionnaire as confidential and will use such information for purposes of regulatory compliance, investor qualification, anti-money laundering screening, tax reporting, and related corporate matters. The Issuer may disclose information to its legal counsel, auditors, regulatory authorities where required by law, or other parties performing services for the Issuer under confidentiality obligations.

10. NOTICES

Notices under this Questionnaire shall be in writing and delivered to the addresses set forth above, and shall be effective upon receipt.

11. AMENDMENTS; WAIVER; COUNTERPARTS

This Questionnaire may be amended or modified only by a written instrument signed by both the Investor and the Issuer. No failure or delay by either party in exercising any right shall operate as a waiver thereof. This Questionnaire may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Questionnaire shall be governed by and construed in accordance with the laws of the jurisdiction selected below without regard to conflicts of law principles.

This Questionnaire, together with any schedules or exhibits hereto and any documents expressly incorporated by reference, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

13. CERTIFICATION

By signing below, the undersigned certifies, represents and warrants that the information provided in this Questionnaire is true, correct and complete, and acknowledges that the Issuer is relying on these representations. The undersigned authorizes the Issuer to obtain such additional information and documentation as it reasonably requires to verify the foregoing representations and consents to disclosures as provided herein.

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