IN WITNESS WHEREOF, the parties hereto have duly executed and delivered this Agreement as of the date first written above.
Exhibit C
Form of Non-Competition Agreement
THIS NON-COMPETITION AGREEMENT (this “Agreement”) is entered into this ____ day of ______________, 2009, by and between SOY ENERGY, LLC, an Iowa Limited Liability Company (“Soy Energy”), and _______________________________ (“Appointee”).
A. Soy Energy and New Equity, LLC (“New Equity”), have entered into a Unit Purchase Agreement (the “Unit Purchase Agreement”), which provides for the purchase of Soy Energy Units by New Equity, and pursuant to which it is anticipated that Appointee will be appointed by New Equity to Soy Energy’s board of directors. Capitalized terms not defined herein have the meanings set forth in the Unit Purchase Agreement.
B. It is a condition to eligibility for appointment to the Soy Energy board of directors that Appointee executes and delivers this Agreement.
NOW, THEREFORE, the parties, intending to be legally bound, hereby agree as follows:
1. Non-Competition and Non-Solicitation Covenants.
(a) Agreement Not to Compete. During the period commencing with the date hereof and continuing until the ten (10) year anniversary of the Closing (the “Term”), Appointee will not, directly or indirectly, be an officer, director, manager or owner of greater than twenty percent (20%) of the voting interests of any biodiesel production facility other than Soy Energy; provided, however, that this covenant shall not apply to any existing investment of the Appointee listed onSchedule 1(a) of this Agreement or to any production facility or other entity listed onSchedule 1(a) in which Appointee is currently an officer or director.
(b) Agreement Not to Hire. During the Term, Appointee will not, directly or indirectly, hire, engage or solicit any person who is then an employee or contractor of Soy Energy or of Freedom Fuels, LLC (“Freedom Fuels”) or who was an employee or contractor of Soy Energy or Freedom Fuels at any time, in any manner or capacity, including without limitation as a proprietor, principal, agent, partner, officer, director, stockholder, member, employee, member of any association, consultant or otherwise.
(c) Agreement Not to Solicit. During the Term, Appointee will not, directly or indirectly, solicit, request, advise or induce any current or potential customer, supplier or other business contact of Soy Energy or Freedom Fuels to cancel, curtail or otherwise adversely change its relationship with Soy Energy or Freedom Fuels.
(d) Blue Pencil Doctrine. If the duration of, the scope of, or any business activity covered by, any provision of this Section 1 is in excess of what is determined to be valid and enforceable under applicable law, such provision will be construed to cover only that duration, scope or activity that is determined to be valid and enforceable. Appointee hereby acknowledges that this Section 1 will be given the construction which renders its provisions valid and enforceable to the maximum extent, not exceeding its express terms, possible under applicable law.
2. Additional Agreements, Covenants and Representations.
(a) Appointee agrees to at all times keep confidential and not divulge, furnish or make accessible to anyone (other than attorneys, accountants and financial advisors of Soy Energy and New Equity) any information regarding or relating to the Unit Purchase Agreement or the Closing until Soy Energy has made a public announcement of the transactions provided therein, and at that time shall only disclose information that is provided in such public announcement.
(b) Appointee agrees to indemnify and hold Soy Energy harmless from any liability, loss or expense (including reasonable attorneys’ fees) if the Appointee, alone or with others, defaults in any of the agreements, representations, warranties or covenants set forth in this Agreement.
C-1
3. Waiver. Appointee hereby waives each provision of any agreement to which Appointee is a party that is or, with or without notice or lapse of time or both, would be inconsistent with or violated by (i) this Non-Competition Agreement, and/or (ii) the execution or delivery of the Unit Purchase Agreement or any related agreement or the consummation any of the transactions contemplated by the Unit Purchase Agreement or any related agreement.
4. Miscellaneous.
(a) This Agreement constitutes the entire agreement between the parties pertaining to the subject matter hereof other than the Unit Purchase Agreement and the documents related thereto. No waiver of any of the provisions of this Agreement shall be deemed, or shall constitute, a waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing waiver. No waiver shall be binding unless executed in writing by the party making the waiver.
(b) This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same document.
(c) This Agreement shall be enforceable by, and shall inure to the benefit of and be binding upon, the parties hereto and their respective successors and assigns. As used herein, the term “successors and assigns” shall mean, where the context so permits, heirs, executors, administrators, trustees and successor trustees, and personal and other representatives.
(d) All notices, requests, consents and other communications required or permitted hereunder will be in writing and will be delivered, or sent by facsimile transmission, or mailed first-class postage prepaid, registered or certified mail, as follows:
if to Appointee, to the address set forth on the signature page to this Agreement; and
if to Soy Energy, to:
| |
| Soy Energy, LLC |
| Attn: Chuck Sand |
| 222 North Main Street |
| Marcus, Iowa 50135 |
| |
with a copy to (that shall not constitute notice): |
| |
| BrownWinick Law Firm |
| Attn: Thomas D. Johnson |
| 666 Grand Avenue, Ste. 2000 |
| Des Moines, Iowa 50309-2510 |
| Facsimile: (515) 323-8514 |
and such notices and other communications will for all purposes of this Agreement be treated as being effective or having been given if delivered personally, or, if sent by mail delivery service or facsimile, when received. Any party may change its address for such communications by giving notice thereof to the other party in conformity with this Section.
(e) This Agreement shall be governed and construed in accordance with the laws of the State of Iowa without regard to any applicable conflicts of law.
(f) If one or more of the provisions of this Agreement are held to be contrary to the laws that govern this Agreement or the laws of any other competent jurisdiction, the parties hereto agree that the offending provision(s) shall be amended in such a way as may be necessary in order to maintain the contents of such clauses as closely as possible to the contents thereof originally intended by the parties.
C-2
(g) Appointee hereby acknowledges that the provisions of this Agreement are reasonable and necessary to protect the legitimate interests of Soy Energy and that any violation of this Agreement by Appointee will cause substantial and irreparable harm to Soy Energy to such an extent that monetary damages alone would be an inadequate remedy. Appointee represents and warrants that Appointee is not subject to any other agreements prohibiting the performance of Appointee’s obligations under this Agreement, including any non-competition agreement.
�� Appointee acknowledges and understands that the representations, warranties and covenants by Appointee set forth herein shall be relied upon by Soy Energy, and its affiliates and counsel, and that substantial losses and damages may be incurred by such persons if Appointee’s representations, warranties or covenants herein are breached or are incorrect or untrue. Appointee has carefully read this Agreement and has had an opportunity to discuss the requirements of this Agreement with Appointee’s professional advisors to the extent Appointee has deemed necessary.
THIS AGREEMENT is executed by the parties hereto as of the date shown on the first page of this Agreement.
| | |
SOY ENERGY, LLC | |
| |
By: | | |
| |
Its: | | |
| | |
APPOINTEE: | |
| | | | |
Signature: | | |
Name: | | |
Address: | | |
| |
| |
C-3
Exhibit D
Form of Investor Suitability Questionnaire
SOY ENERGY
POTENTIAL INVESTOR SUITABILITY QUESTIONNAIRE
TABLE OF CONTENTS
| | |
General Information (For All Investors) | | 2 |
Questionnaire for Individual Investors | | 3 |
Questionnaire for Trust Investors | | 6 |
Questionnaire for IRAs, Pensions and Certain Other Investors | | 7 |
Questionnaire for Corporate, Partnership and Limited Liability Company Investors | | 9 |
Exhibit A | | 11 |
Exhibit B | | 13 |
D-1
GENERAL INFORMATION (FOR ALL POTENTIAL INVESTORS)
Complete the following as applicable.
| | | | | | | | | |
1. | Name: | |
| | | | | | | | | |
2. | Address: | |
| Street City State Zip |
| | | | | | | | | |
3. | Telephone Number: | |
| | | | | | | |
4. | Federal Tax ID Number or Social Security Number: | |
| | | | | | | | |
5. | Marital Status: | |
| | | | | | |
6. | Date of Birth or Organization: | |
| | | | | |
7. | State of Residence or Formation: | |
| | | | |
8. | Type of Ownership (Check appropriate box): | |
| | | | |
| o | Individual | o | Employee Benefit Plan |
| o | Joint Tenants | o | Individual Retirement Account |
| o | Tenants in Common | o | Keogh Plan |
| o | Partnership | o | Other Tax Exempt Entities |
| o | Limited Liability Company | o | Corporation |
| o | Trust | o | Other Taxable Entity |
| | | |
9. | Entity investors must answer the following questions regarding authority: |
| | |
| (a) | Name(s) and title(s) of the persons who have authority to purchase securities on behalf of the Investor. |
| | | |
| | |
| (b) | Is permission or authorization from any other person necessary to effect the purchase of securities? |
| | |
| | __________ Yes __________ No |
| | |
| (c) | If the answer to Question 9(b) is “Yes,” please provide the following additional information: |
| | |
| | Identify all such persons from whom such additional permission or authorization is necessary: |
| | | |
| | |
| | Has such permission or authorization been obtained? |
| | |
| | __________ Yes __________ No |
| |
Instructions for completing the remainder of the questionnaire: |
| |
1. | Soy Energy is referred to in the Questionnaires as the “Company.” |
2. | Individuals, Joint Tenants and Tenants in Common are referred to as “Individual Investors.” |
3. | Joint Tenants or Tenants in Common must complete and signseparate Questionnaires for Individual Investors. |
4. | Business entities, certain plans and trusts should complete the questionnaire applicable to the entity type of the particular investor. |
5. | The appropriate person(s) should complete the Questionnaires attached as exhibits if so indicated by the primary Questionnaire. |
D-2
QUESTIONNAIRE FOR INDIVIDUAL POTENTIAL INVESTORS
| | |
I. | Purchaser Representative for Individual Investors. Please check (a) or (b): |
| |
| o | (a) I do NOT rely upon the advice of a Purchaser Representative such as an attorney, accountant or other adviser in making investment decisions. I believe that I have sufficient knowledge and experience in financial and business matters to be capable of evaluating the merits and risks of an investment. |
| | |
| o | (b) I do rely on the advice of a Purchaser Representative, such as an attorney, accountant or other advisor in making investment decisions. I do not have sufficient knowledge and experience in financial business matters as required above. |
| | |
II. | Investor Accreditation, Sophistication and Suitability. |
| | | |
2.1 | The investor is (check ALL that apply): |
| |
| o | (i) | A natural person whose individual net worth (assets less liabilities), or joint net worth with his or her spouse, exceeds $1,000,000. |
| | | |
| o | (ii) | A natural person whose individual income was in excess of $200,000, or whose joint income with his or her spouse was in excess of $300,000, in each of the two most recent years, and who has a reasonable expectation of reaching the same income level for the current year. |
| | | |
| o | (iii) | A corporation, business trust, or partnership with assets in excess of $5,000,000. |
| | | |
| o | (iv) | A trust with assets in excess of $5,000,000. |
| | | |
| o | (v) | None of the above. |
| | | |
2.2 | Financial Information: |
| | | |
| (a) | Gross Income During Last Two Years: |
| | | | | | | | | | | |
| | Individual | | | | Joint | | | |
| 2007 | | 2008 | | 2007 | | 2008 | | |
| | | | | | | | | Less than $49,000 |
| | | | | | | | | $50,000 - $99,000 |
| | | | | | | | | $100,000 - $199,000 |
| | | | | | | | | $200,000 - $299,000 |
| | | | | | | | | $300,000 or more |
| | |
| (b) | Anticipated Gross Income for 2009: |
| | | | | | | | | |
| | Individual | | | | Joint | | | |
| | | | | Less than $49,000 |
| | | | | $50,000 - $99,000 |
| | | | | $100,000 - $199,000 |
| | | | | $200,000 - $299,000 |
| | | | | $300,000 or more |
| | | | |
| ______ Less than $49,000 | | ______ $300,000 - $599,000 | |
| ______ $50,000 - $99,000 | | ______ $600,000 - $999,000 | |
| ______ $100,000 - $299,000 | | ______ $1,000,000 or more | |
D-3
| | |
| (d) | Current Net Worth Exclusive of Home, Furnishing and Automobiles: |
| | | | |
| ______ Less than $49,000 | | ______ $300,000 - $599,000 | |
| ______ $50,000 - $99,000 | | ______ $600,000 - $999,000 | |
| ______ $100,000 - $299,000 | | ______ $1,000,000 or more | |
| | |
| (e) | Current Value of Net Assets Including Cash and Cash Equivalents, Marketable Securities, Cash Surrender Value of Life Insurance and Other Items Easily Convertible into Cash: |
| | | | |
| ______ Less than $49,000 | | ______ $300,000 - $599,000 | |
| ______ $50,000 - $99,000 | | ______ $600,000 - $999,000 | |
| ______ $100,000 - $299,000 | | ______ $1,000,000 or more | |
| | |
| (a) | Profession, Business or Employment: |
| | |
| | |
| | |
| | |
| (b) | Position or Duties: |
| | |
| | |
| | |
| | |
| | |
2.4 | Prior employment or occupation for the last five years if different from above: |
| |
| |
| | |
| |
| | |
2.5 | College, Business or Professional education: |
| |
| |
| | |
| |
| | |
2.6 | Investment Experience: |
| | |
| (a) | Please indicate the frequency of your investment in marketable securities: |
| | | |
| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
| | | |
| Approximate current value of such securities: $ ___________________________________________. |
| | |
| (b) | Please indicate the frequency of your investment in unmarketable securities: |
| | | |
| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
| | |
| (c) | Investments in private or limited offerings within the last five years: |
| | | |
| _______ Corporate Equity or Debt | | _______ Partnerships |
| _______ Real Estate | | _______ Other __________________________________ |
| | |
| (d) | Do you make your own investment decisions with respect to such investments? |
| | | |
| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
D-4
| | |
| (e) | What are your primary sources of investment knowledge or advice? (You may check more than one.) |
| | | |
| _______ Firsthand experience within the industry | | _______ Trade or industry publication(s) |
| _______ Broker(s) | | _______ Attorney(s) |
| _______ Financial publication(s) | | _______ Banker(s) |
| _______ Investment adviser(s) | | _______ Accountant(s) |
IN WITNESS WHEREOF, the below individual(s) have executed this Questionnaire for Individual Investors this ______ day of ______________, 200___.
| | | |
| Signature: | |
| | | |
| Print Name: | |
| | | |
| JOINT INVESTOR (if applicable): |
| | | |
| Signature: | |
| | | |
| Print Name: | |
D-5
QUESTIONNAIRE FOR POTENTIAL TRUST INVESTORS
| | | | | | | | | | |
I. | TRUST INVESTOR. |
| |
1.1 | Name of Trust: | |
| |
1.2 | Trustee(s): | |
| |
1.3 | Number of Beneficiaries: | | |
| |
1.4 | Type of Trust: __________ Revocable __________ Irrevocable |
| |
| |
| Name of Grantor(s) (persons establishing the trust) of Revocable Trust: | |
| |
► | IF THE TRUST ISREVOCABLE, DO NOT COMPLETE THE REMAINDER OF THIS QUESTIONNAIRE AND EACH GRANTOR SHOULD COMPLETE EXHIBIT A. |
| |
► | IF THE TRUST ISIRREVOCABLE, COMPLETE THE REMAINDER OF THIS QUESTIONNAIRE. |
| |
II. | ACCREDITED INVESTOR STATUS. |
| |
2.1 | The undersigned Trust has as its trustee a bank as defined in Section 3(a)(2) of the Securities Act of 1933. |
| |
| __________ Yes __________ No |
| |
2.2 | The undersigned Trust certifies that it has total assets in excess of $5,000,000, was not formed for the specific purpose of acquiring the Interests and is directed by a sophisticated person as defined in Rule 506(b)(2)(ii). |
| |
| __________ Yes __________ No |
| |
III. | SOPHISTICATION |
| |
Name(s) of person(s) making this investment decision on behalf of the Trust: | |
| |
► IF THE TRUST ANSWERED NO TO QUESTION 2.1, THE ABOVE PERSONS MUST COMPLETE EXHIBIT B. |
| |
V. | SUITABILITY OF TRUST AS INVESTOR. |
| |
5.1 | Current Net Worth of Trust: $ | | |
| | | | | | | |
5.2 | Net Income of Trust For: | | |
|
| 2007 $ | | |
| |
| 2008 $ | | |
| |
5.3 | Anticipated Net Income of Trust for 2009: $ | | |
IN WITNESS WHEREOF, the below trust has executed this Questionnaire for Trust Investors this ______ day of ______________, 200___.
D-6
QUESTIONNAIRE FOR IRAs, PENSIONS, AND CERTAIN OTHER POTENTIAL INVESTORS
(Including IRA/Qualified Pension Plan; Profit-Sharing or Stock/KEOGH Investors)
| | | |
I. | PLAN INVESTORS |
| | |
1.1 | Name of Plan: | |
| | |
1.2 | (a) | Type of Plan: |
| | | |
| _______ Qualified Pension | | _______ Profit Sharing or Stock |
| _______ Bonus Plan | | _______ Keogh |
| _______ IRA | | _______ Other (Specify) |
| | | | | |
| (b) | Plan Fiduciaries: | |
| | |
| | |
1.3 | (a) | Does each Plan Participant who will invest in Interests (i) have the power to direct his/her investments and (ii) intent to invest pursuant to the exercise of such power? |
| | |
| | __________ Yes __________ No |
| | |
| (b) | Does the Plan either (i) have one Plan Participant or (ii) provide for segregated accounts for each Plan Participant? |
| | |
| | __________ Yes __________ No |
| | |
| (c) | Does the Plan certify that investment decisions are made solely by persons that are accredited Investors? |
| | |
| | __________ Yes __________ No |
| | |
| If the Plan answered yes toboth Questions 1.3(a) and 1.3(b)or to Question 1.3(c), please list: |
| | |
| | (i) | Number of Plan Participants: | |
| | | |
| | (ii) | Name of Participant(s) who will invest in Interests: |
| | | | | | | | | |
| | Name | | | Address | | | Telephone No. | |
| | | | | | |
| | |
| | |
| | |
► | IF THE PLAN ANSWERED YES TOBOTH QUESTIONS 1.3(a) AND 1.3(b) ABOVEOR TO QUESTION 1.3(c) ABOVE, EACH PLAN PARTICIPANT SHOULD COMPLETE EXHIBIT A, AND THE PLAN SHOULD NOT COMPLETE THE REMAINDER OF THIS QUESTIONNAIRE. |
| | |
► | IF THE PLAN DIDNOT ANSWER YES TO BOTH QUESTIONS 1.3(a) AND 1.3(b) ABOVE OR TO QUESTION 1.7(c) ABOVE, THEN THE PLAN MUST COMPLETE THE REMAINDER OF THIS QUESTIONNAIRE AND THE PERSON MAKING INVESTMENT DECISIONS FOR THE PLAN MUST COMPLETE EXHIBIT B. |
| |
II. | | PLAN INVESTORS |
| | |
2.1 | | Accredited investor Status. |
| | |
| | The undersigned Plan certifies that it is an employee benefit plan within the meaning of Title I of the Employee Retirement income Security Act of 1974 (“ERISA”) and either (i) has total assets in excess of $5,000,000 or (ii) has its investment decisions 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. |
| | |
| | __________ Yes __________ No |
D-7
| | | | | | |
III. | SUITABILITY OF PLAN AS INVESTOR | | |
| | | |
3.1 | Current Net Worth of Plan: $ | | |
| | | |
3.2 | Net Income of Plan for: | | |
| | | |
| 2007 $ | | | |
| | | | |
| 2008 $ | | | |
| | | |
3.3 | Anticipated Net Income of Plan for 2009: $ | | |
IN WITNESS WHEREOF, the below Plan has executed this Questionnaire for IRAs, Pensions and Certain Other Investors this ______ day of ______________, 200___.
D-8
QUESTIONNAIRE FOR POTENTIAL CORPORATE, PARTNERSHIP AND LIMITED LIABILITY
COMPANY INVESTORS
| | |
I. | GENERAL INFORMATION FOR CORPORATE, PARTNERSHIP OR LIMITED LIABILITY COMPANY INVESTORS. |
| | |
1.1 | Name of Corporation, Partnership, or Limited Liability Company: | |
| | |
1.2 | Type of Organization and Business Description: | |
| | |
1.3 | Number of Shareholders, Partners, or Members: | |
| |
1.4 | Is the entity a partnership, “S” corporation, limited liability company or other form of “pass-through” entity for federal income tax purposes? |
| | |
| _______ Yes ________ No |
| | |
II. | ACCREDITATION, SOPHISTICATION AND SUITABILITY FOR CORPORATE, PARTNERSHIP OR LIMITED LIABILITY COMPANY INVESTORS. |
| | |
Accredited Investor Status. Please complete each of the following certifications: |
| | |
2.1 | The undersigned Corporation, Partnership or Limited Liability Company certifies that it has total assets in excess of $5,000,000 and that it was not formed for the specific purpose of investing in the Interests. |
| |
| _______ Yes ________ No |
| |
2.2 | The undersigned Corporation, Partnership or Limited Liability Company certifies that it is a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934 and purchasing Interests for its own account. |
| |
| _______ Yes ________ No |
| |
2.3 | The undersigned Corporation, Partnership or Limited Liability Company certifies that it is an organization described in Section 501(c)(3) o the Internal Revenue Code with total assets in excess of $5,000,000. |
| |
| _______ Yes ________ No |
| |
2.4 | The undersigned Corporation, Partnership or Limited Liability Company certifies that EACH of its shareholders, partners, or members meets at least ONE of the following conditions: |
| |
| (i) | Each shareholder, partner, or member is a natural person whose individual net worth (or joint net worth with his/her spouse) exceeds $1,000,000 (including his home, home furnishings and personal property). |
| | |
| | _______ Yes ________ No |
| | |
| (ii) | Each shareholder, partner, or member is a natural person who had an individual income in excess of $200,000 in each of the previous two calendar years or joint income with such person’s spouse in excess of $300,000 in each of those years and who reasonably expects to reach the same income level for the current calendar year. |
| | |
| | _______ Yes ________ No |
| | |
| (iii) | The shareholder, partner, or member of the Investor is a corporation, partnership, or limited liability company and all of the shareholders, partners, or members (a “beneficial owner”), respectively, of such corporation, partnership, or limited liability company can answer yes to statement 2.4(i) or 2.4(ii) above. |
| | |
| | _______ Yes ________ No |
D-9
| |
► | IF THE CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY HAS ANSWEREDYES TO ANY PORTION OF STATEMENT 2.4,AND HAS ANSWERED NO TO QUESTIONS 2.1, 2.2 AND 2.3, EACH SHAREHOLDER, PARTNER, MEMBER OR BENEFICIAL OWNER OF A SHAREHOLDER, PARTNER OR MEMBER MUST COMPLETE AND EXECUTE EXHIBIT A AND THE CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY SHOULD NOT COMPLETE THE REMINDER OF THIS QUESTIONNAIRE. |
| |
► | IF THE CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY HAS ANSWEREDYES TO STATEMENT 2.1, 2.2 OR 2.3, THE REMAINDER OF THIS QUESTIONNAIRE MUST BE ANSWERED. |
| |
III. | SOPHISTICATION |
| |
Name(s) of person(s) making this investment on behalf of the Corporation, Partnership, or Limited Liability Company. |
|
|
| |
► | EACH OF THE PERSONS LISTED ABOVE MUST COMPLETE AND EXECUTE EXHIBIT B. |
| |
IV. | SUITABILITY OF CORPORATION OR PARTNERSHIP AS INVESTOR |
| | |
4.1 | Current Net Worth of Corporation or Partnership: $ | |
| |
4.2 | Net Income of Corporation or Partnership for: |
| | |
4.3 | Anticipated Net Income of Corporation or Partnership for 2009: $ | |
IN WITNESS WHEREOF, the below entity has executed this Questionnaire for Corporate, Partnership, or Limited Liability Company Investors this ______ day of ______________, 200___.
D-10
EXHIBIT A
(Complete Only if Required By Applicable Questionnaire)
| | | | | |
| Home Telephone Number: (______) | | | State of Principal Residence: | |
| | | | |
| U.S. Citizen: ________ Yes _________ No | | Social Security Number: | |
| | |
II. | ACCREDITATION AND SUITABILITY |
| |
1. | Accredited Investor Status. Please complete each of the following certifications: |
| | |
| (i) | I certify that I have an individual net worth (or a joint net worth with my spouse) in excess of $1,000,000 (including home, home furnishings and automobiles). |
| | |
| | _______ Yes ________ No |
| | |
| (ii) | I certify that I had individual income (excluding any income of my spouse) of more than $200,000 in each of the previous two calendar years or joint income with my spouse in excess of $300,000 in each of those years and I reasonably expect to reach the same income level in the current year. |
| | |
| | _______ Yes ________ No |
| | |
2. | Financial Information: |
| | |
| (i) | Gross Income During Last Two Years: |
| | | | | | | | | | | | | |
| | Individual | | | | Joint | | | |
| 2007 | | 2008 | | 2007 | | 2008 | | |
| | | | | | | | | Less than $49,000 |
| | | | | | | | | $50,000 - $99,000 |
| | | | | | | | | $100,000 - $199,000 |
| | | | | | | | | $200,000 - $299,000 |
| | | | | | | | | $300,000 or more |
| | |
| (ii) | Anticipated Gross Income During 2009: |
| | | | | | | | | |
| | Individual | | | | Joint | | | |
| | | | | Less than $49,000 |
| | | | | $50,000 - $99,000 |
| | | | | $100,000 - $199,000 |
| | | | | $200,000 - $299,000 |
| | | | | $300,000 or more |
| | | | | |
| | Less than $49,000 | | | $300,000 - $599,000 |
| | $50,000 - $99,000 | | | $600,000 - $999,000 |
| | $100,000 - $299,000 | | | $1,000,000 or more |
D-11
| | |
| (iv) | Current Net Worth Exclusive of Home, Furnishing and Automobiles: |
| | | | |
| ______ Less than $49,000 | | ______ $300,000 - $599,000 | |
| ______ $50,000 - $99,000 | | ______ $600,000 - $999,000 | |
| ______ $100,000 - $299,000 | | ______ $1,000,000 or more | |
| | |
| (i) | Profession, Business or Employment: |
| | |
| | |
| | |
| (ii) | Position or Duties: |
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4. | College, Business or Professional education: |
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5. | Investment Experience: |
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| (i) | Please indicate the frequency of your investment in marketable securities: |
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| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
| Approximate current value of such securities: $_________________________________________. |
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| (ii) | Please indicate the frequency of your investment in unmarketable securities: |
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| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
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| (iii) | Investments in other private or limited offerings within the last five years: |
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| _______ Corporate Equity or Debt | | _______ Real Estate |
| _______ Partnerships | | _______ Other | |
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| (iv) | Do you make your own investment decisions with respect to such investments? |
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| _______ Often | | _______ Seldom |
| _______ Occasionally | | _______ Never |
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| (v) | What are your principal sources of investment knowledge or advice? (You may check more than one.) |
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| _______ First hand experience within the industry | | _______ Trade or industry publication(s) |
| _______ Broker(s) | | _______ Attorney(s) |
| _______ Financial publication(s) | | _______ Banker(s) |
| _______ Investment adviser(s) | | _______ Accountant(s) |
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IN WITNESS WHEREOF, I have executed Exhibit A of this Questionnaire this ______ day of ______________, 200___. |
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| | | (Signature of Individual) |
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EXHIBIT B
(Complete Only if Required By Applicable Questionnaire)
Please be advised that I am a shareholder, officer, director, partner, member, trustee or other fiduciary agent (specify)___________________________ of ________________ a corporation, partnership, limited liability company, plan, trust or other entity (specify) ______________ (the “Purchaser”), and that I have made the investment decision, by myself or together with others, on behalf of the above-named Purchaser. I understand that the information contained in this letter will be used to determine whether the Purchaser has, alone or with its purchaser representative(s), such knowledge and experience in financial and business matters that it is capable of evaluating the merits and risks of an investment.
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1. | Current Occupation: |
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| (a) | Profession, Business or Employment: |
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| (b) | Business Address and Telephone Number: |
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| (c) | Position or Duties: |
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2. | Prior Employment Positions or Occupations During the Last Five Years (if different than above): |
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| Dates | | Employment, Position or Occupation |
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3. | Business or Professional Education: | | | | |
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| School Degree | | Field of Study | | Dates of Attendance | |
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4. | Investment experience: | | |
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| (a) | Please indicate the frequency of your own investment in marketable securities: |
| | | | |
| | _______ Often | | _______ Seldom |
| | _______ Occasionally | | _______ Never |
| | Approximate current value of such securities: $ ____________________________________. |
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| | | | |
| (b) | Please indicate the frequency of your own investment in unmarketable securities: |
| | | | |
| | _______ Often | | _______ Seldom |
| | _______ Occasionally | | _______ Never |
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| (c) | Investments in private or limited offerings: |
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| Name | | Type of Investment (R&D, Corporate Equity or Debt, Real Estate, etc.) and Amount Invested | | Year of Investment |
| | | | | |
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| (d) | Do you make your own investment decisions with respect to such investments? |
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| | _______ Often | | _______ Seldom |
| | _______ Occasionally | | _______ Never |
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| (e) | What are your principal sources of investment knowledge or advice? (You may check more than one.) |
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| | _______ First hand experience within the industry | | _______ Trade or industry publication(s) |
| | _______ Broker(s) | | _______ Attorney(s) |
| | _______ Financial publication(s) | | _______ Banker(s) |
| | _______ Investment adviser(s) | | _______ Accountant(s) |
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| (f) | Please provide in the space below any additional information which would indicate that you have sufficient knowledge and experience in financial and business matters so that you are capable of evaluating the merits and risks of investing in securities such as the Interests. |
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IN WITNESS WHEREOF, I have executed Exhibit A of this Questionnaire this ______ day of ______________, 200___.
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