Form of Subscription Agreement with Consent to Electronic Delivery Form




 Exhibit 4.1 

 

 

 For additional questions or assistance, please call Client Services at 800-557-4830 or 770-243-8282. You
also may contact us by e-mail at client.services@wellsref.com or visit our Web site at www.WellsTimberland.com. 
  

									
	  1.  Investment Information	 	 	 		 	  2.  Type of Ownership
	      ̈  I have an existing account at Wells. My Account Number is             
                        
  
 Investment Type (Please check one)
                   Dollar Amount $
                            
      ̈    Initial Investment (Minimum
$5,000)          In the event of a discrepancy between the
                   dollar amount indicated above and that of the
                   actual check(s) received, the check amount(s)
      ̈  Additional Investment (Minimum
$100)       will govern.
  
 State in which sale was made if other than state of residence
                            
  
 Method of Payment
  
      ̈  Check Enclosed       ̈  Wire       ̈  Transfer Request       ̈  Check Under
                                         
  Separate Cover
  
                 (Check Under Separate Cover may delay the processing of your investment)
  
 Please make check(s) payable to: Wells Timberland REIT, Inc.
  
	 	 	 		 	  
      ̈  Individual
  
            ̈  Transfer on Death Requires “Designation of TOD
    Beneficiary Form”
  
      ̈  Joint Tenants with Right of
Survivorship
  
            ̈  Transfer on Death Requires “Designation of TOD
    Beneficiary Form”
  
      ̈  IRA                      Type        
                                         
              
  
      ̈  Trust/Trust                              
                                         
           
  
           Please specify Family, Living, Revocable, etc.
  
      ̈  UGMA                  State            
                                         
         
  
      ̈  UTMA                  State            
                                         
         
  
      ̈  Community Property
  
      ̈  Tenants-in-Common
  
      ̈  Qualified Plan       Type                     
                                        

  
      ̈  Other
                                         
                                         
       

	 WE DO NOT ACCEPT Cash, Cashier’s Checks under $10,000, Third-Party Checks, Money
Orders, Traveler’s Checks, Starter Checks, or Counter Checks, due to Anti-Money Laundering considerations.
	 		 	 	 		 	

  

	
	  3.  Registration and Contact Information

  

	
	      ̈  Mr.       ̈  Mrs.       ̈  Ms.       ̈  M.D.       ̈  Ph.D.       ̈  D.D.S.       ̈  Other
                                         
                                         
  


  

							
	
	  

	 1st Registration
	 	 Investor Name
	 	 Social Security/Taxpayer ID Number
	 	Birth Date
	
	  

	 2nd Registration
	 	 Investor Name
	 	 Social Security/Taxpayer ID Number
	 	Birth Date
	
	  

	 3rd Registration
	 	 Investor Name
	 	 Social Security/Taxpayer ID Number
	 	Birth Date


							
	
	  

	 Investor Street Address (Required by USA PATRIOT Act)
	 	 City
	 	 State
	 	Zip
	
	  

	 Investor Mailing Address (if different)
	 	 City
	 	 State
	 	Zip
	
	  

	 Investor Home Telephone
	 	 Investor Business Telephone
	 		 	

  

	
	      ̈  U.S Citizen     ̈  Resident Alien - Country of Origin
                                         
          ̈  Nonresident Alien - Country of Origin
                                         
     


 A U.S. street address and a U.S. Social Security number or Taxpayer
Identification Number are required to open an account. In addition, Nonresident Aliens also must supply IRS Form W-8BEN 
 
  

											
	  4.  Institutional Information	 		 	 
	  
	 		 	[Affix Signature Guarantee Stamp Here]
	 Custodian Name
	 		 	 
			 
	  
	 		 	 
	 Custodian Address
	 	 City
	 	 State
	 	 Zip
	 		 	 
			 
	  
	 		 	 
	 Telephone
	 	Custodian Tax ID	 		 		 	 
			 
	  
	 		 	 
	 Custodian Account Number
	 		 	 
			 
	  
	 		 	 
	 Custodian Signature (Required)
	 		 	 

  

	
	  5.  Electronic Delivery Election

 We encourage you to reduce
printing and mailing costs. Please review the accompanying instructions carefully and check the items below. 
  

	
	      ̈  Yes           ̈  No           Receive
stockholder communications electronically.
  

	      ̈  Yes           ̈  No           Receive
quarterly statements online.
  

	     My e-mail address is
                                         
                                         
                                         
                                         
        .


     Your e-mail address will be
held in confidence and used only for matters relating to your Wells Timberland REIT investments. 
  

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	  6. Dividend Information


 If you elect to participate in the Distribution Reinvestment Plan, you must agree that, if at any
time you fail to meet the applicable income and net worth standards or you cannot make the other investor representations or warranties set forth in the then current Prospectus or the Subscription Agreement relating to such investment, you will
promptly notify Wells Timberland REIT in writing of that fact. 
 ONLY ONE OF THE FOLLOWING OPTIONS MAY BE SELECTED. If
this section is not completed, distributions will be paid to the registered owner (or custodian, if applicable) at the address above. 
  

	 ̈	 I prefer to participate in the Distribution Reinvestment Plan. (If selling commission is being waived, attach the Distribution Reinvestment Plan
— Discounted Shares form.) 


  

	 ̈	 I prefer to receive a distribution check at the address of record for my account. 


  

	 ̈	 I prefer to receive my distributions via Electronic Funds Transfer into the following checking account: 


  

							
	  

	 Institution Name
	 	Account Name	 	Institution ABA Number	 	Account Number

  

													
	
 



	  	 TERMS OF AGREEMENT: I/we authorize and direct Wells Timberland REIT to begin making electronic
deposits into the checking account designated above or on the attached voided check. An automated deposit entry shall constitute my/our receipt for each transaction. This authority is to remain in force until Wells Timberland REIT has received
written notification from me/us of its termination at such time and in such manner as to give Wells Timberland REIT reasonable time to act on it.
  
  ̈       I prefer
to have my distributions paid to a third party for the benefit of the registered owner at the following address:

			
	  
	  		  	  

	 Last Name/Third-Party Institution
	  	First	  		  	Middle	  		  	 Telephone Number

			
	  
	  		  	
	 Address
	  		  		  		  		  	
			
	  
	  		  	  

	 City
	  		  	State	  	Zip	  		  	 External Account Number


  

	
	  7.
Subscriber Signatures

 Please separately initial each of the representations in (a) through
(d) below, and the remaining representations as applicable. Except in the case of fiduciary accounts, you may not grant any person a power of attorney to make such representations on your behalf. In order to induce Wells Timberland REIT, Inc.
(the “Company”) to accept this subscription, I hereby represent and warrant to you as follows: 
  

							
	 Primary
 Investor
	  	Joint Investor	  	Joint Investor	  	
	  
	  	  
	  	  
	  	 (a) I have received a final Prospectus and accept the conditions of the Wells Real Estate Funds Privacy Notice. I acknowledge that the Company will
not complete a sale of shares to me until at least five business days after the date I have received a final prospectus. I will receive a written confirmation of purchase. If the sale is not completed, I am entitled to a refund of my subscription
amount upon written request to the Company.

	 Initials	  	Initials	  	Initials	  
		  		  		  
		  		  		  
		  		  		  
	  
	  	  
	  	  
	  	  
 (b) I have (1) a net worth
(exclusive of home, home furnishings, and automobiles) of $250,000 or more; or (2) a net worth (as described above) of at least $70,000 and had during the last tax year or estimate that I will have during the current tax year a minimum of $70,000
gross annual income, or I meet the higher income and net worth requirements imposed by my state of primary residence as set forth in the Prospectus under “Suitability Standards.” I will not purchase additional Shares unless I meet these
income and net worth requirements at the time of final purchase.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
		  		  		  
		  		  		  
		  		  		  
	  
	  	  
	  	  
	  	  
 (c) I acknowledge that the Shares
are not liquid and that the Company has not yet elected nor qualified to be taxed as a REIT. I further acknowledge that it is not anticipated that the Company will qualify for REIT tax status prior to the taxable year ending December 31,
2009.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (d) I am purchasing the Shares for my own account. (Fiduciaries should make the representation if purchasing for the fiduciary
account.)

	  Initials
	  	Initials	  	Initials	  
				
	  
	  	  
	  	  
	  	 (e) If I am an Alabama investor, I must have either (1) net worth of at least $350,000 or (2) annual gross income of at least $70,000 and a
minimum net worth of $100,000. In addition, I must have a liquid net worth of at least 10 times my investment in this program and in other similar programs. If I am an Alabama investor, I am not eligible to participate in the Company’s
automatic investment plan.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
		  		  		  
		  		  		  
				
	  
	  	  
	  	  
	  	 (f) If I am an Arizona or Pennsylvania investor, I have either (1) a net worth of at least $500,000 or (2) an annual gross income of at
least $140,000 and a net worth of at least $140,000. Additionally, I have a net worth of at least 10 times my investment in the Company.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (g) If I am a California, Massachusetts, Ohio, or Oregon investor, in addition to the suitability requirements in 7(b)
above, my investment in the Company may not exceed 10% of my liquid net worth.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (h) If I am an Iowa investor, I have either (1) a minimum annual gross income of $70,000 and a minimum net worth of $100,000 or (2) a minimum
net worth of $350,000. Additionally, I may investment no more than 10% of my liquid net worth in the Company or its affiliated programs.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (i) If I am a Kansas investor, in addition to the suitability requirements in 7(b) above, I understand that the state of Kansas recommends
that my aggregate investment in the Company and similar direct participation investments should not exceed 10% of my liquid net worth, which is defined as that portion of net worth which consists of cash, cash equivalents, and readily marketable
securities.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
		  		  		  
				
	  
	  	  
	  	  
	  	 (j) If I am a Kentucky investor, I have either (1) a minimum annual gross income of $85,000 and a minimum net worth of $85,000 or (2) a
minimum net worth of $300,000. Additionally, my investment in the Company may not exceed 10% of my liquid net worth.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (k) If I am a Michigan investor, in addition to the suitability requirements in 7(b) above, my aggregate investment in the Company and similar
direct participation investments may not exceed 10% of my liquid net worth.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
				
	  
	  	  
	  	  
	  	 (l) If I am a New Jersey investor, I must have either (1) a minimum annual gross income of $200,000 and a minimum net worth of $200,000 or (2)
a minimum net worth of $500,000 exclusive of home, home furnishings, and automobiles. Additionally, I may invest no more than 10% of my liquid net worth in the Company and affiliated programs.

	  Initials
	  	Initials	  	Initials	  
		  		  		  
		  		  		  
				
	  
	  	  
	  	  
	  	 (m) If I am a Tennessee investor, I must have either (1) a minimum annual gross income of $150,000 and a minimum net worth of $150,000 or (2)
a minimum net worth of $500,000, exclusive of home, home furnishings, and automobiles.

	  Initials
	  	Initials	  	Initials	  
		  		  		  

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 I declare that the information supplied above is true and correct and may be relied upon by Wells
Timberland REIT, Inc. in connection with my investment in the Company. 
 Under penalty of perjury, by signing this Signature
Page, I hereby certify that (a) I have provided herein my correct Social Security or Taxpayer Identification Number; (b) I am not subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal
Revenue Service has notified me that I am no longer subject to backup withholding; and (c) I am a U.S. Citizen unless I have indicated otherwise in Section 3. 
 I understand that I will not be admitted as a stockholder until my investment has been accepted. Depositing of my check alone does not constitute acceptance. The acceptance process
includes, but is not limited to, reviewing the Subscription Agreement for completeness and signatures, conducting an Anti-Money Laundering check as required by the USA Patriot Act, and depositing of funds. 
 I represent that I am not a person with whom dealings by U.S. persons are, unless licensed, prohibited under any Executive Order or federal
regulation administered by the U.S. Treasury Department’s Office of Foreign Assets Control. 
 The Internal Revenue
Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. 
  

															
	  
	  		  	  
	  		  	  

	 Signature of Investor or Trustee
	 	 Date    
	  		  	 Signature of Joint Owner, if applicable
	  	 Date    
	  		  	 Signature of Joint Owner, if applicable
	  	Date    

 PLEASE NOTE THAT THIS MUST BE SIGNED AND INITIALED BY TRUSTEE(S) IF A QUALIFIED PLAN. THIS APPLICATION WILL NOT BE PROCESSED IF ANY SIGNATURES OR INITIALS ARE MISSING. 
  

	
	  8. Broker/Dealer or
Registered Investment Adviser (RIA) Information

  

													
	 The Broker/Dealer or RIA must make the representations described in the instructions to this Agreement by signing below to complete the order.

	  		  	 FOR EXPEDITED PROCESSING
 Rep. Number Commission Code
	  		  	
	  
 BROKER/DEALER OR
RIA
	  		  	 	  	
			
	  
	  		  	 IARD/CRD number (if applicable)                                
                             

	 Broker/Dealer or RIA Firm Name
	  		  	
			
	  
	  		  	  

	 Authorized Signature (if necessary)                               
                                         
         Date
	  	 Broker/Dealer or RIA Firm Telephone Number
	  		  	
		
	 INDIVIDUAL REPRESENTATIVE(S)
	  	  
 Broker/Dealer Account Number (if applicable)

	
	  

	 Primary Representative Name
	  	                                         
                Telephone Number
	  	 E-mail Address
	  	Split % (if applicable)        
	
	  

	 Secondary Representative Name
	  	                                         
                Telephone Number
	  	 E-mail Address
	  	Split % (if applicable)        
	
	  

	 Tertiary Representative Name
	  	                                         
                Telephone Number
	  	 E-mail Address
	  	Split % (if applicable)        
	
	  

	 Firm Name (if different from Broker/Dealer or RIA name)                Office Address     
                                         
          City                               
          State                               
                      Zip
	  	Office Telephone        

 THIS SUBSCRIPTION WAS MADE AS FOLLOWS: 
  

					
		 	  ̈
	  	 Through a participating Broker/Dealer — Indicate the one correct commission rate below.

			
		 		  	 — (1) Full commission

			
		 		  	 — (2) Waiver of selling commission; purchase through an investment adviser

			
		 		  	 — (3) Waiver of selling commission; purchase is for participating Broker/Dealer or its retirement plan, or for a representative of participating
Broker/Dealer or his or her retirement plan or family member(s)

			
		 	  ̈
	  	 Through a representative and RIA unaffiliated with a Broker/Dealer (Certification of Client Suitability Form must be attached).



I am aware of all of the Prospectus Supplements that constitute a part of the Prospectus as of this date. I have ensured that all such Prospectus
Supplements were delivered to the investor, and applicable state suitability guidelines were reviewed, prior to the investor’s completion of the Subscription Agreement. 
  

															
	  
	  		  	  
	  		  	  

	 Primary Representative Signature
	 	 Date
	  		  	 Secondary Representative Signature
	  	 Date
	  		  	 Tertiary Representative Signature
	  	Date

 PLEASE NOTE THAT
THIS SUBSCRIPTION AGREEMENT CANNOT BE PROCESSED WITHOUT THE SIGNATURES OF ALL REPRESENTATIVES LISTED ABOVE. 
 For
Internal Use Only 
  

													
	 Accepted by:
	 	  
	  		  		  	
							
	 Batch:
	 	  
	 		  	 Cert:
	  	  
	  	 Wells Account:
	  	  


  

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	TMMPFORMP0911-0944-B	 	© 2009 Wells Real Estate Funds










 

 

 Please follow these instructions carefully. Failure to do so may result in the rejection of your
subscription. 
  

	
	1. INVESTMENT INFORMATION

 A minimum investment of $5,000 is required. A check for the full purchase price of the shares subscribed for should be made payable to “Wells Timberland REIT, Inc.” Only persons meeting
the standards set forth under the “Suitability Standards” section of the Prospectus may purchase shares. Please indicate the state in which the sale was made if other than the state of residence. 
 All additional investments must be for a minimum of $100. If additional investments in Wells Timberland REIT, Inc. (the “Company”)
are made, the investor agrees to notify the participating broker/dealer (“Broker/Dealer”) or investment adviser named in Section 8 of the Subscription Agreement. 
 Note: DUE TO ANTI-MONEY LAUNDERING CONSIDERATIONS, THE COMPANY WILL NOT ACCEPT CASH, CASHIER’S CHECKS UNDER $10,000, THIRD-PARTY CHECKS, MONEY ORDERS, TRAVELER’S CHECKS,
STARTER CHECKS, OR COUNTER CHECKS. 
  

	
	2. TYPE OF OWNERSHIP

 Please check the appropriate box to indicate the account type of subscribing investor. 
 In order to effect a Transfer
on Death (TOD) account registration, a Designation of TOD Beneficiary Form must be completed and submitted with the Subscription Agreement. 
  

	
	3. REGISTRATION AND CONTACT INFORMATION

 Please enter the exact name in which the Shares are to be held: 
  

	 	•	 	 Joint tenants with right of survivorship or tenants-in-common, include the names of both investors 


  

	 	•	 	 Partnerships or corporations, include the name of an individual to whom correspondence will be addressed 


  

	 	•	 	 Trusts should include the name(s) of the trustee(s) 


 All investors must complete the space provided for Taxpayer Identification Number or Social Security number. By signing in Section 7, the investor is certifying that this number is correct. Enter the
mailing address and telephone numbers of the registered owner of this investment. In the case of a qualified plan or trust, this will be the address of the trustee. Indicate the birth date of the registered owner unless the registered owner is a
legal entity. 
  

	
	4. INSTITUTIONAL INFORMATION

 If the investment is being made for an account held with a custodian, the custodian information should be entered here. Fill in the Custodian Name, Address, Telephone Number, and Tax ID along with the
Custodian Account Number. An authorized individual must sign the form approving the investment and include either the Custodian’s Signature Guarantee Stamp or a Corporate Resolution naming the authorized signer along with an example of their
signature. 
  

	
	5. ELECTRONIC DELIVERY ELECTION

 We encourage you to reduce printing and mailing costs and to conserve natural resources by electing to receive electronic delivery of stockholder communications and statement notifications. By consenting
below to electronically receive stockholder communications, including your account-specific information, you authorize Wells Timberland to either (i) e-mail stockholder communications to you directly or (ii) make them available on its
Investor Web site at www.WellsTimberland.com and notify you by e-mail when such documents are available. 
 You will not receive
paper copies of these electronic materials, unless specifically requested. 
 The stockholder communications we may offer
electronically include annual reports, proxy materials, and any other documents that may be required to be delivered under federal or state securities laws as well as account-specific information, such as quarterly account statements or tax
information (“Account information”). In addition, by consenting to electronic access, you will be responsible for your customary Internet Service Provider charges (i.e., online fees) in connection with access to these materials. Account
information may be accessed only via the Investor Web site as described in option (ii) in the above paragraph. Your consent will be effective until you revoke it. 
 JOINT ACCOUNTS: If your Social Security number is the primary number on a joint account and you opt-in to electronic delivery, each consenting stockholder must have access to the e-mail account provided.

 Continued on reverse 

 

 









 



 
  

	
	 6. DISTRIBUTION INFORMATION


 ONLY ONE OF THE OPTIONS MAY BE SELECTED. IF THIS SECTION IS NOT COMPLETED, DISTRIBUTIONS WILL BE PAID TO THE REGISTERED OWNER (OR CUSTODIAN, IF APPLICABLE). 
 Please check the appropriate box to indicate to whom the distributions should be paid, in what form they should be paid, and the address of
the individual(s) or institution receiving the distribution if distributions are to be paid to a third party. If no box is checked in this section, the funds will be paid to the registered owner (or custodian, if applicable). 
 For a discussion of the Distribution Reinvestment Plan, please see the section of the Prospectus entitled “Description of Shares —
Distribution Reinvestment Plan.” 
 To receive your distributions via Electronic Funds Transfer, please check the
highlighted box on the subscription document. 
  

	
	7. SUBSCRIBER SIGNATURES

 Please separately initial the representations where indicated. Note the higher suitability requirements described in the Prospectus and/or supplements for residents of certain states. Many states have
restrictions on net worth and income requirements, and some states have restrictions on concentration in certain types of investments or concentrations of investments offered by the same sponsor. Please initial this only after you have discussed
your specific state requirements with your financial representative. Except in the case of fiduciary accounts, the investor may not grant any person a power of attorney to make such representations on his or her behalf. Each investor must sign and
date this section. If title is to be held jointly, all parties must sign. If the registered owner is a partnership, corporation, or trust, a general partner, officer, or trustee of the entity must sign. 
 Note: THESE SIGNATURES DO NOT HAVE TO BE NOTARIZED. 
  

	
	 8. BROKER/DEALER OR REGISTERED INVESTMENT ADVISER (RIA)
INFORMATION


 Who must sign this section. If the investment is made through an investment adviser
unaffiliated with a broker/dealer (“Registered Investment Adviser”), Section 8 must be signed by an authorized representative of the Registered Investment Adviser. Otherwise, this section must be signed by an authorized representative
of the participating Broker/Dealer. 
 Required Representations. By signing this section, the Broker/Dealer or Registered
Investment Adviser represents that he has made every reasonable effort to determine that the purchase of shares in this offering is a suitable and appropriate investment for each investor based on information provided by the investor regarding the
investor’s financial situation and investment objectives. In making this determination, the Broker/Dealer or Registered Investment Adviser ascertained that the prospective stockholder: 
  

	 	•	 	 meets the minimum income and net worth standards set forth in the Prospectus at “Suitability Standards”; 


  

	 	•	 	 can reasonably benefit from an investment in the shares based on the prospective stockholder’s overall investment objectives and portfolio
structure; 


  

	 	•	 	 is able to bear the economic risk of the investment based on the prospective stockholder’s overall financial situation and has apparent
understanding of: 


  

	 	•	 	 the fundamental risks of the investment; 


  

	 	•	 	 the risk that the stockholder may lose the entire investment; 


  

	 	•	 	 the lack of liquidity of the shares; 


  

	 	•	 	 the restrictions on transferability of the shares; 


  

	 	•	 	 the background and qualifications of Wells TIMO and its affiliates; and 


  

	 	•	 	 the tax consequences of the investment. 


 Relevant information for this purpose will include at least the age, investment objectives, investment experience, income, net worth, financial situation, and other investments of the prospective
stockholder, as well as any other pertinent factors. The Broker/Dealer or Registered Investment Adviser agrees to maintain records of the information used to determine that an investment in shares is suitable and appropriate for the stockholder for
a period of six years. 
 In addition, the registered representative of a Broker/Dealer represents that he or she and the
Broker/Dealer are duly licensed to offer the shares in the state where the investment was made and in the state of the investor’s address set forth in Section 3 of the Subscription Agreement. A Registered Investment Adviser represents that
such adviser is either registered under the Investment Advisers Act of 1940 or exempt from registration. 
 Commission.
Please provide the Representative Number Commission Code to prevent delays in processing. Also, Broker/Dealers should select only one commission rate. “Full commission” may not be selected if the investment is made through an
investment adviser representative compensated on a fee-for-service basis in connection with the sale or if the purchase is for a Broker/Dealer, its retirement plan, or its representative (or the retirement plan or family members of its
representative). 
 Note: The Subscription Agreement, together with a check for the full purchase price, should be delivered or
mailed to one of the addresses noted at the top of the Subscription Agreement by the Broker/Dealer or Registered Investment Adviser, as applicable. Only original, completed copies of Subscription Agreements can be accepted. The Company cannot
accept photocopied or otherwise duplicated Subscription Agreements. 
 IF YOU NEED FURTHER ASSISTANCE IN COMPLETING
THIS SUBSCRIPTION AGREEMENT, PLEASE CALL 800-557-4830. 
  

			
	 TMMPFORMI0911-0944-A
	  	© 2009 Wells Real Estate Funds