or partnership, not
formed for the specific purpose of acquiring the securities offered, with assets
in excess of $5 million.
EXHIBIT "A" TO ACCREDITED INVESTOR QUESTIONNAIRE
ACCREDITED CORPORATIONS, PARTNERSHIPS, LIMITED LIABILITY COMPANIES, TRUSTS OR
OTHER ENTITIES INITIALING QUESTION 8B(xi) MUST PROVIDE THE FOLLOWING
INFORMATION.
I hereby certify that set forth below is a complete list of all equity owners in
__________________ [NAME OF ENTITY], a
[TYPE OF ENTITY] formed pursuant
to the laws of the State of
. I also certify
that EACH SUCH OWNER HAS INITIALED THE SPACE OPPOSITE HIS OR HER NAME and that
each such owner understands that by initialing that space he or she is
representing that he or she is an accredited individual investor satisfying the
test for accredited individual investors indicated under "Type of Accredited
Investor."
signature of authorized corporate officer, general partner or trustee
Name of Equity Owner
Name of Equity Owner2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2 Indicate which Subparagraph of 8.1 ‐ 8.3 the equity owner satisfies.