Skip to content
Home
About Us
Why Texas?
Income Investments
Upcoming Investments
Team
How It Works
Contact
Home
About Us
Why Texas?
Income Investments
Upcoming Investments
Team
How It Works
Contact
COMPLETE THE QUESTIONNAIRE
FOR CONSIDERATION AS AN INVESTOR.
I am a(n):
*
Individual Investor
Corporation, Partnership, Trust, or other Entity
For Individual Investors
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
*
Date of Birth
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you a U.S. Citizen?
Yes
No
College
How did you hear about us?
Business/Employer Name
Nature of Business Employment
Occupations or Duties
Please set forth other prior occupations or duties during the past five years
Year of Anticipated Retirement
For Investors that are Corporations, Partnerships, Trusts, or other Entities
Name
Name of Corporation, Partnership, Trust, or Other Entity
Office Phone
Address of Principle Office
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
State of Incorporation or Organization
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Incorporation or Organization
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Taxpayer Identification Number
Nature of Business
Name and Title
Name and Title of Authorized Individual to Execute the Questionnaire
Name of record and beneficial owners of entity (10% ownership or more)
Please list name and percentage of ownership. One name per line.
For All Investors
Relationship to the Company or Manager of the Company
Is the undersigned an officer or director of a publicly-held company?
Yes
No
If yes, please specify
I ______ personally invested in investments sold by means of private placements within the past five years.
have
have not
Please list all investments made during the past five years (include dates, nature, and amounts of investment)
Do you consider yourself to have such knowledge and experience in financial and business matters to enable yourself to evaluate the merits and risks of investment in the Company?
Yes
No
If yes, please set forth the basis for your answer (e.g. investment or business experience, profession, past review of other investment offerings, etc.)
Listed below are the categories of accredited investors, as defined by Regulation D, promulgated under the Securities Act of 1933, as amended. Please check the appropriate space provided below if the Investor falls within one or more of these categories.
Any natural person whose individual net worth or joint net worth with that person's spouse, at the time of his purchase, exceeds $1,000,000. Net worth includes homes, furnishings and automobiles.
Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
A bank, insurance company, registered investment company, employee benefit plan if the investment decision is made by a bank, insurance company or registered investment adviser, or an employee benefit plan with more than $5 million of assets.
Any private business development company as defined in Section 202(a) (22) of the Investment Advisers Act of 1940.
Any organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose or acquiring the securities offered, with total assets in excess of $5,000,000.
Any director, executive officer or general partner of the issuer of the securities being offered or sold, or any director, executive officer or general partner of a general partner of that issuer.
Any trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii).
Any entity in which all of the equity owners are accredited investors.
The Investor does not qualify in any accredited category as indicated above.
Please indicate whether you intend to have an attorney, accountant, investment advisor or other consultant act as its Purchaser Representative in connection with this investment
Yes
No
If yes, please list below the name, business address and telephone number of the person who is your purchaser representative.
Representative Name
Firm
Phone
Address of Representative
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If the undersigned utilizes a Purchaser Representative, the Purchaser Representative will be required to complete a questionnaire to be supplied by the Company.
Gross Income
If the undersigned is an individual. was your personal income from all sources for the previous calendar year more than (check the HIGHEST number applicable for each year.)
2021 (projected)
$150,000
$200,000
$250,000
2020
$150,000
$200,000
$250,000
2019
$150,000
$200,000
$250,000
Net Worth
My estimated liquid assets equal:
My estimated non-liquid assets equal:
Entities
If the undersigned is an entity which checked item (8) under Paragraph 3(f) above in reliance upon the accredited investor categories set forth in items 1 and 2 of Paragraph 3(f), please state the name, address, total personal income from all sources for the previous calendar year, and the net worth (exclusive of home, furnishings, and personal automobiles) for each equity owner of said entity.
Investor Acknowledgement
The Investor hereby certifies that the information contained herein is complete and accurate and the Investor will notify the Company promptly of any change of information. Specifically, the Investor hereby certifies that the information contained above concerning the residency of the Investor is true and correct. The Investor realizes and understands that, but for the truth of the information contained herein, the Investor would not receive consideration by the Company pertaining to this investment. If the Questionnaire is completed on behalf of a corporation, partnership, trust, or estate, I, the person executing on behalf of the Investor, represent that I have the authority to execute and deliver the Questionnaire on behalf of such corporation, partnership, trust, or estate.
Date
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Signature for Corporation, Partnership, Trust, or other Entity
Name of Investor
By
Signature
Name
Title
Signature for Individual Investor
Signature
Name
Signature of Joint Investor
Name of Joint Investor
Digital Signature
By checking this box, you agree and understand that using an "electronic signature" is legal and binding. By filling in the field labeled "Signature," you are agreeing that all the information given is to the best of your abilities true.
*
I agree