ACCREDITED (SOPHISTICATED) INVESTOR FORM
(All information supplied in response to this form will be treated as confidential.)
This form must be completed for EACH Individual Investor.
Owners of joint accounts must complete separate forms.
SECTION I.
Individual Name (“Investor”):
Print Individual Name
Social Security Number - -
Print Social Security Number
The above Investor is investing in the following company that has been certified as a Qualified New Business Venture (QNBV) by the Wisconsin Economic Development Corporation.
QNBV Name (“Issuer”):
Print Name of QNBV
SECTION II. (Check all that apply.)
a) The undersigned is an individual with a net worth or a joint net worth together with his or her spouse in excess of $1,000,000, excluding the value of the primary residence. (In calculating net worth, you may include equity in personal property, real estate [excluding primary residence], cash, short-term investments, stock and securities. Please note that the equity in personal property and real estate should be based on the fair market value of such property minus debt secured by such property.)
b) The undersigned is an individual that had income in excess of $200,000 in each of the prior two years and reasonably expects an individual income in excess of $200,000 in the current year.
c) The undersigned is an individual that had with his/her spouse joint income in excess of $300,000 in each of the prior two years and reasonably expects joint income in excess of $300,000 in the current year.
d) The undersigned is a director or executive officer or general partner of the Issuer.
e) The undersigned is an individual who has knowledge and experience in financial and business matters, and he or she is capable of evaluating the merits and risks of the prospective investment, or the Issuer reasonably believes immediately prior to making this sale that the undersigned comes within this description.
SECTION III. CERTIFICATIONS AND ATTESTATIONS (Please read and initial each paragraph)
______The undersigned certifies and understands that WEDC does not endorse the quality of management or the potential for earnings of the Issuer. Furthermore, the Issuer’s use of the phrase “certified” and/or “qualified new business venture” is not a recommendation or endorsement of the investment or the company by the Wisconsin Economic Development Corporation.
______The undersigned certifies than he or she does not control or is not closely related (spouse, grandparent, parent, sibling, child, stepchild, grandchild) to someone who controls more than 20% of the ownership interest in the Issuer at the time of the investment.
______The undersigned further attests and certifies that the investment was/will be used for legitimate business purposes* and is expected to be kept in the certified business* for a minimum of 36 months from the date the investment is made. An investment held for less than 36 months or not used for legitimate business purposes shall be subject to revocation and recapture of the tax credit benefits by WEDC and the Wisconsin Department of Revenue.
*These terms are further defined in the Wisconsin Economic Development Corporations policies on this program. For more information see (
______
Signature (digital signature acceptable)Date
Printed Name of Above SignatureArea Code/Phone
Home Address (Street, PO Box, City, State, Zip)
Annual Investment Credits are issued first come, first served and based on the date Wisconsin Economic Development Corporation receives the completeddocumentation of the investment from the Issuer, not based on the date the investment is made by the Investor.
Accredited (Sophisticated) Investor Status Form.docCDS 12/7/2011