|
Scroll down ↓ to bottom of page for a printable copy of this questionnaire.
1. RETURN OF FORM. All responses will be kept confidential. After you complete and sign this form,
please mail, fax or email it to:
Local Loan Company
125 N.W. 114th, #2
Portland, OR 97229
Telephone: 503-646-5626
Email: vincekane@alocalloan.com
2. PERSON COMPLETING THIS FORM
a. Name: (First, Middle Initial, Last): ______________________________________________
b. Date of Birth: __________________
c. Home Address: ____________________________________________________________
d. State in which you are registered to vote: _________________
e. Home Telephone: _____-_______-__________
f. Cell Phone: _____-_______-__________
g. Email Address: ____________________________________________________________
h. Business/Profession: ________________________________________________________
i. Title: ____________________________________________
j. Company Name: ___________________________________
k. Employed Since: ____________________
l. Business Address: ___________________________________________________________
m. Business Telephone: ____-______-___________
3. CONTACT METHOD FOR COMMUNICATIONS. To which place would you prefer that communications
be sent?
____ Home Address ____ Business Address ____Email Address
____ Other (please specify)________________________________________________
4. ENTITY INFORMATION. If you are submitting this form on behalf of an entity (corporation,
limited liability company, etc), employee benefit plan or trust with assets of at least $5 million, please complete
the following:
a. Name of entity, plan or trust:_________________________________________________
b. Name of state where entity, plan or trust was formed: _______________
and check any of the following that apply:
c._____ The undersigned is a corporation, partnership, business trust or charitable organization
with assets in excess of $5 million that was not formed to acquire securities offered by the
company presenting this questionnaire;
d._____ The undersigned is a bank, a savings and loan association, a broke or dealer registered
pursuant to Section 15 of the Securities Exchange Act of 19343, an insurance company, an investment
company registered under the Investment Company Act of 1940, a business development company
as defined in Section 2(a)(48) of that Act, a Small Business Investment Company licensed by the U.S. Small
Business Administration
under section 301(c) or (d) of the Small Business Investment Act of 1958,
a private business development company as defined in Section 202(a)(22) of the Investment Advisors
Act of 1940;
e.______ The undersigned is an employee benefit plan a) either established and maintained by a
government entity or governed by the Employee Retirement Income Security Act of 1974 (ERISA)
and in either case with total assets in excess of $5 million, or b) governed by ERISA and where investment
decisions are either made by a bank, savings and loan association, insurance company, or registered
investment adviser or, if a self-directed plan, with investment decisions made solely by persons that are
accredited investors;
f._____ The undersigned is a trust with assets of at least $5 million, not formed to acquire securities
offered by the company presenting this questionnaire, and whose purchases are directed by a
sophisticated person who, either alone or with his/her independent purchaser representative, has such
knowledge and experience in financial and business matters that he/she is capable of evaluating the merits
and risks of a prospective investment.
If you have checked any of these items, please skip to the signature lines at the bottom.
g. Was your corporation, limited liability company, partnership, or other organization specifically
formed for the purpose of acquiring securities offered by company presenting you with this questionnaire?
_____ Yes _____ No
If the answer is YES, each of the owners is your company will need to complete this questionnaire.
5. OVERALL INVESTMENT OBJECTIVES. Please rank your investment objectives from
1 through 4 in order of priority; 1 being the highest):
_____Growth
_____Current Income
_____Tax Deferral
_____Liquidity
6. RISK TOLERANCE. Please check one:
_____Aggressive ______Moderate ______Conservative
7. SPECULATION. Do your investment objectives allow speculation?
_____Yes ______No
8. ACCREDITED INVESTOR STATUS; please check every item that applies
a._____ My net worth (either individually or with my spouse, if any), including home(s), investments
and all property and other assets, is at least $1,000.000.
b._____ My individual annual income was at least $2000,000 in each of the two most recent
years, and I expect such income in the current year.
c._____ My annual income, jointly with my spouse, was at least $3000,000 in each of the
two most recent years, and I expect such income in the current year.
d._____ The undersigned is an entity and all of the entity's equity owners meet at least
one of the three tests listed above.
e._____ The undersigned is a revocable trust created by the undersigned for his or her
own benefit who meets at least one of the first three tests listed above.
9. QUALIFIED INVESTOR STATUS; please check every item that applies:
a. _______I, either individually or jointly with my spouse, have a minimum net worth of
two hundred fifty thousand dollars ($250,000) and had, during the immediately preceding tax year,
gross income in excess of one hundred thousand dollars ($100,000) and reasonably expect gross
income in excess of one hundred thousand dollars ($100,000) during the current tax year.
I understand that for this purpose ?Net worth? excludes my and my spouse’s home, home
furnishings, and automobiles, and other assets are valued at fair market value.
b. _______ I, either individually or jointly with my spouse, have a minimum net worth
of five hundred thousand dollars ($500,000). ?Net worth? must be determined exclusive of home,
home furnishings, and automobiles. I understand that for this purpose ?Net worth? excludes
my and my spouse’s home, home furnishings, and automobiles, and other assets are
valued at fair market value.
10. EDUCATION. Please list your highest level of education and any degrees (including field if
applicable) that you have received:
______________________________________________________________
_______________________________________________________________
11. LICENSES. Please list any job-related licenses that you hold or have held in the past:
_______________________________________________________________
_______________________________________________________________
12. JOB EXPERIENCE. Please briefly summarize any job experience that you have had that may
show familiarity with business matters and/or investments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
13. PRIMARY SOURCE OF INCOME:
_______ Investments _______Compensation
14. PRIOR INVESTMENT EXPERIENCE; please check all that apply:
I have experience as an investor in:
_______ Stocks which are listed on a national securities exchange.
_______ Mutual funds which hold a portfolio primarily consisting of stocks.
_______ Taxable bonds or other debt instruments.
_______ Tax exempt bonds.
_______ Partnerships, limited liability companies, corporations which invest in real estate or real estate
investment trusts (REITs).
_______ Other types of investments not mentioned in any of the previous categories (please describe):
_____________________________________________________________________________________
15. PORTFOLIO. Please estimate the percentage of your assets that you currently have in each category:
_______% Stocks (including mutual funds)
_______%Bonds
_______% Certificates of Deposit/Loans/Savings Accounts
_______% Principal Residence
_______%Vacation Home(s)
_______% Rental Property
_______%Ownership of business(es) in which you are actively involved
_______%Other
100% total
16. SOPHISTICATED INVESTOR STATUS; please check each item that applies:
_______ I have such knowledge and experience in financial, investment and business matters that
I am capable of evaluating the merits and risks of any investments.
_______ I am using a financial advisor, planner, or consultant, or some other advisor who has such
knowledge and experience in financial and business matters that he/she/it is capable of evaluating the
merits and risks of any investments. (If this is checked, please complete the following:)
The name and contact information for this advisor is as follows:
Name: ___________________________________________
Address: _________________________________________
___________________________________________
___________________________________________
Telephone Number: _______-_________-________
Email address (if available): __________________________
Date: _________________________
Sign Name: _______________________________
Print Name: _______________________________
Name of Entity, Pension Plan or Trust, if applicable:________________________________
|
