Accredited Investor Form / Checklist

 

This form, or one very similar, will often be given to the investor, by a startup, prior to commencing the investment.  Any of the criteria below qualifies one as an accredited investor.

Whether you are making a direct investment, you invest in a Venture Fund or you join an Angel Group, you should expect to sign the agreement below.  I have signed such an agreement for each investment I’ve made as well as for the Angel Group I joined.

Accredited Investor Certification.pdf

ACCREDITED INVESTOR CERTIFICATION

I hereby certify that I am familiar with the definition of “accredited investor” as defined in Rule 501 of Regulation D issued pursuant to the Securities Act of 1933, as amended, and that I meet the criteria to qualify as an accredited investor, in the category or categories indicated below.

  1. [        ] I am a director, executive officer, or general partner of the issuer of the securities being offered or sold, or a director, executive officer, or general partner of a general partner of that issuer.
  2. [        ] I am a natural person whose individual net worth, or joint net worth with that of my spouse, is at least $1,000,000, excluding the value of my primary residence, but including indebtedness secured by such residence in excess of the value of such residence, and calculated in accordance with the below-described rules.
  3. [        ] I am a natural person who had individual income in excess of $200,000 in each of the two most recent years or joint income with my spouse in excess of $300,000 in each of those years and I have a reasonable expectation of reaching the same income level in the current year.

 

Rules regarding primary residences: In calculating my net worth, I have (i) excluded my primary residence as an asset, (ii) excluded debt secured by such residence, up to the estimated fair market value of the residence; (iii) included the amount of any increase on the debt secured by the primary residence incurred within 60 days prior to the purchase of the securities (unless related to the acquisition of the primary residence); and (iv) included debt in excess of the fair market value of the primary residence.

 

Dated:

Signature:

Print name:

Address:

 

 
   

   

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