Name

Street Address:

City:

Zip:

Phone:

Occupation:

Business Address:

Business City:

Business Zip:

Business Phone:

1. Principal place of residence:

2. Is a residence maintained in any other state?

Yes

No

2 (a). If yes, in which state(s)?

3. 11 state income tax return filed?

Yes

No

3 (a). If yes, in which state(s)?

4. State in which you are registered to vote:

5. State(s) in which you hold a driver’s license:

6. Age:

Under 21

21 - 30

31 - 40

41 - 50

51 - 64

Over 64

7. Gross income for the calendar year ended 12/31/10. More than (check one):

$60,000

$80,000

$100,000

$200,000

$500,000

8. Federal income tax bracket for the calendar year ended 12/31/11 (i.e., the taxable rate imposed upon the last dollar of taxable income reported on the 2011 federal tax return):

9. Approximately what percentage of your gross income for the calendar year ended 12/31/11 remained after payment of federal, state, and local taxes, and after payment of all ordinary necessary living expenses?

10. Estimated gross income for the calendar year ending 12/31/12. More than (check one):

$60,000

$80,000

$100,000

$200,000

$500,000

11. Estimated average yearly gross income from all sources anticipated for the three-year period ending 12/31/11. More than (check one):

$60,000

$80,000

$100,000

$200,000

$500,000

11 (a). What percentage of your 2011 income as shown above is anticipated to be derived from sources other than salary?

12. Current estimated net worth in excess of (check one):

$100,000

$200,000

$500,000

$1,000,000

$2,000,000

12 (a). What percentage of your net worth shown is invested in “tax shelter” investments and investments in marketable securities (stocks, bonds, debentures, or notes)?

12 (b). What percentage of your net worth as shown above constitutes home, furnishings, and automobiles?

12 (c). What percentage of your net worth as shown above constitutes liquid assets (cash or assets readily convertible to cash)?

13. Education background, including dates of attendance and degrees:

14. Please describe briefly principal positions held during the last ten years or since graduation from college. Specific employers need not be identified. What is sought is a sufficient description to enable The Company to determine the extent of vocationally related experience in financial and business matters.

Investment Experience

15 (a). Please indicate the frequency of your investment in marketable securities such as publicly-traded stocks or bonds:

Often

Occasionally

Seldom

Never

15 (b). Please indicate the frequency of your investment in unmarketable securities such as privately-offered interests such as herein:

Often

Occasionally

Seldom

Never

15 (c). Please describe below your principal investments, including date of investment, name of company, amount invested, and brief description of company’s business:

15 (d). Do you have an advisor who will assist you in evaluating the merits and risks of this investment? If so, how long have you know him and in what capacity?

15 (e). Please indicate in the space provided below any additional information which you think might be helpful in enabling the Company to determine that your knowledge and experience in finance and business is sufficient to enable you to evaluate the merits and risks of this investment.

By clicking submit, I acknowledge that to the best of my knowledge and belief, the above information supplied by me is true and correct in all respects.

IN WITNESS WHEREOF, I have executed this Questionnaire this 22 day of February, 2012.