1714 lines
80 KiB
Markdown
1714 lines
80 KiB
Markdown
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# Investor Subscription Agreement
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# UNICORN PAIRS FUND, LP
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## Delaware Limited Partnership
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#### UNICORN CAPITAL PARTNERS, LLC
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```
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General Partner, Investment Manager
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```
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```
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January 1, 2017
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```
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#### DISCLAIMER
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#### THE LIMITED PARTNERSHIP INTERESTS OF UNICORN PAIRS FUND, LP (THE
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#### "FUND") HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933 (THE
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#### "SECURITIES ACT"), OR THE SECURITIES LAWS OF ANY STATE. THE FUND IS NOT
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#### REGISTERED UNDER THE INVESTMENT COMPANY ACT OF 1940 OR THE
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SECURITIES LAWS OF ANY STATE. _(See PPM “Exemptions” § 9.1 & § 9.2)_
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THE FUND OPERATES PURSUANT TO SEC RULE 506(c) OF REGULATION D WHICH
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PROVIDES EXEMPTIVE RELIEF TO BROADLY SOLICIT AND GENERALLY
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ADVERTISE THE OFFERING BUT STILL BE DEEMED TO BE UNDERTAKING A
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PRIVATE OFFERING. _(See PPM “Exemptions” § 9.3)_
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THESE SECURITIES MAY NOT BE TRANSFERRED EXCEPT AS PERMITTED UNDER
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THE SECURITIES ACT AND APPLICABLE STATE SECURITIES LAWS PURSUANT TO
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REGISTRATION THEREUNDER OR EXEMPTION THEREFROM, AND MAY NOT BE
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TRANSFERRED EXCEPT IN ACCORDANCE WITH THE LIMITED PARTNERSHIP
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AGREEMENT. _(See PPM “Assignment” § 8.1)_
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AN INVESTMENT IN THE FUND INVOLVES A SIGNIFICANT RISK OF LOSS.
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_(See PPM “Certain Risk Factors” Article II)_
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THE DELIVERY OF OFFERING DOCUMENTS SHALL NOT CONSTITUTE AN OFFER
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TO SELL, OR THE SOLICITATION OF AN OFFER TO BUY, INTERESTS IN THE FUND
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IN ANY JURISDICTION IN WHICH SUCH OFFER OR SOLICITATION IS NOT
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AUTHORIZED OR TO ANY PERSON TO WHOM IT IS UNLAWFUL TO MAKE SUCH
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OFFER OR SOLICITATION.
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THIS MEMORANDUM DOES NOT CONSTITUTE AN OFFER TO SELL, OR A
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SOLICITATION OF AN OFFER TO BUY, TO ANY PERSON WHO HAS NOT EXECUTED
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AND RETURNED A SUBSCRIPTION AGREEMENT IN FORM AND SUBSTANCE
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SATISFACTORY TO THE GENERAL PARTNER, AND WHOSE PURCHASER
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REPRESENTATIVE, IF ANY, HAS NOT COMPLETED AND RETURNED A PURCHASER
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REPRESENTATIVE QUESTIONNAIRE IN FORM AND SUBSTANCE SATISFACTORY
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TO THE GENERAL PARTNER. THIS OFFERING IS MADE ONLY TO A LIMITED
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NUMBER OF ACCREDITED INVESTORS, AS THAT TERM IS DEFINED IN
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REGULATION D UNDER THE ACT.
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NEITHER THE SECURITIES AND EXCHANGE COMMISSION ("SEC") NOR ANY STATE
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SECURITIES COMMISSION HAS PASSED UPON THE MERITS OF PARTICIPATING IN
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#### THE FUND, NOR HAS ANY COMMISSION PASSED UPON THE ADEQUACY OR
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#### ACCURACY OF THIS MEMORANDUM. ANY REPRESENTATION TO THE CONTRARY
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#### IS A CRIMINAL OFFENSE.
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#### PROSPECTIVE INVESTORS ARE NOT TO CONSTRUE THE CONTENTS OF THIS
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#### MEMORANDUM AS INVESTMENT, TAX OR LEGAL ADVICE. THIS MEMORANDUM
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#### AND THE OTHER DOCUMENTS DELIVERED IN CONNECTION HEREWITH SHOULD
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#### BE REVIEWED BY EACH PROSPECTIVE INVESTOR OR SUCH INVESTOR'S
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#### PURCHASER REPRESENTATIVE, IF ANY, AND SUCH INVESTOR'S FINANCIAL, TAX
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#### OR LEGAL COUNSEL.
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#### THE INFORMATION CONTAINED HEREIN IS ACCURATE ONLY AS OF THE DATE OF
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#### THIS MEMORANDUM. THE INFORMATION IS SUBJECT TO CHANGE AT ANY TIME.
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#### ADDITIONAL INFORMATION IS AVAILABLE FROM UNICORN CAPITAL PARTNERS,
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#### LLC, WHOSE ADDRESS AND TELEPHONE NUMBER IS SET FORTH IN THE
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#### DIRECTORY.
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#### THE OFFERING IS MADE BY DELIVERY OF A COPY OF THIS MEMORANDUM TO
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#### THE PERSON WHOSE NAME APPEARS HEREON AND MEETS THE SUITABILITY
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#### INVESTOR QUALIFICATION STANDARDS (PPM, §3.1) SET FORTH IN THIS
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#### MEMORANDUM.
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#### ACCORDINGLY, IF YOU PURCHASE AN INTEREST, YOU WILL BE REQUIRED TO -
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#### REPRESENT AND WARRANT THAT YOU HAVE READ THIS MEMORANDUM AND
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#### ARE AWARE OF AND CAN AFFORD THE RISKS OF AN INVESTMENT IN THE FUND.
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#### YOU WILL ALSO BE REQUIRED TO REPRESENT THAT YOU ARE ACQUIRING THE
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#### INTEREST FOR YOUR OWN ACCOUNT, FOR INVESTMENT PURPOSES ONLY, AND
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#### NOT WITH ANY INTENTION TO RESELL OR TRANSFER ALL OR ANY PART OF THE
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#### INTEREST. THIS INVESTMENT IS SUITABLE FOR YOU ONLY IF YOU HAVE
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#### ADEQUATE MEANS OF PROVIDING FOR YOUR CURRENT AND FUTURE NEEDS
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#### AND CAN AFFORD TO LOSE THE ENTIRE AMOUNT OF YOUR INVESTMENT.
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#### ALTHOUGH THIS MEMORANDUM CONTAINS SUMMARIES OF CERTAIN TERMS OF
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#### CERTAIN DOCUMENTS, YOU SHOULD REFER TO THE ACTUAL DOCUMENTS
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#### (COPIES OF WHICH ARE ATTACHED HERETO OR ARE AVAILABLE FROM THE
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#### GENERAL PARTNER) FOR COMPLETE INFORMATION CONCERNING THE RIGHTS
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#### AND OBLIGATIONS OF THE PARTIES THERETO. ALL SUCH SUMMARIES ARE
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#### QUALIFIED IN THEIR ENTIRETY BY THE TERMS OF THE ACTUAL DOCUMENTS. NO
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#### PERSON HAS BEEN AUTHORIZED TO MAKE ANY REPRESENTATIONS OR FURNISH
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#### ANY INFORMATION WITH RESPECT TO THE FUND OR THE INTERESTS, OTHER
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#### THAN THE REPRESENTATIONS AND INFORMATION SET FORTH IN THIS
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#### MEMORANDUM OR OTHER DOCUMENTS OR INFORMATION FURNISHED BY THE
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#### GENERAL PARTNER UPON REQUEST, AS DESCRIBED ABOVE.
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#### NO RULINGS HAVE BEEN SOUGHT FROM THE INTERNAL REVENUE SERVICE
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#### ("IRS") WITH RESPECT TO ANY TAX MATTERS DISCUSSED IN THIS
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#### MEMORANDUM. YOU ARE CAUTIONED THAT THE VIEWS CONTAINED HEREIN
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#### ARE SUBJECT TO MATERIAL QUALIFICATIONS AND SUBJECT TO POSSIBLE
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#### CHANGES IN REGULATIONS BY THE IRS OR BY CONGRESS IN EXISTING TAX
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#### STATUTES OR IN THE INTERPRETATION OF EXISTING STATUTES AND
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#### REGULATIONS.
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#### EXCEPT WHERE OTHERWISE INDICATED, THIS MEMORANDUM SPEAKS AS OF
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#### THE DATE HEREOF. NEITHER THE DELIVERY OF THE MEMORANDUM NOR ANY
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#### SALE OF THE SECURITIES DESCRIBED HEREIN SHALL, UNDER ANY
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#### CIRCUMSTANCES, CREATE ANY IMPLICATION THAT THERE HAS BEEN NO
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#### CHANGE IN THE AFFAIRS OF THE FUND OR THE GENERAL PARTNER SINCE THE
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#### DATE HEREOF.
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### Instruction To Subscription Agreement
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A person who desires to invest (“Investor”) in Unicorn Pairs Fund, LP (the “Fund”) should:
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```
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A. Review the attached Subscription Agreement, along with the Fund's Limited Partnership
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Agreement (“LPA”) and Private Placement Memorandum (“PPM”) identified on the
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signature page (page 42), and consult as necessary with Investor’s advisors.
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```
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```
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B. Answer the questionnaires incorporated into the Subscription Agreement. The
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questionnaires begin on page 1 2 (see table of contents on next page). Note to existing
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Investor making an additional capital contribution: If Investor is already a limited
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partner of the Fund and is now making an additional capital contribution, Investor needs
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to supply the requested information only to the extent that Investor’s previous answers
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have changed. See the top portion of the signature page (page 42) for details.
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```
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```
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C. Fill in all requested information on the signature page (page 42), and sign and date that
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page. Also complete, date and sign the Form W- 9 attached to the Subscription Agreement
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(following the signature page). By doing so, Investor will offer to make a cash capital
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contribution to the Fund in the amount specified on the signature page, on the
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“Subscription Date” to be specified on that page. Unicorn Capital Partners, LLC (the
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“General Partner”) will specify the Subscription Date when it countersigns the signature
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page to accept the subscription.
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```
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```
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D. For your records, keep copies of the completed Subscription Agreement and Form W-9,
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and of the Fund’s Limited Partnership Agreement and Private Placement Memorandum
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(including Exhibits).
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```
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```
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E. Send the executed originals of the entire Subscription Agreement and the Form W-9 (by
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mail, and by email as well if possible) to the Fund's subscription administrator at the
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following address:
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```
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```
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Unicorn Capital Partners, LLC
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2323 Hurley Mountain Road
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Kingston, NY 12401
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```
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```
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peter.delrio@unicornfunds.com
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Telephone: (917)- 902 - 0148
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```
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Acceptance of Subscription
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If the General Partner accepts Investor’s offer, a counter-signed copy of the Subscription
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Agreement will be delivered to Investor to confirm acceptance. The General Partner has the right
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to decline any offer.
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Payment
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Payment in U.S. currency, by wire-transfer, will be required at least three business days before
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the Subscription Date. Once the Investor is notified that the Investor's subscription has been
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accepted, the amount of Investor's investment should be transferred to the Fund's custodial
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subscription account (and not to the General Partner) according to the following wiring
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instructions. If the financial institution is located outside the United States, please contact us for
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wiring instructions.
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WIRING INSTRUCTIONS:
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TD BANK NATIONAL ASSOCIATION
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4240 ALBANY POST RD
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HYDE PARK
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NY 12538 US
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Wire Transfer Routing Number: 026013673
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For credit to:
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UNICORN PAIRS FUND LP
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Account Number: 4326140417
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Other information to be provided with payment: Indicate name of Investor, ABA routing
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number and Investor's bank account number).
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## TABLE OF CONTENTS TO QUESTIONNAIRES
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```
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Title Page
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Instruction To Subscription Agreement
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SECTION
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```
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(^) Page
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Basic Investor Information........................................................................ 12
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Contact Information................................................................................ (^14)
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Authorized Investor Representatives and Investor Account Information................... (^16)
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United States Person Status........................................................................ (^18)
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Investor Identity Verification..................................................................... (^20)
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Education, Employment, Experience and Investment Objectives.......................... 22
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Questions to Determine Whether Investor Must Have Purchaser Representative....... (^25)
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Anti-Money-Laundering Provisions.............................................................. (^27)
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Accredited Investor Status......................................................................... (^31)
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Questions to Determine Whether Investor is a Covered Person Under Rule 506........ (^34)
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Private Investment Companies.................................................................. 36
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Benefit Plan Investor Status...................................................................... (^39)
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Subscription Agreement Signature Page....................................................... (^42)
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Notary Acknowledgement....................................................................... (^44)
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The "Investor" identified on the signature page of this Subscription Agreement ("Investor"), and
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Unicorn Pairs Fund, LP (the "Fund"), whose sole general partner is Unicorn Capital Partners,
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LLC (the "General Partner, Investment Manager"), hereby agree as set forth in this Agreement.
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This Agreement is also made for the benefit of the person identified as the "Investment Adviser"
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in the Private Placement Memorandum of the Fund bearing the date specified on the signature
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page of this Agreement (the "Private Placement Memorandum").
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#### SECTION 1
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Investor desires to become a Limited Partner (LPA § 4.1) of the Fund, or to make an additional
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capital contribution if Investor is already a limited partner of the Fund, in either case as of the
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"Subscription Date" to be specified by the General Partner on the signature page of this
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Agreement when the General Partner executes this Agreement on behalf of the Fund. In
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accordance with the terms of the Limited Partnership Agreement identified on the signature page
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of this Agreement (the "Limited Partnership Agreement"), Investor will make a cash capital
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contribution to the Fund in the amount specified as the "Capital Contribution" on the signature
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page of this Agreement. The Fund agrees to admit Investor as a Limited Partner of the Fund, or
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to accept an additional capital contribution from Investor if Investor is already a Limited Partner
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of the Fund, on the Subscription Date, subject to all terms and conditions of the Limited
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Partnership Agreement.
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SECTION 2
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Investor represents, warrants, acknowledges and agrees that:
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```
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A. Investor (with the assistance of Investor's Purchaser Representative, if one has been
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designated on page 2 5 of this Agreement (Investor's "Purchaser Representative") is
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making this investment decision based solely on the facts and terms set forth in this
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Agreement, the Private Placement Memorandum and the Limited Partnership Agreement,
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including the risk factors described in the Private Placement Memorandum. Investor has
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received copies of all such documents. Neither the General Partner, nor any person acting
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or purporting to act on its behalf, has made any representations of any kind to induce
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Investor to enter into this Agreement except as specifically set forth in such documents.
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```
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```
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B. Investor recognizes that an investment in the Fund involves certain risks, including
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those described in the Private Placement Memorandum. Investor (or Investor's
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Purchaser Representative) has carefully reviewed the disclosures of risks
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throughout the Private Placement Memorandum, especially those explained in the
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section entitled "Certain Risk Factors."
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```
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```
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C. Investor (or Investor's Purchaser Representative, if any) has such knowledge and
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experience in financial and business matters that the person can evaluate the merits and
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risks of an investment in the Fund, and Investor can bear the economic risk of a complete
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loss of Investor's investment in the Fund.
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```
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```
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D. Investor will be acquiring an ownership interest in the Fund for investment, for Investor's
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own account, not for the interest of any other person and not for distribution or resale to
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others. THE INVESTOR UNDERSTANDS THAT THE FUND'S OWNERSHIP
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INTERESTS HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF
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1933 (THE "SECURITIES ACT"), OR UNDER THE SECURITIES LAWS OF ANY
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STATE OR OTHER JURISDICTION, AND THE INVESTOR AGREES THAT
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INVESTOR'S INTEREST IN THE FUND MAY NOT BE SOLD, TRANSFERRED, OR
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OTHERWISE DISPOSED OF EXCEPT PURSUANT TO AN EXEMPTION FROM
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REGISTRATION UNDER THE SECURITIES ACT AND UNDER THE SECURITIES
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LAWS OF ANY STATE OR OTHER JURISDICTION WHOSE LAWS MAY APPLY
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TO SUCH PROPOSED TRANSFER. Investor will not assign Investor's ownership
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interest in the Fund or any beneficial interest therein, in whole or in part, to any other
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person, nor will Investor be entitled to substitute any other person for Investor as a
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```
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```
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Limited Partner of the Fund, except on the restrictive terms and conditions stated in the
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Limited Partnership Agreement.
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```
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```
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E. Investor (or Investor's Purchaser Representative, if any) has carefully reviewed the
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provisions in the Private Placement Memorandum relating to certain conflicts of interest
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that will or may arise between the Fund, the General Partner and the Investment
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Manager, or affiliates thereof. Notwithstanding such conflicts, Investor consents to any
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transactions that may be entered into between any such persons in connection with the
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Fund's business, provided that the transaction complies with any applicable terms and
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conditions stated in the Limited Partnership Agreement. Investor's consent shall not
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relieve any person from any fiduciary duty that the person may have to Investor.
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```
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```
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F. Investor (or Investor's Purchaser Representative) has carefully reviewed the provisions, if
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any, in the Private Placement Memorandum relating to the brokerage arrangements of the
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Fund. Investor consents to the Fund engaging in such arrangements.
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```
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```
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G. Investor has provided Investor's correct Social Security or other taxpayer identification
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number where requested in this Agreement (or Investor has applied, and is waiting, for
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such a number to be issued and will promptly report it to the Fund when received).
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Investor is not subject to backup withholding. Investor acknowledges that its failure to
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provide the Fund a correct Social Security number or other taxpayer identification
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number could subject Investor to United States withholding tax on a portion of Investor's
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distributive share of the Fund's income.
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```
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#### SECTION 3
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If Investor is a corporation, partnership, trust or other entity, the person executing this
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Agreement on behalf of Investor represents and warrants by doing so that he or she has authority
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under Investor's governing instruments to bind Investor to this Agreement and the Limited
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Partnership Agreement, and that Investor has authority under its governing instruments to invest
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in the Fund pursuant to this Agreement and the Limited Partnership Agreement. Investor's
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execution of this Agreement shall constitute Investor's agreement to the Limited Partnership
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Agreement fully as if Investor were presently also executing a counterpart signature page of the
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Limited Partnership Agreement.
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SECTION 4
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Any representation made hereunder shall be deemed to be reaffirmed by Investor at any time
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Investor makes an additional capital contribution to the Fund (whether or not Investor executes
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an additional copy of this Agreement in connection with such additional capital contribution, as
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contemplated on the signature page of this Agreement). The act of making the additional
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|||
|
contribution shall be conclusive evidence of such reaffirmation, except to the extent that Investor
|
|||
|
may expressly change, in writing, such a representation and warranty at the time of the additional
|
|||
|
|
|||
|
|
|||
|
capital contribution. If any of the statements, representations or warranties made herein
|
|||
|
shall hereafter become untrue or inaccurate, Investor shall promptly notify the Fund in
|
|||
|
writing, specifically referring to this Agreement and to the specific statements,
|
|||
|
representations or warranties involved, and providing detail sufficient for the General
|
|||
|
Partner to understand and confirm the change(s) described in the notice.
|
|||
|
|
|||
|
SECTION 5
|
|||
|
If Investor is a pension plan, individual retirement account ("IRA") or other tax-exempt entity,
|
|||
|
Investor is aware that it may be subject to Federal income tax, and possibly to certain state
|
|||
|
income taxes, on any unrelated business taxable income from its investment in the Fund, to the
|
|||
|
extent, if any, that the Fund engages in certain forms of leveraged transactions, margin
|
|||
|
borrowing or other borrowing.
|
|||
|
|
|||
|
SECTION 6
|
|||
|
This Subscription Agreement necessarily requests private personal information from Investor.
|
|||
|
The Fund and its representatives will obtain additional information about Investor, such as
|
|||
|
account balances and amounts and dates of additional capital contributions and redemptions. The
|
|||
|
Fund and its representatives do not disclose this information to third parties, other than service
|
|||
|
providers who must obtain access to the information to permit the Fund and the Investment
|
|||
|
Manager to conduct their affairs (for example, auditors, accountants, prime brokers, attorneys
|
|||
|
and other consultants). The Fund and the Investment Manager restrict access to such information
|
|||
|
internally to those personnel who need the information in order to conduct the Fund's and the
|
|||
|
Investment Manager's business. The Fund and the Investment Manager obtain contractual
|
|||
|
assurances from third-party service providers where the Fund and/or the Investment Manager
|
|||
|
consider it necessary or otherwise appropriate to do so, and maintain physical and procedural
|
|||
|
safeguards to provide reasonable protection for the confidentiality of nonpublic personal
|
|||
|
information about Limited Partners. While the Fund and its representatives will use their best
|
|||
|
reasonable efforts to keep confidential Investor's investment in the Fund and the information
|
|||
|
Investor provides to the Fund, (i) there may be circumstances in which a law or regulation
|
|||
|
relating to combating terrorism or money laundering may require the release of such information
|
|||
|
to law enforcement or regulatory officials; (ii) the Fund may present such information to
|
|||
|
regulatory bodies or other parties as may be appropriate to establish the availability of
|
|||
|
exemptions from certain securities and similar laws, or the compliance of the Fund and/or the
|
|||
|
Investment Manager with applicable laws; and (iii) the Fund may disclose such information
|
|||
|
relating to Investor's investment in the Fund when required by judicial process, to the extent
|
|||
|
permitted under privacy laws or to the extent the Fund considers the information relevant to any
|
|||
|
issue in any lawsuit or similar proceeding to which the Fund is a party or by which it is or may
|
|||
|
be bound. If Investor has instructed the Fund to send duplicate reports to third parties pursuant to
|
|||
|
this Agreement, Investor may revoke this instruction at any time by sending a written notice to
|
|||
|
the Fund indicating that a previously authorized third party is no longer authorized to receive
|
|||
|
Investor's reports.
|
|||
|
|
|||
|
|
|||
|
#### SECTION 7
|
|||
|
|
|||
|
Investor recognizes that the Fund operates, or may hereafter operate, in such a way that the
|
|||
|
number of the Fund's beneficial owners is restricted by certain laws, and that, in determining the
|
|||
|
number of beneficial holders, the Fund may have to count separately, as beneficial owners of the
|
|||
|
Fund, the beneficial owners of Investor if Investor is an entity and it owns 10% or more of the
|
|||
|
Fund's ownership interests. Accordingly, if Investor is an entity, it agrees to take whatever action
|
|||
|
is requested by the General Partner at any time, including but not limited to a partial withdrawal
|
|||
|
of Investor's interest in the Fund, to ensure that Investor owns less than 10% of the Fund's
|
|||
|
ownership interests. Investor agrees further to provide the Fund, upon request from the General
|
|||
|
Partner at any time, such information as the General Partner may reasonably request to determine
|
|||
|
whether any or all beneficial owners of Investor are required to be counted separately from
|
|||
|
Investor as beneficial owners of the Fund for the purpose of determining the Fund's compliance
|
|||
|
with the above-described laws. Nothing in this section is intended to limit any other right the
|
|||
|
General Partner may have to require at any time the partial or complete withdrawal of Investor
|
|||
|
from the Fund.
|
|||
|
|
|||
|
SECTION 8
|
|||
|
Investor shall indemnify the Fund, the General Partner and the Investment Manager, and their
|
|||
|
respective affiliates, directors, officers, employees, agents, attorneys and other representatives,
|
|||
|
from and against any and all losses, claims, damages, expenses and liabilities relating to or
|
|||
|
arising out of any breach of any representation, warranty or covenant made by or on behalf of
|
|||
|
Investor in this Subscription Agreement (including its questionnaires) or in any other document
|
|||
|
furnished by Investor to the Fund in connection with Investor's investment in the Fund.
|
|||
|
|
|||
|
SECTION 9
|
|||
|
Disputes arising under this Agreement shall be governed by the law that applies to disputes
|
|||
|
arising under the Limited Partnership Agreement. Notices given under this Agreement shall be
|
|||
|
governed by the provisions applicable to notices given under the Limited Partnership Agreement.
|
|||
|
This Agreement may be signed in counterparts, all of which taken together shall constitute one
|
|||
|
and the same Agreement. This Agreement shall benefit and bind each of the parties hereto, and
|
|||
|
the parties' heirs and legal representatives. This Agreement, and the Limited Partnership
|
|||
|
Agreement it incorporates by references herein, constitute the entire agreement on the subject
|
|||
|
matter hereof between the Fund and Investor, and supersede any prior or contemporaneous
|
|||
|
agreements, arrangements, understandings or representations, whether written or oral, regarding
|
|||
|
such subject matter. This Agreement may be amended, and any or all of its provisions may be
|
|||
|
waived, whether for one instance or (only if so specified) both for a present instance and all
|
|||
|
future instances, only upon the written consent of both parties, or, in the case of such a waiver,
|
|||
|
upon the written consent of the party who agrees to waive enforcement of the provision. If any
|
|||
|
provision of this Agreement, or its application to any person or circumstance, is held invalid or
|
|||
|
unenforceable, the remainder of this Agreement, or the application of the provision to persons or
|
|||
|
|
|||
|
|
|||
|
circumstances other than those as to which it is held invalid or unenforceable, shall not be
|
|||
|
affected thereby.
|
|||
|
|
|||
|
SECTION 10
|
|||
|
Investor shall provide the General Partner and the Fund with any information, representations,
|
|||
|
certificates or forms relating to Investor (or Investor's direct or indirect owners or account
|
|||
|
holders) that are requested from time to time by the General Partner in order for (i) the Fund; (ii)
|
|||
|
any entity in which the Fund holds (directly or indirectly) an interest (whether in the form of debt
|
|||
|
or equity); (iii) any member of any “expanded affiliated group” (as defined in section 1471(e)(2)
|
|||
|
of the Internal Revenue Code (the "Code")) of which any person described in clause (i) or (ii) is
|
|||
|
a member; or (iv) the General Partner or any of its affiliates, to (A) enter into, maintain or
|
|||
|
comply with the agreement contemplated by section 1471(b) of the Code; (B) satisfy any
|
|||
|
requirement imposed under sections 1471 through 1474 of the Code in order to avoid any
|
|||
|
withholding required under sections 1471 through 1474 of the Code (including any withholding
|
|||
|
upon any payments to Investor); (C) comply with any reporting or withholding requirements
|
|||
|
under sections 1471 through 1474 of the Code or (D) comply with any fiscal or regulatory
|
|||
|
legislation, rules or practices adopted pursuant to any intergovernmental agreement entered into
|
|||
|
in connection with sections 1471 through 1474 of the Code. Investor shall take such additional
|
|||
|
actions as the General Partner may request in good faith in connection with the foregoing. If
|
|||
|
Investor fails to provide any of the information, representations, certificates or forms (or
|
|||
|
undertake any of the actions) required pursuant to this paragraph, the General Partner shall have
|
|||
|
full authority to (1) terminate Investor’s interest in the Fund or (2) take any other steps the
|
|||
|
General Partner determines, in its sole discretion, are necessary or appropriate to mitigate the
|
|||
|
consequences of Investor’s failure to comply with this paragraph to the Fund, the General
|
|||
|
Partner, a Fund affiliate or the other Partners. If Investor fails to comply with this paragraph,
|
|||
|
Investor shall, unless otherwise agreed by the General Partner in writing, to the fullest extent
|
|||
|
permitted by law, indemnify and hold harmless the General Partner and the Fund (and/or its
|
|||
|
affiliates or the other Partners, as applicable) from any costs or expenses arising out of such
|
|||
|
failure, including any withholding tax imposed under sections 1471 through 1474 of the Code or
|
|||
|
as a result of any intergovernmental agreement described in clause (D) above on the Fund, and
|
|||
|
any expenses, withholding or other taxes imposed as a result of such failure. Any such
|
|||
|
indemnification payments for such costs or expenses shall not constitute a contribution to the
|
|||
|
capital of the Fund.
|
|||
|
|
|||
|
|
|||
|
### Basic Investor Information
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
For security reasons, please ONLY handwrite your SSN/Tax ID and
|
|||
|
mail the page with the Notary Acknowledgement on page 44
|
|||
|
```
|
|||
|
Full legal name of Investor: _____________________________________________________________
|
|||
|
|
|||
|
Investor's Social Security Number (if individual)
|
|||
|
or Taxpayer Identification Number (if entity): ________________ Date of birth: ___________
|
|||
|
|
|||
|
If Investor is an individual (including IRAs), Investor's state of residence: __________________
|
|||
|
|
|||
|
If Investor is a trust, trustee name(s): ________________________________________________
|
|||
|
|
|||
|
If Investor is an entity (including a trust), jurisdiction(s) of Investor's:
|
|||
|
|
|||
|
Formation: ___________________ Principal place of business: _________________________
|
|||
|
|
|||
|
Check one or more of the following boxes. Investor is:
|
|||
|
|
|||
|
⎕ Individual adult(s) ⎕ Individual minor(s) (custodian required)
|
|||
|
|
|||
|
⎕ IRA ⎕ Keogh plan or similar plan
|
|||
|
|
|||
|
⎕ Other employee benefit plan/trust ⎕ Corporation
|
|||
|
|
|||
|
⎕ Revocable living trust ⎕ Limited liability company
|
|||
|
|
|||
|
⎕ Irrevocable trust ⎕ Investment trust or business trust
|
|||
|
|
|||
|
⎕ Investment partnership ⎕ Foundation (check one: public ___ private ___)
|
|||
|
|
|||
|
⎕ Endowment ⎕ Other (specify): _________________________
|
|||
|
|
|||
|
Will this investment be held in joint tenancy or in tenancy in common (check "No" if Investor's
|
|||
|
Interest will be held as community property with Investor's spouse)?
|
|||
|
|
|||
|
⎕ No ⎕ Yes
|
|||
|
|
|||
|
If Yes, please provide the following information:
|
|||
|
|
|||
|
⎕ Joint Tenancy (please list all joint tenants _–_ copy this page if necessary).
|
|||
|
|
|||
|
Joint tenant: ________________________ SSN/Tax ID: ________________________
|
|||
|
|
|||
|
|
|||
|
Joint tenant: ________________________ SSN/Tax ID: ________________________
|
|||
|
|
|||
|
⎕ Tenancy in common (please list all tenants in common _–_ copy this page if necessary).
|
|||
|
|
|||
|
Tenant in common: ___________________ SSN/Tax ID: ________________________
|
|||
|
|
|||
|
Tenant in common: ___________________ SSN/Tax ID: ________________________
|
|||
|
|
|||
|
⎕ Check this box if the joint investor is married to Investor named at the beginning of this
|
|||
|
section. (Do not check box if Interest will be held as community property.)
|
|||
|
|
|||
|
Is Investor regulated by any governmental agency that regulates financial institutions or
|
|||
|
financial intermediaries (e.g., banking, insurance or securities regulatory authorities)?
|
|||
|
|
|||
|
⎕ No ⎕ Yes If Yes, please provide the following information:
|
|||
|
___________________________________________________________________________
|
|||
|
___________________________________________________________________________
|
|||
|
___________________________________________________________________________
|
|||
|
|
|||
|
|
|||
|
### Contact Information
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
INSTRUCTIONS: Please provide the appropriate contact information for Investor. All Fund
|
|||
|
related materials will be sent to the Primary Contact. Please complete additional sections as
|
|||
|
necessary.
|
|||
|
```
|
|||
|
### Investor Information (Primary Contact)
|
|||
|
|
|||
|
Contact Name:
|
|||
|
|
|||
|
Mailing Address: ⎕ Home ⎕ Business Home Phone:
|
|||
|
|
|||
|
Street:
|
|||
|
|
|||
|
City:
|
|||
|
|
|||
|
State/Zip-code:
|
|||
|
|
|||
|
```
|
|||
|
Business Phone:
|
|||
|
```
|
|||
|
```
|
|||
|
Fax:
|
|||
|
```
|
|||
|
```
|
|||
|
Email:
|
|||
|
```
|
|||
|
### Secondary Contact (as necessary)
|
|||
|
|
|||
|
Contact Name:
|
|||
|
|
|||
|
Mailing Address: ⎕ Home ⎕ Business Home Phone:
|
|||
|
|
|||
|
Street:
|
|||
|
|
|||
|
City:
|
|||
|
|
|||
|
State/Zip-code:
|
|||
|
|
|||
|
```
|
|||
|
Business Phone:
|
|||
|
```
|
|||
|
```
|
|||
|
Fax:
|
|||
|
```
|
|||
|
```
|
|||
|
Email:
|
|||
|
```
|
|||
|
Types of Reports: ⎕ All ⎕ Valuations ⎕ Tax Info. ⎕ Other
|
|||
|
|
|||
|
|
|||
|
### Custodian Information
|
|||
|
|
|||
|
```
|
|||
|
Please provide this information if Investor is IRA or
|
|||
|
self-directed pension plan, or minor(s) represented by
|
|||
|
a custodian
|
|||
|
```
|
|||
|
Custodian (firm name, if any):
|
|||
|
|
|||
|
Mailing Address:
|
|||
|
|
|||
|
Street:
|
|||
|
|
|||
|
City:
|
|||
|
|
|||
|
State/Zip-code:
|
|||
|
|
|||
|
```
|
|||
|
Contact Name:
|
|||
|
```
|
|||
|
```
|
|||
|
Contact Title:
|
|||
|
```
|
|||
|
Account Name: Account Number:
|
|||
|
|
|||
|
Minor name(s): Business Phone:
|
|||
|
|
|||
|
Minor name(s): Fax:
|
|||
|
|
|||
|
Minor name(s): Email:
|
|||
|
|
|||
|
### Purchase Representative Information
|
|||
|
|
|||
|
```
|
|||
|
Please provide this information only if Investor has
|
|||
|
designated a Purchaser Representative on page 25
|
|||
|
```
|
|||
|
Name:
|
|||
|
|
|||
|
Mailing Address: Business Phone:
|
|||
|
|
|||
|
Street:
|
|||
|
|
|||
|
City:
|
|||
|
|
|||
|
State/Zip-code:
|
|||
|
|
|||
|
```
|
|||
|
Fax:
|
|||
|
```
|
|||
|
```
|
|||
|
Email:
|
|||
|
```
|
|||
|
Employer Name: (^)
|
|||
|
Job Description:
|
|||
|
|
|||
|
|
|||
|
### Authorized Investor Representatives And Investor Account Information
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
Individual(s) Authorized to Give and Receive Instructions on Behalf of Investor. Investor
|
|||
|
represents that the following individual or individuals are authorized to act on behalf of Investor
|
|||
|
to give and receive instructions between the Fund (or its representatives) and Investor. Such
|
|||
|
individual or individuals are the only persons so authorized until further written notice, signed
|
|||
|
by Investor or by one or more of these individuals, is received by the General Partner:
|
|||
|
Name Specimen Signature
|
|||
|
__________________________ __________________________
|
|||
|
__________________________ __________________________
|
|||
|
```
|
|||
|
Account Information for Source of Funds. Investor's Subscription Amount will be transferred
|
|||
|
from this account:
|
|||
|
|
|||
|
Bank Name: _________________________________________________
|
|||
|
|
|||
|
Bank Address: _________________________________________________
|
|||
|
|
|||
|
ABA Routing or CHIPS No.:_________________________________________________
|
|||
|
|
|||
|
Account Name: ________________________ Account No: _____________
|
|||
|
|
|||
|
Contact person name: _________________________________________________
|
|||
|
|
|||
|
Telephone number: _______________ Email: __________________________
|
|||
|
|
|||
|
Account Information for Amounts Payable to Investor. Investor agrees that any funds
|
|||
|
|
|||
|
payable to Investor (including redemption proceeds) may be wire transferred to Investor in
|
|||
|
accordance with the following instructions, until further written notice, signed by Investor or by
|
|||
|
one or more of the individuals authorized to act on behalf of Investor (see above on this page), is
|
|||
|
received by the General Partner.
|
|||
|
|
|||
|
Check one of the following, and supply additional information if you check Box B:
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. The bank account specified above. ⎕ B. The bank account identified below:
|
|||
|
```
|
|||
|
Bank Name: _________________________________________________
|
|||
|
|
|||
|
Bank Address: _________________________________________________
|
|||
|
|
|||
|
ABA Routing or CHIPS No.:_________________________________________________
|
|||
|
|
|||
|
|
|||
|
Account Name: ________________________ Account No: _____________
|
|||
|
|
|||
|
Contact person name: _________________________________________________
|
|||
|
|
|||
|
Telephone number: ________________ Email: ___________________________
|
|||
|
|
|||
|
|
|||
|
### United States Person Status
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
Individual(s) Authorized to Give and Receive Instructions on Behalf of Investor. Investor
|
|||
|
represents that the following individual or individuals are authorized to act on behalf of Investor
|
|||
|
to give and receive instructions between the Fund (or its representatives) and Investor. Such
|
|||
|
individual or individuals are the only persons so authorized until further written notice, signed
|
|||
|
by Investor or by one or more of these individuals, is received by the General Partner:
|
|||
|
```
|
|||
|
1. United States Person. Is Investor a "United States Person" as defined below? Unless the
|
|||
|
General Partner approves an exception, Investor must be a United States Person.
|
|||
|
⎕ A. Yes (a United States Person) ⎕ B. No (not a United States Person)
|
|||
|
2. U.S. Income Tax Status. Is Investor subject to U.S. federal income taxes (i.e. not tax-
|
|||
|
exempt)?
|
|||
|
|
|||
|
⎕ A. Yes (not tax-exempt) ⎕ B. No (tax-exempt)
|
|||
|
|
|||
|
```
|
|||
|
Definition of "United States Person"
|
|||
|
```
|
|||
|
For individuals, "United States Person" means any U.S. citizen (and certain former U.S.
|
|||
|
citizens) or "resident alien" within the meaning of U.S. income tax laws in effect from time to
|
|||
|
time.
|
|||
|
|
|||
|
For persons other than individuals, "United States Person" means:
|
|||
|
|
|||
|
```
|
|||
|
a. any partnership, corporation or other entity organized or incorporated under the laws of
|
|||
|
the United States or that has its principal place of business in the United States;
|
|||
|
```
|
|||
|
```
|
|||
|
b. any estate of which any executor or administrator is an individual United States Person or
|
|||
|
an entity described in clause (a) above or the income of which is subject to income tax in
|
|||
|
the United States;
|
|||
|
```
|
|||
|
```
|
|||
|
c. a trust of which (i) any trustee is an individual United States Person or an entity described
|
|||
|
in clause (a) above or (ii) the income of which is subject to income tax in the United
|
|||
|
States regardless of source;
|
|||
|
```
|
|||
|
```
|
|||
|
d. any agency or branch of a non-United States Person located in the U.S.;
|
|||
|
```
|
|||
|
```
|
|||
|
e. any account (other than an estate or trust) held by a dealer or other fiduciary (i) if
|
|||
|
nondiscretionary, for the benefit of a United States Person or (ii) if discretionary, if the
|
|||
|
dealer or fiduciary is organized, incorporated or, if an individual, resident in the United
|
|||
|
```
|
|||
|
|
|||
|
```
|
|||
|
States, other than an account held by a professional fiduciary exclusively for the account
|
|||
|
or benefit of non-United States Persons;
|
|||
|
```
|
|||
|
f. any partnership or corporation formed in any jurisdiction by United States Persons
|
|||
|
principally for the purpose of investing generally in securities not eligible for sale to the
|
|||
|
public within the United States, unless the entity is organized or incorporated and owned
|
|||
|
by accredited investors that are not natural persons, trusts or estates; or
|
|||
|
|
|||
|
g. any entity organized principally for passive investment such as a commodity pool,
|
|||
|
investment company or other similar entity (other than a pension plan for the employees,
|
|||
|
officers or principals of an entity organized and with it principal place of business outside
|
|||
|
the United States) in which United States Persons hold units of participation representing
|
|||
|
in the aggregate 10% or more of the beneficial interest in the entity, or that has as a
|
|||
|
principal purpose the facilitating of investment by United States Persons in the Fund.
|
|||
|
|
|||
|
|
|||
|
### Investor Identity Verification
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
Why the Fund Requests Identity Verification: To avoid assisting terrorists and certain other
|
|||
|
persons designated by the U.S. government as wrong-doers, the Fund takes certain steps to
|
|||
|
verify Investor's identity. Please indicate what proof you are able to supply to verify Investor's
|
|||
|
identity and place of residence or business, and whether you are supplying that proof now. The
|
|||
|
Fund may request additional documentation to verify Investor's identity. The General Partner
|
|||
|
may instead be able to rely to some extent on identity-verification procedures implemented by
|
|||
|
Investor's bank (see "Important Note" at the bottom of this page). If you have any questions,
|
|||
|
please contact the General Partner.
|
|||
|
```
|
|||
|
```
|
|||
|
Individual Investors (including IRAs):
|
|||
|
```
|
|||
|
⎕ Copy of passport or other government photo ID (e.g. driver's license).
|
|||
|
|
|||
|
⎕ Check box at left if you are supplying this item now
|
|||
|
|
|||
|
⎕ Proof of current address, only if not included in photo ID (for example, original utility bill
|
|||
|
not more than six months old).
|
|||
|
|
|||
|
⎕ Check box at left if you are supplying this item now
|
|||
|
|
|||
|
```
|
|||
|
Entity Investors:
|
|||
|
```
|
|||
|
⎕ A copy of a certificate of formation (or similar document) of Investor and a certificate
|
|||
|
evidencing Investor's continued authorization to conduct business in the jurisdiction of its
|
|||
|
organization (for example, a certificate of good standing).
|
|||
|
|
|||
|
⎕ Check box at left if you are supplying this item now
|
|||
|
|
|||
|
⎕ A list of all persons who directly or indirectly own 10% or more of any class of equity
|
|||
|
interests of Investor (use space below if sufficient; otherwise, attach separate list).
|
|||
|
|
|||
|
Name(s) of 10% owner(s): ___________________________________________
|
|||
|
|
|||
|
⎕ If Investor is a trust of which the trustee is not a regulated bank or trust company, a list of
|
|||
|
all beneficiaries that directly or indirectly hold 25% or more of any interest in Investor. That
|
|||
|
list should include the name of the settlor and trustees of the trust. (Use space below if
|
|||
|
sufficient; otherwise, attach separate list).
|
|||
|
|
|||
|
Names of 25% beneficiary(ies): _______________________________________
|
|||
|
|
|||
|
|
|||
|
Important note: The Fund may be able to rely on identity-verification procedures carried out by
|
|||
|
Investor's bank, which may reduce the burden otherwise placed on Investor. Please indicate
|
|||
|
whether Investor's source-of-funds bank specified on page 16 is located in any of the following
|
|||
|
countries: United States of America, Australia, Austria, Belgium, Bermuda, Canada, Cayman
|
|||
|
Islands, Channel Islands, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland,
|
|||
|
Ireland, Isle of Man, Italy, Japan, Luxembourg, Netherlands (including Netherlands Antilles and
|
|||
|
Aruba), New Zealand, Norway, Portugal, Singapore, Spain, Sweden, Switzerland, Turkey,
|
|||
|
United Kingdom. If so, please check box and write name of bank country if not U.S:
|
|||
|
|
|||
|
⎕ United States Bank ⎕ Other Bank Country: __________________
|
|||
|
|
|||
|
|
|||
|
### Education, Employment, Experience And Investment Objectives
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
Education
|
|||
|
Please provide the following information for Investor unless you are completing this
|
|||
|
Application as a representative of Investor (for example, an officer of a corporation that is
|
|||
|
subscribing or a custodian for the account of a minor). If you are acting as a representative,
|
|||
|
provide this information for yourself.
|
|||
|
|
|||
|
```
|
|||
|
College/University Degree/Major Year
|
|||
|
```
|
|||
|
Employment
|
|||
|
Please provide the following information for Investor unless you are completing this
|
|||
|
Application as a representative of Investor (for example, an officer of a corporation that is
|
|||
|
subscribing or a custodian for the account of a minor). If you are acting as a representative,
|
|||
|
provide this information for yourself.
|
|||
|
|
|||
|
Name of Employer: ____________________________________________________________
|
|||
|
|
|||
|
Address of Employer: __________________________________________________________
|
|||
|
|
|||
|
Nature of Employment: _________________________________________________________
|
|||
|
|
|||
|
If self-employed, nature of business: _______________________________________________
|
|||
|
|
|||
|
Prior employment you consider relevant (optional): ___________________________________
|
|||
|
|
|||
|
Other Financial Experience
|
|||
|
Please provide the following information for Investor unless you are completing this
|
|||
|
Application as a representative of Investor (for example, an officer of a corporation that is
|
|||
|
subscribing or a custodian for the account of a minor). If you are acting as a representative,
|
|||
|
provide this information for yourself.
|
|||
|
|
|||
|
Other positions/background related to financial, business, accounting, economics, tax or
|
|||
|
investment matters that demonstrate investment sophistication:
|
|||
|
|
|||
|
|
|||
|
#### _____________________________________________________________________________
|
|||
|
|
|||
|
#### _____________________________________________________________________________
|
|||
|
|
|||
|
#### _____________________________________________________________________________
|
|||
|
|
|||
|
#### _____________________________________________________________________________
|
|||
|
|
|||
|
```
|
|||
|
Investment Objectives
|
|||
|
Order of investment objectives of Investor. Reminder: This investment is most appropriate for
|
|||
|
persons seeking capital appreciation.
|
|||
|
```
|
|||
|
Please number Investor's preferences from 1 (most preferred) to 3 (least preferred):
|
|||
|
|
|||
|
```
|
|||
|
__ Capital appreciation* __ Current income** __ Liquidity***
|
|||
|
```
|
|||
|
* Although these guidelines vary among investors, an investor seeking "capital appreciation" generally will favor
|
|||
|
investments that are expected to increase in value over a substantial holding period, but are not expected to (though
|
|||
|
they may) generate substantial (if any) income distributions (dividends or interest, for example) during that time
|
|||
|
frame and may (or may not) be relatively difficult to liquidate for cash in a short time frame.
|
|||
|
|
|||
|
** An investor seeking "current income" generally will favor investments on which the investor anticipates that
|
|||
|
dividends, interest, royalties or similar distributions of income are likely to be paid regularly (for example, quarterly
|
|||
|
or annually) while the investor holds the investment. Such investments may (or may not) be relatively difficult to
|
|||
|
liquidate for cash in a short time frame, though often they are easier to liquidate than are investments held for capital
|
|||
|
appreciation.
|
|||
|
|
|||
|
*** An investor seeking "liquidity" generally will favor investments that can be liquidated for cash in a short time
|
|||
|
frame, even if the investment is less likely to grow in value over time than "capital appreciation" investments and is
|
|||
|
less likely to generate regular distributions of income than "current income" investments.
|
|||
|
|
|||
|
Investment Experience
|
|||
|
Please provide the following information for Investor unless you are completing this Application
|
|||
|
as a representative of Investor (for example, an officer of a corporation that is subscribing or a
|
|||
|
custodian for the account of a minor). If you are acting as a representative, provide this
|
|||
|
information for yourself.
|
|||
|
|
|||
|
```
|
|||
|
Approximate number of years you have been investing: _____ years
|
|||
|
```
|
|||
|
```
|
|||
|
Please check frequency of your investment in:
|
|||
|
```
|
|||
|
|
|||
|
(^) Often Occasionally Seldom Never
|
|||
|
Marketable securities (stocks, bonds, debentures,
|
|||
|
notes) ⎕^ ⎕^ ⎕^ ⎕^
|
|||
|
Mutual funds (^) ⎕ ⎕ ⎕ ⎕
|
|||
|
Other private investment funds, including hedge
|
|||
|
funds and commodity pools ⎕^ ⎕^ ⎕^ ⎕^
|
|||
|
Speculative or venture capital investments ⎕ ⎕ ⎕ ⎕
|
|||
|
Commodities or commodity futures (^) ⎕ ⎕ ⎕ ⎕
|
|||
|
Real estate, other than principal residence
|
|||
|
(directly or through partnerships or other entities
|
|||
|
managed by others)
|
|||
|
|
|||
|
#### ⎕ ⎕ ⎕ ⎕
|
|||
|
|
|||
|
Tax shelter programs (real estate, leasing, oil and
|
|||
|
gas, cattle breeding) ⎕^ ⎕^ ⎕^ ⎕^
|
|||
|
|
|||
|
|
|||
|
### Question To Determine Whether Investor Must Have Purchase Representative
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
Reason For This Page. Investor or the person completing this Subscription Agreement as
|
|||
|
Investor's representative (for example, an officer of a corporation that is subscribing, or a
|
|||
|
custodian for the account of a minor), either alone or together with a "purchaser representative"
|
|||
|
(such as an investment adviser, attorney, accountant or other consultant) (a "Purchaser
|
|||
|
Representative"), must have such knowledge and experience in financial and business matters
|
|||
|
that Investor (with the assistance of Investor's Purchaser Representative, if any) can evaluate the
|
|||
|
merits and risks of this investment and protect Investor's interests in this investment.
|
|||
|
|
|||
|
Please check one box below:
|
|||
|
|
|||
|
```
|
|||
|
⎕ No Purchaser Representative. Without the assistance of any Purchaser
|
|||
|
Representative, Investor has such knowledge and experience in financial and
|
|||
|
business matters that Investor can evaluate the merits and risks of this investment,
|
|||
|
make an informed investment decision and otherwise protect Investor's interests in
|
|||
|
this transaction. Investor chooses not to engage any Purchaser Representative.
|
|||
|
Notwithstanding Investor's decision not to designate a Purchaser Representative,
|
|||
|
Investor will remain free at any time, and is encouraged, to seek advice from any
|
|||
|
person or persons before deciding whether to invest in the Fund.
|
|||
|
```
|
|||
|
```
|
|||
|
Please skip the remainder of this page if you checked the box above.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ Purchaser Representative Designated. Investor will be relying on the advice of the
|
|||
|
Purchaser Representative identified below in evaluating the merits and risks of this
|
|||
|
investment. Investor should (1) furnish the information requested below and on
|
|||
|
page 14 about Investor's Purchaser Representative; (2) ask the Purchaser
|
|||
|
Representative to complete and sign a Purchaser Representative Questionnaire (a
|
|||
|
copy of which will be provided to Investor on request); (3) sign the "Investor's
|
|||
|
Acknowledgement of Purchaser Representative" on the last page of the Purchaser
|
|||
|
Representative Questionnaire, after reviewing the completed Purchaser
|
|||
|
Representative Questionnaire; and (4) deliver the Purchaser Representative
|
|||
|
Questionnaire to the General Partner.
|
|||
|
```
|
|||
|
```
|
|||
|
Name of Purchaser Representative:
|
|||
|
```
|
|||
|
```
|
|||
|
If you checked this box, please provide contact information for
|
|||
|
Investor's Purchaser Representative at the bottom of page 1 4.
|
|||
|
```
|
|||
|
|
|||
|
Eligibility Requirements of Purchaser Representative: As explained further in the
|
|||
|
Purchaser Representative Questionnaire, a person may not serve as Investor's
|
|||
|
Purchaser Representative if the person is being compensated by the Fund (or
|
|||
|
certain related persons) for advising Investor in connection with this investment,
|
|||
|
or if the Purchaser Representative has certain present or past relationships with the
|
|||
|
Fund (or certain related persons). In addition, the Purchaser Representative must
|
|||
|
have such knowledge and experience in financial and business matters that he or
|
|||
|
she, either alone or together with Investor, is capable of evaluating the merits and
|
|||
|
risks of Investor's prospective investment in the Fund.
|
|||
|
|
|||
|
|
|||
|
### Anti-Money-Laundering Provisions
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
```
|
|||
|
Please read and check ALL FOUR boxes (A through D) on this page and next page
|
|||
|
```
|
|||
|
Reason For This Section. To avoid assisting terrorists and certain other persons designated by
|
|||
|
the U.S. government as wrong-doers, the Fund takes steps to comply with applicable anti-money
|
|||
|
laundering laws. Those steps include (among others) obtaining certain representations and
|
|||
|
warranties from Investors, and taking reasonable steps to verify the identity of Investors (see
|
|||
|
page 2 0 ). Without limiting the foregoing, Investor agrees to provide any information and
|
|||
|
execute and deliver such documents as deemed necessary by the General Partner or the
|
|||
|
Investment Manager in their sole discretion, to verify the accuracy of Investor’s representations,
|
|||
|
warranties, and covenants herein or to comply with any law or regulation to which the Fund, the
|
|||
|
General Partner or the Investment Manager may be subject, including but not limited to the
|
|||
|
General Partner's anti-money laundering and anti-terrorist financing program and related
|
|||
|
responsibilities. The capitalized terms used below in this section are defined where used, or
|
|||
|
separately on page 2 8.
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. Investor understands that the Fund prohibits the investment of funds by any
|
|||
|
persons or entities that are acting, directly or indirectly, (i) in contravention of
|
|||
|
any U.S. or international laws and regulations, including anti-money
|
|||
|
laundering regulations or conventions, (ii) on behalf of terrorists or terrorist
|
|||
|
organizations, including those persons or entities that are included on the List
|
|||
|
of Specially Designated Nationals and Blocked Persons maintained by the
|
|||
|
U.S. Treasury Department's Office of Foreign Assets Control ("OFAC"), as
|
|||
|
the list may be amended from time to time, (iii) for a Senior Foreign Political
|
|||
|
Figure, any Immediate Family member of a Senior Foreign Political Figure or
|
|||
|
any Close Associate of a Senior Foreign Political Figure, unless the General
|
|||
|
Partner, after being specifically notified by Investor in writing that it is such a
|
|||
|
person, conducts further due diligence, and determines that such investment
|
|||
|
shall be permitted, or (iv) for a Foreign Shell Bank (such persons or entities in
|
|||
|
(i) – (iv) being collectively referred to below as "Prohibited Investors").
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ B. Investor represents, warrants and agrees that: (i) Investor is not a Prohibited
|
|||
|
Investor, nor is any person or entity controlling, controlled by or under
|
|||
|
common control with Investor a Prohibited Investor, and (ii) to the extent
|
|||
|
Investor has any Beneficial Owners, (a) Investor has carried out thorough due
|
|||
|
diligence to establish the identities of such Beneficial Owners, (b) based on
|
|||
|
such due diligence, Investor reasonably believes that no such Beneficial
|
|||
|
```
|
|||
|
|
|||
|
```
|
|||
|
Owner is a Prohibited Investor, (c) Investor holds the evidence of such
|
|||
|
identities and status and will maintain all such evidence for at least five years
|
|||
|
from the date of Investor's complete withdrawal from the Fund, and (d)
|
|||
|
Investor will make available such information and evidence, and any related
|
|||
|
additional information that the Fund may request, in accordance with
|
|||
|
applicable regulations.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ C. Investor understands that, if any of the foregoing representations, warranties
|
|||
|
or covenants ceases to be true or if the Fund no longer reasonably believes
|
|||
|
that it has satisfactory evidence as to their truth, notwithstanding any other
|
|||
|
agreement to the contrary, the Fund may, in accordance with applicable
|
|||
|
regulations, be obligated to freeze Investor's investment, either by prohibiting
|
|||
|
additional investments, declining or suspending any withdrawal requests
|
|||
|
and/or segregating the assets constituting the investment, or Investor's
|
|||
|
investment may immediately be involuntarily withdrawn from the Fund, and
|
|||
|
the Fund may also be required to report such action and to disclose Investor's
|
|||
|
identity to OFAC or other authority. If the Fund is required to take any of the
|
|||
|
foregoing actions, Investor agrees that Investor shall have no claim against the
|
|||
|
Fund or the General Partner or their respective affiliates, directors, members,
|
|||
|
partners, shareholders, officers, employees and agents for any damages as a
|
|||
|
result of any of the aforementioned actions, and Investor further agrees that it
|
|||
|
shall indemnify and hold harmless all of such persons from any such claim
|
|||
|
that may be asserted against them by any person.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ D.^ Investor agrees that all subscription payments transferred to the Fund on
|
|||
|
behalf of Investor shall originate directly from a bank or brokerage account in
|
|||
|
the name of Investor. Investor agrees further that any withdrawal proceeds
|
|||
|
paid to Investor will be paid to the account from which Investor's investment
|
|||
|
in the Fund was originally received, unless the General Partner, in its sole
|
|||
|
discretion, agrees otherwise with Investor.
|
|||
|
```
|
|||
|
```
|
|||
|
Definitions of Capitalized Terms in Anti-Money Laundering Provisions on Preceding Page
|
|||
|
```
|
|||
|
```
|
|||
|
Please skip to page 3 1 if you have already read and checked Boxes A through D above.
|
|||
|
```
|
|||
|
Beneficial Owner is any individual or entity that will have a beneficial ownership interest in
|
|||
|
Investor's Interest in the Fund, including but not limited to: (i) shareholders of a corporation; (ii)
|
|||
|
partners of a partnership; (iii) members of a limited liability company; (iv) investors in a fund-
|
|||
|
of-funds; (v) the grantor of a revocable or grantor trust; (vi) the beneficiaries of an irrevocable
|
|||
|
trust; (vii) the individual who established an IRA; (viii) the participant in a self-directed pension
|
|||
|
plan; (ix) the sponsor of any other pension plan; and (x) any person being represented by
|
|||
|
Investor in an agent, representative, intermediary, nominee or similar capacity. If the Beneficial
|
|||
|
|
|||
|
|
|||
|
```
|
|||
|
Owner is itself an entity, the information and representations set forth herein must also be given
|
|||
|
with respect to its individual beneficial owners. If Investor is a publicly-traded company, it need
|
|||
|
not conduct due diligence as to its beneficial owners.
|
|||
|
```
|
|||
|
```
|
|||
|
Close Associate of a Senior Foreign Political Figure is a person who is widely and publicly
|
|||
|
known internationally to maintain an unusually close relationship with the Senior Foreign
|
|||
|
Political Figure, and includes a person who is in a position to conduct substantial domestic and
|
|||
|
international financial transactions on behalf of the Senior Foreign Political Figure.
|
|||
|
```
|
|||
|
```
|
|||
|
FATF-Compliant Jurisdiction is a jurisdiction that (1) is a member in good standing of FATF
|
|||
|
and (2) has undergone two rounds of FATF mutual evaluations.
|
|||
|
```
|
|||
|
```
|
|||
|
FATF means the Financial Action Task Force on Money Laundering.
|
|||
|
```
|
|||
|
Foreign Bank means an organization that (1) is organized under the laws of a non-U.S. country
|
|||
|
(2) engages in the business of banking, (3) is recognized as a bank by the bank supervisory or
|
|||
|
monetary authority of the country of its organization or principal banking operations, (4)
|
|||
|
receives deposits to a substantial extent in the regular course of its business, and (5) has the
|
|||
|
power to accept demand deposits, but does not include the U.S. branches or agencies of a non-
|
|||
|
U.S. bank.
|
|||
|
|
|||
|
Foreign Shell Bank means a Foreign Bank without a Physical Presence in any country, but does
|
|||
|
not include a Regulated Affiliate.
|
|||
|
|
|||
|
Immediate Family of a Senior Foreign Political Figure typically includes such person's
|
|||
|
parents, siblings, spouse, children and in-laws.
|
|||
|
|
|||
|
Non-Cooperative Jurisdiction means any non-U.S. country that has been designated as non-
|
|||
|
cooperative with international anti-money laundering principles or procedures by an
|
|||
|
intergovernmental group or organization, such as the FATF, of which the United States is a
|
|||
|
member and with which designation the United States representative to the group or
|
|||
|
organization continues to concur. For a current list of Non-Cooperative Countries and
|
|||
|
Territories, refer to the Financial Action Task Force website (see link above at definition of
|
|||
|
"FATF-Compliant Jurisdiction").
|
|||
|
|
|||
|
Physical Presence means a place of business that is maintained by a Foreign Bank and is located
|
|||
|
at a fixed address, other than solely a post office box or an electronic address, in a country in
|
|||
|
which the Foreign Bank is authorized to conduct banking activities, at which location the
|
|||
|
Foreign Bank (1) employs one or more individuals on a full-time basis, (2) maintains operating
|
|||
|
records related to its banking activities, and (3) is subject to inspection by the banking authority
|
|||
|
that licensed the Foreign Bank to conduct banking activities.
|
|||
|
|
|||
|
Prohibited Investor means (1) a person or entity whose name appears on one or more of the
|
|||
|
various lists issued and maintained by the U.S. Office of Foreign Assets Control ("OFAC"),
|
|||
|
|
|||
|
|
|||
|
including the List of Specially Designated Nationals and Blocked Persons, the Specially
|
|||
|
Designated Terrorists List and the Specially Designated Narcotics Traffickers List; (2) a Foreign
|
|||
|
Shell Bank; or (3) a person or entity who is a citizen or resident of, or which is located in, or
|
|||
|
whose subscription funds are transferred from or through, a Foreign Bank in a Non-Cooperative
|
|||
|
Jurisdiction or Sanctioned Regime.
|
|||
|
|
|||
|
Regulated Affiliate means a Foreign Shell Bank that (1) is an affiliate of a depository institution,
|
|||
|
credit union or Foreign Bank that maintains a Physical Presence in the United States or a non-
|
|||
|
U.S. country, as applicable, and (2) is subject to supervision by a banking authority in the
|
|||
|
country regulating such affiliated depository institution, credit union or Foreign Bank.
|
|||
|
|
|||
|
Sanctioned Regimes means targeted foreign countries, terrorism sponsoring organizations and
|
|||
|
international narcotics traffickers in respect of which OFAC administers and enforces economic
|
|||
|
and trade sanctions based on U.S. foreign policy and national security goals.
|
|||
|
|
|||
|
Senior Foreign Political Figure means a senior official in the executive, legislative,
|
|||
|
administrative, military or judicial branch of a foreign government (whether elected or not), a
|
|||
|
senior official of a major foreign political party, or a senior executive of a foreign government-
|
|||
|
owned corporation. In addition, a Senior Foreign Political Figure includes any corporation,
|
|||
|
business or other entity that has been formed by, or for the benefit of, a Senior Foreign Political
|
|||
|
Figure.
|
|||
|
|
|||
|
USA Patriot Act means the Uniting and Strengthening America by Providing Appropriate Tools
|
|||
|
Required to Intercept and Obstruct Terrorism (USA PATRIOT) Act of 2001 (Pub. L. No. 107-
|
|||
|
56).
|
|||
|
|
|||
|
|
|||
|
### Accredited Investor Status
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
Note: Investor will be required to provide additional information as requested by the General
|
|||
|
**_Partner to verify investor’s accredited investor status._**
|
|||
|
|
|||
|
Reason For This Questionnaire. Investor must be an "accredited investor" as defined in Rule
|
|||
|
501(a) of Regulation D under the Securities Act of 1933. By marking the appropriate box(es) in
|
|||
|
this questionnaire, Investor indicates each category under which Investor is an accredited
|
|||
|
investor (list of categories continues on next page).
|
|||
|
|
|||
|
Check one or more of the boxes on this page and the next page:
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. Individual – Income Test. An individual who had income in excess of
|
|||
|
$200,000 in each of the two most recent years (or had joint income with his or
|
|||
|
her 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.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ B. Individual – Net Worth Test. An individual who has a net worth (or joint net
|
|||
|
worth with his or her spouse) in excess of $1,000,000. For the purpose of
|
|||
|
calculating Investor's net worth, ignore both the value of Investor's primary
|
|||
|
residence and any indebtedness on that residence, except that (1) if such
|
|||
|
indebtedness exceeds such value, count the excess as a liability (even if
|
|||
|
Investor is legally or practically not liable for the excess indebtedness); and
|
|||
|
(2) if non-acquisition indebtedness on the residence has increased in the last
|
|||
|
60 days (for example, Investor has borrowed on a line of credit secured by
|
|||
|
Investor's primary residence), count the net increase as a liability.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ C.^ IRA –^ Beneficiary Makes Investment Decisions and is Accredited.^ An
|
|||
|
individual retirement account ("IRA") whose beneficiary is an individual who
|
|||
|
(1) makes investment decisions for the IRA, and (2) is an accredited investor
|
|||
|
on the basis of Box A or B above
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ D. IRA – Person Other than Beneficiary Makes Investment Decisions and
|
|||
|
Decision-Maker is Accredited. An individual retirement account ("IRA")
|
|||
|
whose investment decisions are made by an individual or entity other than the
|
|||
|
IRA beneficiary, and that decision-maker is an accredited investor under
|
|||
|
Category(ies) ____ in this Questionnaire. In the blank, please insert the letter
|
|||
|
of each Category in this Questionnaire that applies to the decision-maker.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ E. Revocable Trust other than IRA – Income or Net Worth Test Applied to
|
|||
|
Grantor(s) and Decision-Maker. A revocable trust (other than an IRA), and
|
|||
|
```
|
|||
|
|
|||
|
```
|
|||
|
(1) each grantor of the trust is an accredited investor on the basis of Box A or
|
|||
|
B above, and (2) the person who makes investment decisions for Investor is an
|
|||
|
accredited investor under Category(ies)_________ in this Questionnaire. In
|
|||
|
the blank, please insert the letter of each Category in this Questionnaire that
|
|||
|
applies to the decision-maker.
|
|||
|
```
|
|||
|
⎕ F.^ Self-Directed Pension Plan other than IRA **_–_**^ Income or Net Worth Test
|
|||
|
Applied to Participant. A self-directed pension plan (other than an IRA), and
|
|||
|
the participant who directed that assets of his or her account be invested in the
|
|||
|
Fund is (1) an accredited investor on the basis of Box A or B above, and (2)
|
|||
|
the only participant whose account is being invested in the Fund.
|
|||
|
|
|||
|
⎕ G. Other Pension Plan. A pension plan that is not a self-directed plan, and either
|
|||
|
(1) the plan has total assets in excess of $5,000,000; or (2) the plan's
|
|||
|
investment decisions are made by a plan fiduciary that is a bank, savings and
|
|||
|
loan association, insurance company or registered investment adviser.
|
|||
|
|
|||
|
⎕ H. Irrevocable Trust. An irrevocable trust that consists of a single trust (1) with
|
|||
|
total assets in excess of $5,000,000, and (2) which was not formed for the
|
|||
|
specific purpose of investing in the Fund, and (3) whose purchase is directed
|
|||
|
by a person who has such knowledge and experience in financial and business
|
|||
|
matters that he or she is capable or evaluating the merits and risks of the
|
|||
|
prospective investment.
|
|||
|
|
|||
|
⎕ I.^ Corporation, Partnership, Business Trust.^ A corporation, a partnership, or
|
|||
|
similar business trust, or an organization described in Section 501(c)(3) of the
|
|||
|
Internal Revenue Code, that was not formed for the specific purpose of
|
|||
|
acquiring an interest in the Fund, with total assets in excess of $5,000,000.
|
|||
|
|
|||
|
⎕ J. Other Entities. Any of the following entities that has a net worth of at least
|
|||
|
$5,000,000:
|
|||
|
⎕ a bank, as defined in Section 3(a)(2) of the Securities Act of 1933;
|
|||
|
⎕ acting for its own account;
|
|||
|
⎕ acting in a fiduciary capacity;
|
|||
|
⎕ a savings and loan association or similar institution, as defined in
|
|||
|
Section 3(a)(5)(A) of the Securities Act of 1933;
|
|||
|
⎕ acting for its own account;
|
|||
|
⎕ acting in a fiduciary capacity;
|
|||
|
⎕ a broker-dealer registered under the Securities Exchange Act of 1934;
|
|||
|
⎕ an insurance company, as defined in Section 2(13) of the Securities Act of
|
|||
|
1933;
|
|||
|
|
|||
|
|
|||
|
```
|
|||
|
⎕ an investment company registered under the Investment Company Act of
|
|||
|
1940;
|
|||
|
⎕ a "business development company," as defined in Section 2(a)(48) of the
|
|||
|
Investment Company Act of 1940;
|
|||
|
⎕ a small business investment company licensed under Section 301(c) or
|
|||
|
301(d) of the Small Business Investment Act of 1958, as amended;
|
|||
|
⎕ a "private business development company" as defined in Section
|
|||
|
202(a)(22) of the Investment Advisers Act of 1940.
|
|||
|
```
|
|||
|
⎕ K.^ None Of The Above Applies (further information may be required to
|
|||
|
determine Investor's accredited investor status).
|
|||
|
|
|||
|
|
|||
|
### Questions To Determine Whether Investor Is A Covered Person Under Rule 506
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page
|
|||
|
```
|
|||
|
Reason For This Questionnaire. In its offering of Interests, the Fund may rely on a registration
|
|||
|
exemption that is available under Regulation D under the Securities Act of 1933. That
|
|||
|
exemption may be unavailable or limited if one or more “Covered Persons” has experienced a
|
|||
|
“Disqualifying Event.” The questions below aim to determine whether Investor is a “Covered
|
|||
|
Person.” If Investor is a Covered Person, the General Partner may ask additional questions to
|
|||
|
determine whether Investor has experienced a “Disqualifying Event.” Capitalized terms are
|
|||
|
defined alphabetically below the questions.
|
|||
|
|
|||
|
**_Questions to Determine Whether Investor is a “Covered Person”_** (check Box A if none applies)
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. Investor Is Not A Covered Person. Investor does not fall into Category B, C,
|
|||
|
or D below.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ B. Certain Relationships with General Partner, Investment Manager, or
|
|||
|
Fund. Investor is a Management Person and/or a Twenty Percent Owner of
|
|||
|
the General Partner, the Investment Manager, or the Fund (or another issuer of
|
|||
|
securities affiliated with the Fund).
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ C.^ Solicitor for Fund.^ Investor is a Solicitor in the Fund’s offering of Interests,
|
|||
|
or is a Management Person of a Solicitor if the Solicitor is an entity
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ D. Promoter of Fund. Investor is a Promoter of the Fund, or is a Management
|
|||
|
Person of a Promoter if the Promoter is an entity.
|
|||
|
```
|
|||
|
### Some Definitions Used In This Questionnaire
|
|||
|
|
|||
|
“Covered Person” means an individual or entity described in Category B, C or D above.
|
|||
|
|
|||
|
“Executive Officer” means a company’s president, any vice president in charge of a principal
|
|||
|
business unit, division or function (such as sales, administration or finance), any other officer
|
|||
|
who performs a policy-making function, or any other person who performs similar policy-
|
|||
|
making functions.
|
|||
|
|
|||
|
“Management Person” of an entity means a general partner of a partnership, a managing
|
|||
|
member or manager of a limited liability company, a director of a corporation or similar entity, a
|
|||
|
trustee of a trust, an Executive Officer, or an Officer Participating in the Offering. If Investor has
|
|||
|
none of such titles or functions but is commonly referred to as a “principal” of the entity, assume
|
|||
|
that Investor is a Management Person of the entity for the purposes of this Questionnaire.
|
|||
|
|
|||
|
|
|||
|
“Officer Participating in the Offering” means a company’s president, vice president, secretary,
|
|||
|
treasurer or principal financial officer, comptroller or principal accounting officer, as well as any
|
|||
|
person who routinely performs corresponding functions, if such person is participating in the
|
|||
|
Fund’s offering of Interests. Such a person may or may not also be an Executive Officer.
|
|||
|
“Participation” in the offering means more than transitory or incidental involvement. For
|
|||
|
example, it may include activities such as participation or involvement in due diligence
|
|||
|
activities, involvement in the preparation of disclosure documents, or communication with the
|
|||
|
Fund, the General Partner, prospective investors, or other offering participants.
|
|||
|
|
|||
|
“Promoter” means an individual or entity that is a “promoter” of the Fund under the broad
|
|||
|
definition of that term in Rule 405 under the Securities Act of 1933. In general, “promoter”
|
|||
|
includes anyone who, either alone or with others, directly or indirectly, takes the initiative in
|
|||
|
founding or organizing the business of the issuer (the Fund, here), or, in connection with such
|
|||
|
founding or organization, directly or indirectly receives 10% or more of any class of the issuer’s
|
|||
|
securities or 10% or more of the proceeds from the sale of any class of the issuer’s securities
|
|||
|
(other than securities received solely as underwriting commissions or solely in exchange for
|
|||
|
property).
|
|||
|
|
|||
|
“Solicitor” means an individual or entity that has received or may receive compensation for
|
|||
|
soliciting investors in the Fund’s offering of Interests (whether or not a broker-dealer).
|
|||
|
|
|||
|
“Twenty Percent Owner” of an entity means an individual or entity that owns 20% or more of
|
|||
|
the equity securities of the entity, based on total voting power rather than on ownership of any
|
|||
|
particular class of securities.
|
|||
|
|
|||
|
|
|||
|
### Private Investment Companies
|
|||
|
|
|||
|
```
|
|||
|
Please Skip to page 39 if investor is an individual (including IRA).
|
|||
|
```
|
|||
|
```
|
|||
|
Otherwise check appropriate box(es).
|
|||
|
```
|
|||
|
Reason For This Questionnaire. The Fund relies on a registration exemption under the
|
|||
|
Investment Company Act of 1940 that limits the number of owners of its equity securities.
|
|||
|
Certain counting rules under that exemption may require the Fund to count, as owners of the
|
|||
|
Fund, the owners of an entity that invests in the Fund. The questions on this page will enable the
|
|||
|
Fund to determine whether those counting rules will apply. The General Partner may need to ask
|
|||
|
for additional information. Check one or more boxes on this page, and then turn to page 39 :
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. Section 3(c)(1) Company. Investor is a Section 3(c)(1) Company (see
|
|||
|
definition on page 3 8 ). If you checked this box, please skip to page 39.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ B.^ Section 3(c)(7) Company. Investor is a Section 3(c)(7) Company (see
|
|||
|
definition on page 3 8 ). If you checked this box, please skip to page 39.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ C. Not a Section 3(c)(1) Company or Section 3(c)(7) Company. Investor is
|
|||
|
neither a Section 3(c)(1) Company nor a Section 3(c)(7) Company.
|
|||
|
```
|
|||
|
```
|
|||
|
If you checked this box, please answer each additional question below on this
|
|||
|
page.
|
|||
|
```
|
|||
|
```
|
|||
|
C1. Immediately after Investor invests in the Fund, will more than 40% of
|
|||
|
Investor’s assets be invested in the Fund?
|
|||
|
⎕ Yes ⎕ No
|
|||
|
```
|
|||
|
```
|
|||
|
C2. Was Investor formed for the specific purpose of investing in the Fund?
|
|||
|
⎕ Yes ⎕ No
|
|||
|
```
|
|||
|
```
|
|||
|
C3. Does Investor have, or will it have, other substantial business activities or
|
|||
|
investments besides its investment in the Fund?
|
|||
|
⎕ Yes ⎕ No
|
|||
|
```
|
|||
|
```
|
|||
|
C4. Under Investor's governing documents or in practice, do Investor's owners
|
|||
|
have the right to vary the level of their participation in different investments
|
|||
|
made by Investor?
|
|||
|
⎕ Yes ⎕ No
|
|||
|
C5. Under Investor's governing documents and in practice, are Investor's
|
|||
|
```
|
|||
|
|
|||
|
```
|
|||
|
investment decisions based only on the collective investment objectives of
|
|||
|
Investor and its owners, or are the varying investment objectives of its owners
|
|||
|
also taken into account?
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ Only the collective objectives of Investor and its owners are taken into
|
|||
|
account when an investment decision is made
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ Varying objectives of Investor's separate owners may be taken into
|
|||
|
account when an investment decision is made.
|
|||
|
```
|
|||
|
```
|
|||
|
C6. If Investor is a trust, is the trust revocable by any person specified below?
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ Person who created the trust. ⎕ Trustee or trustees.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ Beneficiary or beneficiaries. ⎕ Not revocable by any such person.
|
|||
|
```
|
|||
|
### Some Definitions Used In This Questionnaire
|
|||
|
|
|||
|
“Company” means a corporation, partnership, association, joint-stock company or trust, or any
|
|||
|
other organized group of persons whether incorporated or not; a receiver, bankruptcy trustee or
|
|||
|
similar official; or a liquidating agent for any of the foregoing. The definition excludes, however,
|
|||
|
any such entity that is required to be registered as an "investment company" under the
|
|||
|
Investment Company Act of 1940 (see definition below) but is not registered.
|
|||
|
|
|||
|
“Look-Through Entity” refers to three types of Companies that are not eligible for Qualified
|
|||
|
Client status unless each equity owner (with some exceptions) of the Look-Through Entity is a
|
|||
|
Qualified Client: (a) an investment company (see definition below) registered under the
|
|||
|
Investment Company Act of 1940; (b) a business development company, as defined in Section
|
|||
|
202(a)(22) of the Investment Advisers Act of 1940; and (c) a Section 3(c)(1) Company (see
|
|||
|
definition below). As used in the preceding paragraph (and in other parts of this Subscription
|
|||
|
Agreement that expressly refer to this definition), "investment company" has the meaning
|
|||
|
assigned to it in Section 3(a) of the Investment Company Act of 1940: any entity that (i) is or
|
|||
|
holds itself out as being engaged primarily, or proposes to engage primarily, in the business of
|
|||
|
investing, reinvesting, or trading in securities; or (ii) is engaged or proposes to engage in the
|
|||
|
business of issuing face-amount certificates of the installment type, or has been engaged in such
|
|||
|
business and has any such certificate outstanding; or (iii) is engaged or proposes to engage in the
|
|||
|
business of investing, reinvesting, owning, holding, or trading in securities, and owns or
|
|||
|
proposes to acquire investment securities (i.e., any securities other than government securities,
|
|||
|
securities issued by any employee securities company and securities issued by any majority
|
|||
|
owned subsidiary of the entity that is not itself an investment company or a private investment
|
|||
|
company) having a value exceeding 40% of the value of the entity's total assets (excluding
|
|||
|
government securities and cash items) on an unconsolidated basis.
|
|||
|
|
|||
|
|
|||
|
A “Section 3(c)(1) Company” is a Company that would be an “investment company” under the
|
|||
|
Investment Company Act of 1940 (see definition above) but for the exception under Section
|
|||
|
3(c)(1) of that Act. That exception generally is available if (1) the Company is not making (or
|
|||
|
presently proposing to make) a public offering of its securities, and (2) its outstanding securities
|
|||
|
(other than its short-term paper) are beneficially owned by not more than 100 persons. Most
|
|||
|
private investment funds, for example, rely on this registration exemption.
|
|||
|
|
|||
|
A “Section 3(c)(7) Company” is a Company that would be an “investment company” under the
|
|||
|
Investment Company Act of 1940 (see definition above) but for the exception under Section
|
|||
|
3(c)(7) of that Act. That exception generally is available if (1) the Company is not making (or
|
|||
|
presently proposing to make) a public offering of its securities, and (2) its outstanding securities
|
|||
|
are owned exclusively by persons who, at the time of their purchase of such securities, are
|
|||
|
"qualified purchasers" as defined in Section 2(a)(51) of the Investment Company Act – generally
|
|||
|
individuals who own at least $5,000,000 in "investments" and entities that own at least
|
|||
|
$25,000,000 in "investments" (as "investments" is defined in Section 2(a)(51) and rules
|
|||
|
thereunder). Many private investment funds, for example, rely on this registration exemption.
|
|||
|
|
|||
|
|
|||
|
### Benefit Plan Investor Status
|
|||
|
|
|||
|
```
|
|||
|
All Investors should complete this page, which continues on the next page.
|
|||
|
```
|
|||
|
```
|
|||
|
Individual Investors (but NOT IRAs): See Box A below.
|
|||
|
```
|
|||
|
By checking the appropriate box below, Investor represents and warrants either that (a) if
|
|||
|
Investor checks the first box below, Investor is not, and for so long as it holds an ownership
|
|||
|
interest in the Fund will not be, a "Benefit Plan Investor" within the meaning of U.S.
|
|||
|
Department of Labor Regulation 29 CFR 2510.3-101 (the "Plan Assets Regulation"); or (b)
|
|||
|
Investor has indicated the category under which Investor is a Benefit Plan Investor.
|
|||
|
|
|||
|
Generally, a "Benefit Plan Investor" is any plan or fund organized by an employer or employee
|
|||
|
organization to provide retirement, deferred compensation, welfare or similar benefits to
|
|||
|
employees; an IRA; a Keogh plan; a 403(b) plan; or an entity, including a hypothetical entity
|
|||
|
described in Section (g) of the Plan Assets Regulation, with 25% or more of any class of equity
|
|||
|
that is owned by such plans and that is primarily engaged in the business of investing capital.
|
|||
|
|
|||
|
Check one of the following boxes:
|
|||
|
|
|||
|
```
|
|||
|
⎕ A. Investor Is Not A Benefit Plan Investor.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ B. Investor is an employee benefit plan that is subject to Title I of the Employee
|
|||
|
Retirement Income Security Act of 1974, as amended ("ERISA").
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ C.^ Investor is an employee benefit plan that is not subject to ERISA (for
|
|||
|
example, some pension plans, profit-sharing and 401(k) plans).
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ D. Investor is a plan described in Section 4975(e)(1) of the Internal Revenue
|
|||
|
Code of 1986, as amended (the "Code") (for example, IRAs, Keogh plans or
|
|||
|
403(b) plans).
|
|||
|
If you checked this box, please provide the following information (IRAs should
|
|||
|
check first box below).
|
|||
|
⎕ Owner-Only Plan. The plan beneficiaries include only the owner of the
|
|||
|
business that sponsors the plan (or the owner and the owner's spouse).
|
|||
|
⎕ Not an Owner-Only Plan. The plan beneficiaries include persons other
|
|||
|
than (or in addition to) the owner of the business that sponsors the plan (or
|
|||
|
the owner and the owner's spouse).
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ E.^ Investor is an entity whose underlying assets include "plan assets" by
|
|||
|
operation of the Plan Assets Regulation (for example, a group trust, separate
|
|||
|
account, fund of funds or a hypothetical entity with significant (25% or more)
|
|||
|
Benefit Plan Investor ownership).
|
|||
|
```
|
|||
|
|
|||
|
⎕ F. Investor is an insurance company general account whose underlying assets
|
|||
|
include "plan assets" and, the undersigned hereby represents and warrants that
|
|||
|
the percentage of such assets used to purchase this investment that represents
|
|||
|
plan assets does not exceed the following percentage (fill in): ____%.
|
|||
|
|
|||
|
|
|||
|
```
|
|||
|
Acknowledgements, Representations and Warranties by Benefit Plan Fiduciary
|
|||
|
```
|
|||
|
```
|
|||
|
Skip this page if you checked Box A on preceding page.
|
|||
|
```
|
|||
|
```
|
|||
|
If you instead checked Box B through F above, please read this page carefully.
|
|||
|
```
|
|||
|
If Investor is a Benefit Plan Investor subject to ERISA or Section 4975 of the Code (a "Plan"),
|
|||
|
the fiduciary executing this Agreement on behalf of Investor (the "Fiduciary") and Investor
|
|||
|
represent and warrant to the Fund, the General Partner and the Investment Manager that:
|
|||
|
|
|||
|
1. The Fiduciary has considered the following with respect to the Plan's investment in the
|
|||
|
Fund and has determined that, in view of such considerations, the Plan's purchase of a
|
|||
|
Fund interest is consistent with the Fiduciary's responsibilities under ERISA or the Code,
|
|||
|
including (i) whether this investment is prudent for the Plan; (ii) whether the risk,
|
|||
|
structure and operation of the incentive fee arrangement (if any) has been adequately
|
|||
|
disclosed, furthers the interests of the Plan and provides reasonable compensation to
|
|||
|
Fund Management; (iii) whether the Plan's current and anticipated liquidity needs would
|
|||
|
be met, given the limited rights to redeem or transfer the Plan's ownership interest in the
|
|||
|
Fund; (iv) whether the investment would permit the Plan's overall portfolio to remain
|
|||
|
adequately diversified; and (v) whether the investment is permitted under documents
|
|||
|
governing the Plan.
|
|||
|
2. The Fiduciary (i) is responsible for the Plan's decision to invest in the Fund; (ii) has
|
|||
|
determined that the Fund is not a "party in interest" or a "disqualified person" (as such
|
|||
|
terms are defined in ERISA and the Code) with respect to the Plan; (iii) is qualified to
|
|||
|
make this investment decision and, to the extent the Fiduciary deems necessary, has
|
|||
|
consulted the Fiduciary's own investment advisors and legal counsel regarding this
|
|||
|
investment; and (iv) in making its decision to invest in the Fund, has not relied on any
|
|||
|
advice or recommendation of the Fund, the General Partner, the Investment Manager or
|
|||
|
any of their affiliates.
|
|||
|
|
|||
|
|
|||
|
### Subscription Agreement Signature Page
|
|||
|
|
|||
|
IN WITNESS WHEREOF, the "Investor" identified below and Unicorn Pairs Fund, LP (the
|
|||
|
"Fund") have executed this Agreement to agree to Investor's initial or additional (as specified
|
|||
|
below) capital contribution to the Fund pursuant to the Fund's Limited Partnership Agreement
|
|||
|
dated February 11, 201 6 , which Agreement is attached as Exhibit A to the Fund's Private
|
|||
|
Placement Memorandum dated February 11, 2016. This Agreement shall be effective as of the
|
|||
|
"Subscription Date" to be specified below by the General Partner when it executes this
|
|||
|
Agreement.
|
|||
|
|
|||
|
Please check Box A or B:
|
|||
|
|
|||
|
```
|
|||
|
⎕ A.^ New Investor: Investor requests admission as a limited partner of the Fund^
|
|||
|
⎕ B. Existing Investor: Investor desires to contribute additional capital to the Fund.
|
|||
|
Investor hereby confirms the following. If you checked Box B, please check 1
|
|||
|
or 2):
|
|||
|
⎕ 1. Investor has supplied some or all information concerning Investor that is
|
|||
|
requested above in this Agreement. Except as supplied above in this Agreement,
|
|||
|
all such information remains unchanged from the information most recently
|
|||
|
supplied to the Fund.
|
|||
|
```
|
|||
|
```
|
|||
|
⎕ 2. Investor has supplied none of the information concerning Investor
|
|||
|
requested above. All such information remains unchanged from information
|
|||
|
most recently supplied.
|
|||
|
```
|
|||
|
```
|
|||
|
Print Full Name of Investor:
|
|||
|
(for entities, print exact name as registered in jurisdiction of formation –
|
|||
|
must match Investor name on page 12)
|
|||
|
```
|
|||
|
```
|
|||
|
Taxpayer Identification Number:
|
|||
|
(must match number on page 12)
|
|||
|
Capital Contribution: $
|
|||
|
```
|
|||
|
```
|
|||
|
Signature of Authorized Signer:
|
|||
|
```
|
|||
|
```
|
|||
|
Date signed:
|
|||
|
Print Name of Authorized Signer:
|
|||
|
(add title, if Investor is an entity)
|
|||
|
Driver's License or Passport Number of Signer:
|
|||
|
```
|
|||
|
|
|||
|
```
|
|||
|
Additional Certification if Investor is an IRA or Self-Directed Pension Plan
|
|||
|
NOTE: Custodian or trustee should sign below. IRA/plan participant should sign above.
|
|||
|
```
|
|||
|
The undersigned, acting solely on behalf of ________________________________________,
|
|||
|
which serves as the custodian or trustee for the IRA or self-directed pension plan identified as
|
|||
|
"Investor" above (the "Custodian"), hereby consents to Investor's investment in the Fund. By
|
|||
|
giving its consent, the Custodian does not represent or warrant that Investor’s representations
|
|||
|
and warranties set forth herein are true and correct, nor express any opinion on the merits of
|
|||
|
Investor's investment in the Fund.
|
|||
|
|
|||
|
Print Name/Title of Signer: Signature:
|
|||
|
|
|||
|
```
|
|||
|
Unicorn Pairs Fund, LP
|
|||
|
2323 Hurley Mountain Road,
|
|||
|
Kingston, NY 12401
|
|||
|
```
|
|||
|
```
|
|||
|
Email: peter.delrio@unicornfunds.com
|
|||
|
```
|
|||
|
```
|
|||
|
Accepted on behalf of
|
|||
|
the Fund by:
|
|||
|
```
|
|||
|
```
|
|||
|
For General Partner:
|
|||
|
Name and Title:
|
|||
|
```
|
|||
|
```
|
|||
|
Unicorn Capital Partners, LLC
|
|||
|
Peter del Rio, Managing Member
|
|||
|
```
|
|||
|
```
|
|||
|
Subscription Date:
|
|||
|
```
|
|||
|
|
|||
|
#### ____________________________________________
|
|||
|
|
|||
|
```
|
|||
|
Print Name of Authorized Signer
|
|||
|
```
|
|||
|
```
|
|||
|
____________________________________________
|
|||
|
Signature of Authorized Signer
|
|||
|
```
|
|||
|
### Notary Acknowledgement
|
|||
|
|
|||
|
State or Province of ____________)
|
|||
|
|
|||
|
County of _____________________) ss.:
|
|||
|
|
|||
|
On this _______day of ______________, 20______, before me _______________, the
|
|||
|
undersigned officer, personally appeared ____________________________, known to me (or
|
|||
|
satisfactorily proven) to be the person(s) whose name(s) is (are) in this Investor Subscription
|
|||
|
Agreement.
|
|||
|
|
|||
|
In WITNESS HEREOF, I hereunto set my hand and official seal.
|
|||
|
|
|||
|
#### ____________________________________________
|
|||
|
|
|||
|
Notary Public/Commissioner of Oaths
|
|||
|
|
|||
|
```
|
|||
|
My Commission Expires______________
|
|||
|
```
|
|||
|
#### (SEAL)
|
|||
|
|
|||
|
|