PCRS CAPITAL PARTNERS, LLC
A Delaware Limited Liability Company
INVESTOR QUALIFICATION QUESTIONAIRE
I. INSTRUCTIONS
This Questionnaire is being distributed to certain individuals who may be offered the opportunity to purchase Membership Units (the “Securities”) of PCRS Capital Partners, LLC, a Delaware limited liability company (the “Company”). The purpose of this Questionnaire is to assure the Company that all such offers and purchases will meet the standards imposed by the Securities Act of 1933, as amended (the “Act”), and applicable state securities laws.
Your answers will be kept confidential. However, by signing this Questionnaire you agree that the Company and its counsel may rely on the information set forth in this Questionnaire for purposes of complying with all applicable securities laws and may present this Questionnaire to such parties as it reasonably deems appropriate if called upon to establish its compliance with such securities laws.
Please complete, sign, date and return one copy of this Questionnaire to the Company’s Manager, Taiwanese American Elders Corp. Attn: John Wang, 5325 E. Pacific Coast Highway, Long Beach, California 90804. If the answer to a question is “none” or “not applicable,” please so state.
II. IDENTIFYING INFORMATION
Full Name(s):
Home Address:
Home Phone:
Business Address:
Business Phone:
Date of Birth:
Marital Status:
Number of Dependents:
In what state do you maintain your principal residence? (If you have resided in this state less than one year, or plan to change your state of residence, please explain.)
Is there any reason you might be considered a resident of another state (e.g. live part of the year, have an office or business, registered to vote, pay taxes or hold a driver’s license in another state)? If so, please explain:
III. EMPLOYMENT/EDUCATION
If you are an individual, please furnish all of the following information regarding yourself. If a husband and wife are investing jointly, please furnish all of the following information with respect to each spouse and identify the spouse to which the information pertains. If you are an entity or are investing jointly with a person other than your spouse, please furnish all of the following information in this Part B regarding each officer, partner, trustee or other person who will participate in the investment decision.
A. Education:
College/University Degree Major Year
B. Employment:
Name and Address of Current Employer:
Nature of Employment:
If self-employed, nature of business:
Name and Address of Current Employer of Spouse/Co-Investor:
Nature of Employment:
If self-employed, nature of business:
Describe briefly all positions (including directorships) held during the past five years which were related to financial, business, accounting, economics, taxation or investment matters which you feel demonstrate your investment sophistication. Where appropriate, briefly describe the business of the company or other entity in which the position was held:
Describe your other background in business (particularly in the insurance industry), economics, finance, accounting, taxation, law, investing or relating fields (include any relevant educational experience) that demonstrates investment sophistication):
IV. FINANCIAL INFORMATION
General Instructions: If you are an entity (corporation, partnership, trust, etc.), complete the section below entitled “Entities.” In addition, each partner of an investor that is a partnership, each beneficiary of an investor that is a trust and each shareholder of an investor that is a closely held corporation should complete the section below entitled “Individuals.”
A. Entities:
Type of Entity:
Number of partners, shareholders or beneficiaries:
What is the investor’s approximate net worth? $
B. Individuals (including certain partners, shareholders and beneficiaries). (See general instructions.)
Was your gross income from all sources (check appropriate blank(s)):
For Calendar For last Reasonably
Year Prior Calendar Expected for This
To Last Year Year Calendar Year
Alone greater
Than:
$100,000
$200,000
$300,000
Jointly with
Spouse Greater
than:
$100,000
$200,000
$300,000
Is your individual or joint net worth with your spouse (excluding personal residence, furnishings and automobiles), as of the date hereof, at least five times the amount of your proposed investment?
Yes ______No ______
Is your individual or joint net worth with your spouse (including personal residence, furnishings and automobiles),as of the date hereof, at least:
$1,000,000? Yes No ;
Ten times the amount of your proposed investment? Yes No .
V. INVESTMENT EXPERIENCE/PRE-EXISTING RELATIONSHIP WITH COMPANY
Approximate number of years you have been investing:
Please indicate your prior experience in investing in new, speculative companies [e.g., start up business ventures] such as the Company for which there is no public market.
Please indicate any other relevant investment experience.
Please describe any pre-existing personal or business relationship between you and the Company, or any of its managers, board members or officers.
VI. OWNERSHIP INFORMATION:
____ / INDIVIDUAL OWNERSHIP(one signature required) / ____ / TENANTS-IN-COMMON
(both parties must sign)
____ / JOINT TENANTS WITH RIGHT OF SURVIVORSHIP
(both parties must sign) / ____ / TRUST
(please include name of Trust, name of Trustee. date Trust was formed and copy of the Trust Agreement or other authorization)
____ / COMMUNITY PROPERTY
(one signature required)
VII. ADDITIONAL INVESTOR REPRESENTATIONS
1. I have had and continue to have access to such information concerning the Company as I consider necessary for me to make an informed decision concerning an investment in the Company. In addition, I acknowledge that I have had and continue to have access to the managers of the Company and the Company’s executive officers, and the opportunity to ask questions of and receive answers from such managers, members, officers, or both, concerning my prospective investment in the Company and the Company generally.
2. I have the business and financial knowledge and experience necessary to be able to evaluate the merits and risks of a purchase of the Securities and an investment in the Company.
3. I am interested in making this investment solely for my own account and not directly or indirectly for the account of any other person whatsoever, for investment and not with a view to, or for sale in connection with, any distribution of the Securities. I do not have any contract, undertaking or arrangement with any person to sell, transfer or grant a participation to any person with respect to this investment.
4. I represent that the information contained herein is complete and accurate and may be relied upon by the Company, and that the undersigned will notify the Company of any material change in any of such information prior to the undersigned’s investment in the Company.
In Witness Whereof, the undersigned has executed this Investor Qualification Questionnaire this _____ day of ______, ______.
Signature
Printed Name
Signature
Printed Name
5.