Name of Subscriber:                                                                      

 

Alliance Medical Fund I LLC SUBSCRIPTION AGREEMENT

Alliance Medical Fund I LLC 2201 Waukegan Rd. Suite 120

Bannockburn, IL 60015 Dear Sirs:

 

This Alliance Medical Fund I LLC Subscription Agreement (this “Agreement”) is entered into by and among, Alliance Medical Fund I LLC, a Delaware limited liability company (the “Company”); Alliance Medical Fund I Manager LLC, a Delaware limited liability company (the “Manager”); and the undersigned subscriber (the “Subscriber”). Capitalized terms used but not defined herein shall have the meanings set forth in the LLC Agreement (defined below).

 

 

(iii) agrees to perform all obligations in the LLC Agreement imposed upon a Member with respect to the Company Interest, including making capital contributions (“Contributions”) to the Company in accordance with the terms thereof, including without limitation additional amounts in the case Subscriber is admitted at a Subsequent Closing.

 

1. The Subscriber understands that this Subscription, when and if accepted by the Manager, will be irrevocable and will constitute a commitment to contribute to the Company the amount of the Subscription accepted by the Manager (the “Capital Commitment”), plus any additional amounts required to be paid by the Subscriber pursuant to the LLC Agreement if the Subscriber is making this Subscription or increasing the Capital Commitment after the Initial Closing. The Subscriber shall be admitted as a Member at the time this Agreement is accepted and executed by the Manager, which shall be at the Initial Closing or a Subsequent Closing. The Subscriber acknowledges that this Agreement will become irrevocable with respect to the Subscriber at the time of its submission to the Company and that it may not

 

be withdrawn by the Subscriber unless the Manager rejects this Agreement. The Subscriber acknowledges that this Agreement may be accepted or rejected by the Manager, in whole or in part, in its sole discretion on behalf of the Company. The Subscriber acknowledges and understands that if this Subscription is accepted by the Company, the Company Interest issued to Subscriber will be a Class A limited liability company interest or Class B limited liability company interest, or Class C limited liability company interest, depending on the amount of the Capital Commitment and as determined by the Manager in accordance with the LLC Agreement.

 

 

 

 

 

1. If this subscription is accepted, in order to effect the admission of the Subscriber as a Member of the Company, the Subscriber herewith delivers to the Manager a counterpart signature page to the LLC Agreement, duly executed by the Subscriber, and hereby irrevocably authorizes the Manager to (i) annex said

 

signature pages to the LLC Agreement and (ii) enter Subscriber’s name on Schedule A to the LLC Agreement as holder of the Company Interest.

 

 

 

In connection with the Subscriber’s Subscription for a Company Interest, the Subscriber hereby represents, warrants, acknowledges and agrees as of the date hereof and through and including each date that this Agreement is accepted in whole or in part by the Manager as follows:

 

 

• Individual
• Joint Tenants with Rights of Survivorship
  • Tenants-in-Common
  • Community Property
  • Revocable Living Trust with          Grantors
  • Irrevocable Trust
  • Partnership or Corporation
  • Limited Liability Company
    • Self Directed Individual Retirement Account (“IRA”)
    • SEP/Keogh/Employee Benefit Plan
    • Other:                                             

 

1. The Company Interest is being purchased by the Subscriber with the Subscriber’s own funds and not with the funds of any other person. Except in the case of a Subscriber that is a Qualified Plan Investor (as described herein), on acceptance of this Agreement by the Manager, no person other than the Subscriber will have any interest, beneficial or otherwise, in the Company Interest. The Subscriber acknowledges that if this Agreement is accepted by the Manager, the Subscriber will become a Member having the rights and obligations described in the LLC Agreement, except that participants in and beneficiaries of any Subscriber that is a Qualified Plan Investor shall benefit as provided in plan documents.

 

 

 

 

1. The Subscriber acknowledges receipt of the Company’s Confidential Private Placement Memorandum dated April 14, 2022, and as may be amended or restated thereafter (the “Memorandum”), and the LLC Agreement and acknowledges that the Subscriber has been furnished with such financial and other information concerning the Company, the Manager and the business and proposed business of the Company as the Subscriber considers necessary in connection with the Subscriber’s investment in the Company Interest. The Subscriber has carefully reviewed the Memorandum, including all of the risk factors disclosed therein, and the LLC Agreement and is thoroughly familiar with the proposed business,

 

operations, properties and financial condition of the Company and has discussed or been afforded the opportunity to discuss with (1) the Manager and (2) the Subscriber’s own legal, tax, accounting and other advisers any questions the Subscriber may have had with respect to the terms and conditions of the LLC Agreement and the merits and risks of the Subscriber’s investment in the Company Interest. The Subscriber understands and acknowledges the following:

 

 

 

 

 

 

(C) prior business performance of the Managing Members and their Affiliates set forth in the Memorandum or in any supplemental disclosures or material thereto are not necessarily indicative of the returns, if any, which may be achieved by the Company.

 

 

1. That the distribution of the Memorandum and the offer and sale of the Company Interest in certain jurisdictions may be restricted by law. The Memorandum does not constitute an offer to sell or the solicitation of an offer to buy in a state or other jurisdiction to any person to whom it is unlawful to make such offer or solicitation in such state or jurisdiction. Only investors who are both “accredited investors” as defined in Rule 501(a) of Regulation D promulgated under the 1933 Act and “qualified clients” (as defined under Rule 205-3 of the Advisers Act) are eligible to purchase a Company Interest. The Company Interest may not be offered or sold,

 

directly or indirectly, and the Memorandum may not be distributed, in any jurisdiction, except in accordance with the legal requirements applicable in such jurisdiction.

 

 

 

 

 

1. Except as indicated in a writing attached hereto by the Subscriber, no statute, rule, regulation, administrative procedure of general applicability or order of any federal, state or other regulatory agency or other governmental body to which the Subscriber is subject would prohibit the Subscriber from investing in one or more of the investments falling within the investment objectives of the Company.

 

 

 

 

 

1. the participant who directed that assets of his or her account be invested in the Company (A) has an individual net worth, or joint net worth with his or her spouse or spousal equivalent, in excess of $1 million excluding the value of the individual’s primary residence and any indebtedness that is secured by the individual’s primary residence, except for the amount of indebtedness that is secured by the individual’s primary residence that exceeds, at the time of his or her purchase of the Company Interest, (A) the estimated fair market value of the primary residence or (B) the amount of indebtedness outstanding 60 days before the time of his or her purchase of

 

the Company Interest, other than as a result of the acquisition of the primary residence, or (B) had an income in excess of $200,000 in each of the two most recent years (or joint income with his or her spouse or spousal equivalent in excess of $300,000 in each of those years) and has a reasonable expectation of reaching the same income level in the coming year, and (ii) such participant is the only participant whose account is being invested in the Company.

 

 

 

 

 

 

60 days before the time of his or her purchase of the Company Interest, other than as a result of the acquisition of the primary residence, or (ii) had an income in excess of $200,000 in each of the two most recent years (or joint income with his or her spouse or spousal equivalent in excess of $300,000 in each of those years) and has a reasonable expectation of reaching the same income level in the coming year.

 

• neither of the above applies (further information may be required to determine eligibility to invest in the Company).

 

$5,000,000 in assets under management, as each term is defined under the Investment Advisers Act of 1940, as amended (the “Advisers Act”).

 

 

 

$5 million.

 

 

Subscriber has also completed the accredited investor verification process established by the Manager, by either (i) completing, executing, and delivering the Accredited Investor Verification material attached hereto as Attachment E (“Accredited Investor Verification”) or (ii) by completing the process and making the statements via the online portal maintained by the Company’s administrator. Subscriber understands and acknowledges that (A) the Manager intends to generally solicit and advertise the Company’s offering of the Company Interests to the public under Rule 506(c) of Regulation D promulgated under the 1933 Act and, accordingly, (B) the Manager is relying on the statements made by Subscriber in the Accredited Investor Verification and online portal regarding Subscriber’s status as an accredited investor.

 

 

• is
• is not

 

a United States person.1

 

If the Subscriber is a United States person, the Subscriber confirms that the taxpayer identification number (or social security number) shown on Attachment A and Attachment B to this Agreement is true, correct and complete and that the Subscriber is not subject to backup withholding either (A) because the Subscriber has not been notified that it is subject to backup withholding as a result of a failure to report all interest or dividends or (B) because the Internal Revenue Service has notified the Subscriber that the Subscriber is no longer subject to backup withholding. If Subscriber is (i) not a U.S. citizen or resident and has so indicated in this Agreement, or (ii) a U.S. citizen or resident and fails to provide Subscriber’s correct Social Security or taxpayer identification number, Subscriber acknowledges that Subscriber could be subject to United States withholding tax on a portion of Subscriber’s distributive share of the Company’s income.

 

 

• has
• has not

 

utilized a purchaser representative. If the Subscriber has utilized a purchaser representative, the Subscriber has previously notified the Manager in writing of such fact, specifying that such purchaser representative is acting as the Subscriber’s “purchaser representative” as defined in Rule 501(h) of Regulation D under the 1933 Act.

 

 

 

1 A “United States person” includes (i) a citizen or resident of the United States; (ii) a corporation, partnership, limited liability company or other entity created or organized in or under the laws of the United States or of any state thereof; (iii) a trust if a court within the United States is able to exercise primary supervision over the administration of the trust and one or more U.S. fiduciaries have the authority to control all substantial decisions of the trust; or (iv) an estate the income of which is subject to U.S. federal income taxation regardless of its source.

 

person by any department, agency, division, board, bureau or other instrumentality of the U.S. government, including those persons, entities and organizations 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”), which list can be accessed on the Web at https://www.treasury.gov/resource-center/sanctions/Pages/ default.aspx, as such list may be amended from time to time, or (B) residing or having a place of business in a country or territory subject to embargo under laws enforced by OFAC; or (3) for any senior foreign political figure or an immediate family member or a close associate of a senior foreign political figure2 (all such persons described in (1)-(3) are collectively referred to as “Blocked Persons”).

 

(y) any person having a beneficial interest in the Subscriber if the Subscriber is a privately held entity, or (z) any person for which the Subscriber is acting as agent or nominee in connection with this Agreement (those persons covered by (x), (y) and (z) collectively being referred to as “Related Parties”) is a Blocked Person. The Subscriber now holds and will maintain all evidence of such Related Parties’ identities and status for at least five years from the date that the Subscriber no longer has any interest in the Company. The Subscriber acknowledges that, to comply with anti-money-laundering, OFAC and related requirements that are applicable to the Company, the Manager may at any time require such information as the Manager may deem necessary to establish the identity of the Subscriber and any Related Parties and may seek to verify such identity and the source of funds for the Commitment. The Subscriber agrees that, upon demand by the Manager, it will promptly furnish any information, and execute and deliver such documents, as reasonably may be required in the determination of the

2 “Senior foreign political figure” means a senior official in the executive, legislative, administrative, military or judicial branches 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. The “immediate family member” of a senior foreign political figure typically includes the senior foreign political figure’s parents, siblings, spouse, children and in-laws. A “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.

 

Company or Manager, to comply with, or to confirm compliance with, any applicable laws or regulations or other obligations of Subscriber or the Company. The Subscriber also understands and agrees that, notwithstanding any provision of this Agreement, the LLC Agreement or the Memorandum to the contrary, the Company may release confidential information about the Subscriber and, if applicable, any underlying beneficial owners of the Subscriber to law enforcement agencies to the extent necessary to ensure compliance with all applicable laws, rules and regulations if the Manager, in its sole discretion, determines that it is in the best interests of the Company in light of the relevant rules and regulations concerning money laundering and similar activities.

 

1. The Subscriber understands and agrees that the Company may undertake any actions that the Company deems necessary or appropriate to ensure compliance with applicable laws, rules and regulations established to combat money laundering or terrorism. In the event that any of the representations, warranties or covenants by the Subscriber in this Section 3(p) are no longer true or the Company or Manager no longer believes that it has satisfactory evidence as to their truth, the Company may, in accordance with applicable regulations, (A) prohibit additional Contributions from the Subscriber,
2. prohibit any withdrawal or transfer of the Subscriber’s Company Interest and segregate the assets in the account of the Subscriber in compliance with governmental regulations, or (C) if legally permissible, cause the withdrawal of the Subscriber from the Company and the redemption of the Subscriber’s Company Interest. The Company or Manager may also be required to report such action and to disclose the Subscriber’s and Related Parties’ identities to OFAC and other government authorities. The Subscriber understands and agrees that any withdrawal proceeds paid to it will be paid to the same account from which the Subscriber’s investment in the Company was originally remitted, unless the Manager, in its sole discretion, agrees otherwise.
3. The Subscriber further represents and warrants that its subscription funds do not originate from, nor will they be routed through, an account maintained at

 

a foreign shell bank,3 an “offshore bank” or a bank organized or chartered under the laws of a Non-Cooperative Jurisdiction.4

 

 

 

 

3 A “foreign shell bank” is any non-U.S. bank that does not have a physical presence in any location but is NOT a regulated affiliate.

 

A “regulated affiliate” means a foreign shell bank (a) that is an affiliate of a United States depository institution, United States credit union or foreign bank that maintains a physical presence in the United States or a foreign country, and (b) is subject to supervision by a banking authority in the country regulating such affiliate depository institution, credit union or foreign bank.

 

A “foreign bank” is any organization (a) that is organized under non-United States law,

(b) engages in the banking business, (c) is recognized as a bank by the bank supervisory or monetary authority of the country of its organization or principal banking operations, and (d) receives deposits in the regular course of its business; however, the term does NOT include (i) a branch of a foreign bank in the United States, other than a branch in a territory of the United States, Puerto Rico, Guam, American Samoa or the U.S. Virgin Islands; (ii) an insured bank organized under the laws of a territory of the United States, Puerto Rico, Guam, American Samoa or the U.S. Virgin Islands; (iii) a foreign central bank or foreign monetary authority that functions as a central bank; or (iv) an international financial institution of which the United States is a member.

 

“Physical presence” means a place of business that is maintained by the non-U.S. 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 bank is authorized to conduct banking activities, at which location the non-U.S. bank

U.S. bank to conduct banking activities.

 

A foreign shell bank is an “affiliate” of another institution if it is controlled by or under common control with the other institution. “Control” means (i) ownership, control or power to vote 25 percent or more of any class of voting shares or other voting interests of another company, or (ii) control in any manner of the election of a majority of the directors (or individuals exercising similar functions) of another company.

4 A “Non-Cooperative Jurisdiction” means any foreign country or territory that has been designated as non-cooperative with international anti-money-laundering principles or procedures by an intergovernmental group or organization, such as the Financial Action Task Force on Money Laundering (“FATF”), of which the United States is a member and which designation the United States representative to the group or organization ceases to concur. See http://www.fatf-gafi.org for FATF’s list of Non-Cooperative Jurisdictions.

 

state of residence, if different). The Subscriber, if not an individual, is empowered and duly authorized to enter into this Agreement (including the power of attorney herein) under any governing document, limited partnership agreement, trust instrument, pension plan, charter, certificate of incorporation, bylaw provision or the like of the Subscriber. The person, if any, signing this Agreement on behalf of the Subscriber is empowered and duly authorized to do so by the governing document or trust instrument, pension plan, charter, certificate of incorporation, bylaw provision, board of directors or stockholder resolution, or the like of the Subscriber. The execution and delivery of this Agreement and the LLC Agreement by the Subscriber, the completion by the Subscriber of the transactions contemplated hereby and thereby, and the performance by the Subscriber of the Subscriber’s obligations hereunder and thereunder will not conflict with, or result in a violation of or default under, any provision of any governing instrument available to the Subscriber, or any agreement or instrument to which the Subscriber is a party or by which it or any of its properties is bound, or any permit, franchise, judgment, decree, statute, rule or regulation applicable to the Subscriber or any of the Subscriber’s properties.

 

1. The Subscriber acknowledges that non-public information about the Subscriber given to the Company and the Manager by this Agreement or otherwise disclosed to the Manager through correspondence or conversations, such as the Subscriber’s name, address, telephone number, social security number or taxpayer identification number, assets, bank account information, income, date of birth, and information about the Subscriber’s transactions with the Company, including, but not limited to, account balance, cost basis information, management fees paid and other financial information (the “Protected Information”) may be disclosed (i) to the Company, the Manager, Affiliates of the Manager, attorneys, accountants and auditors in furtherance of the Company’s business; (ii) to third-party service providers that have a need for the Protected Information in connection with providing services to the Company, provided that such persons must agree to protect the confidentiality of the Protected Information and use the Protected Information only for the purposes of providing services to the Company; and (iii) as otherwise permitted by law. The Company restricts access to non-public information about the Subscriber to the personnel of the Manager, Affiliates of the Manager, and the Company who provide services to the Company or those who need access to the Subscriber’s information to service the Company or maintain its books and records. The Company also maintains physical, electronic and procedural controls in keeping with federal and/or state standards to safeguard the Subscriber’s non-public personal information. Subscriber acknowledges and agrees that (i) information relating to the identity of Subscriber and each other Member shall appear on Schedule A to the LLC Agreement and may appear on the financial statements of the Company, and (ii) other Members shall receive such information and may share such information with their advisers and other parties. If a natural person (or an entity that is an “alter ego” of a natural person (e.g., a revocable grantor trust, an IRA or an estate planning vehicle)), the Subscriber acknowledges that it has received, read, and understands the Company’s privacy

 

policy (contained in the Memorandum) with respect to the Manager’s and the Company’s collection and maintenance of non-public personal information regarding the Subscriber.

 

 

• is
  • is not

 

(i) an “employee benefit plan” as defined in section 3(3) of ERISA (such plans referred to as “ERISA Plans”), (ii) a plan with respect to which section 4975 of the Code applies or (iii) an entity or account that is deemed to be a “benefit plan investor” under the U.S. Department of Labor final plan assets regulation, 29

C.F.R. § 2510.3-101, as it may be amended from time to time (the “Plan Assets Regulation”), as modified by section 3(42) of ERISA, because its underlying assets include “plan assets” by reason of a plan’s investment in the entity, including, by way of example only, a partnership not qualifying as an operating company within the meaning of the Plan Assets Regulation in which 25 percent or more of each class of equity interests is owned by entities described above in this Section 3(s) (such ERISA Plans, plans and persons are referred to herein as “Qualified Plan Investors”). If the Subscriber is a Qualified Plan Investor, Subscriber represents and warrants to the Manager to the effect set forth on Attachment C to this Agreement. The Subscriber acknowledges that for the Company to avoid “plan assets” treatment under ERISA, the Company may, in some circumstances, redeem the Company Interests of certain Qualified Plan Investors in accordance with the LP Agreement, and that the Subscriber will be obligated to cooperate with the Company to help ensure compliance with ERISA.

* If the Subscriber checked the box “is” because it is a Qualified Plan Investor due to clause (iii), the Subscriber hereby certifies that   % of the total value of equity interests in the Subscriber is held by “benefit plan investors.”

 

 

 

1. The Subscriber has not engaged in a “disqualifying event” as defined within Rule 506 of Regulation D under the 1933 Act, including:

 

 

 

 

 

 

1.        having been suspended or expelled from membership in, or suspended or barred from association with a member of, a registered national securities exchange or a registered national or affiliate securities association for any act or omission to act constituting conduct inconsistent with just and equitable principles of trade;

 

 

 

If the Subscriber engaged in one of the “disqualifying events” described above or as otherwise set forth in Rule 506 of Regulation D, it must inform the Manager and provide information regarding the disqualifying event including the date of such event. If in the future, the Subscriber can no longer make this representation, it must promptly notify the Manager and provide information regarding the disqualifying event including the date of any such event. Subscriber specifically consents to the disclosure of any such disqualifying event to any other Member and third parties as the Manager may deem necessary to ensure the Company can continue to claim the Rule 506 safe harbor.

 

 

 

1. The Subscriber understands the meaning and legal consequences of the representations and warranties made by the Subscriber herein, and that the Manager and Company are relying on such representations and warranties in making their determination to accept or reject this Agreement.

 

 

The Manager, on behalf of the Company, represents and warrants to the Subscriber that:

 

 

 

 

 

1. No suit, action, claim, investigation or other proceeding is pending or, to the best of the Company’s or the Manager’s knowledge, is threatened against the Company or the Manager or the Affiliates of either of them which questions the validity of the LLC Agreement or this Agreement or any action taken or to be taken pursuant to the LLC Agreement or this Agreement.

 

 

The Subscriber understands and agrees that, unless otherwise determined by the Manager in its discretion, the Company Interest will not be represented by a certificate or similar document subject to Article 8 of the Uniform Commercial Code. If the Manager determines to have the Company Interest be represented by an instrument or certificate, such instrument or certificate may bear such legends as the Company may consider necessary or advisable to facilitate compliance with the 1933 Act or any state securities law, including, without limitation, legends stating that the Company Interest has not been registered under the 1933 Act or registered or qualified under any state securities law and setting forth the limitations on dispositions imposed thereby.

 

 

To the extent permitted by law, the Subscriber hereby agrees to indemnify and defend the Company and the Manager, and each of their respective Affiliates, partners, members, shareholders, directors, managers, officers, employees, and agents, and hold them harmless, from and against any and all claims, liabilities, damages, costs and expenses (including, without limitation, court costs and attorneys’ fees) incurred on account of or arising out of:

 

 

 

(ii) any disposition of any part or all of the Company Interest.

 

 

The Subscriber hereby irrevocably makes, constitutes and appoints the Manager, with full power of substitution and resubstitution, as the true and lawful attorney-in-fact for the Subscriber and in the Subscriber’s name (as the Manager shall determine), place and stead and for the Subscriber’s use and benefit to sign, execute, deliver, certify, acknowledge, swear to, file, record and publish:

 

 

1. Any other certificates, instruments, agreements and documents necessary to qualify or continue the Company as a limited liability company or a partnership

 

wherein Members have limited liability in the states or other jurisdictions where the Manager deems necessary or advisable;

 

 

 

The power of attorney granted herein is coupled with an interest; shall be irrevocable; shall survive the death, disability or incapacity of the Subscriber; shall be deemed given by each and every assignee and successor of the Subscriber; and may be exercised by said attorney by listing, or attaching a list of, the name of the Subscriber along with the names of other persons for whom said attorney is acting and executing the LLC Agreement and such other certificates, instruments and documents with the signature or signatures of said attorney, or an officer of the Manager on its behalf, acting as such attorney-in-fact for all of the persons whose names are so listed.

 

 

 

1. The Subscriber represents that all the information, financial or otherwise, which the Subscriber has furnished to the Company or the Manager in connection with this subscription, or which is set forth herein, including all representations, warranties and agreements contained herein (the “Subscriber Information”), is correct and complete, to the Subscriber’s knowledge, as of the date of this Agreement, and shall be correct and complete at the time such subscription is accepted by the Manager. Subscriber covenants and agrees that if there should be any material change in any Subscriber Information that would cause the Subscriber Information to become untrue or misleading in a material way, the Subscriber will immediately notify the Company and the Manager and furnish such revised or corrected information to the Manager. The Subscriber also covenants and agrees to provide the Manager with any additional information requested from time to time by the Manager as deemed necessary to determine (i) the eligibility of the Subscriber to hold a Company Interest or participate in certain Company investments, (ii) the Company’s or the Manager’s compliance with applicable

 

regulatory (including tax) requirements or (iii) the Company’s tax status. The Subscriber also agrees to provide the Company all information that otherwise may be reasonably requested by the Manager (and its affiliates) and the Company and its funds and portfolio investments (and their affiliates).

 

 

 

The attorneys, accountants and other experts who perform services for the Manager may also perform services for the Company and other investment funds managed by an Affiliate of the Manager. It is contemplated that any such dual representation, if commenced, will continue. The Manager may, without the consent of any Member, execute on behalf of the Company any consent to the representation of the Company that counsel may request pursuant to the rules of professional conduct in the applicable jurisdiction. The Manager has retained Counsel (“Counsel”) in connection with the formation of the Company and the offering of the Company Interests and may retain Counsel as legal counsel in connection with the management and operation of the Company, including, without limitation, making, holding, and disposing of investments. Counsel will not represent the Subscriber or any other Member in connection with the formation of the Company or the Manager, the offering of the Company Interests, the management and operation of the Company or any dispute that may arise between any Member, on one hand, and the Manager and/or the Company on the other hand. The Subscriber acknowledges and agrees that Counsel is not providing any advice, opinion, representation, warranty or other assurance of any kind as to any matter to any Member.

 

All Subscribers acknowledge and agree that certain of them have previously been represented by, are presently represented by or in the future may be represented by Counsel, and to the extent any conflicts of interest exist or arise from such relationship and Counsel’ representation of, or work performed for, the Manager in connection with the formation of the Company and the transactions contemplated hereby, each Subscriber hereby waives any such conflict by executing this Agreement.

 

All investors acknowledge and agree that the Manager and its Affiliates will be subject to various conflicts of interest in carrying out the Manager’s responsibilities to the Company. Affiliates of the Manager may also be in competition with the Company or its investments. Other such funds may be formed in the future with objectives that are the same as or similar to the Company’s objectives. Investment funds formed in the future by affiliates of the Manager will compete with the Company for investments and for the time and attention of the manager, members, officers and employees of the Manager. Each Subscriber hereby waives any such conflicts of the Manager and its Affiliates by executing this Agreement.

 

 

The representations, warranties and agreements contained in this Agreement (including any attachments and supplements) shall survive the execution of this Agreement by the Subscriber and acceptance of this Agreement by the Company.

 

 

Subject to Subscriber’s consent below, at its discretion, the Company and the Manager may provide to Subscriber (or an agent designated by Subscriber) (i) statements, reports and all other communications relating to (A) the Company and/or (B) Subscriber’s investment in the Company, including capital account information about Company Interests, Commitment, Contribution and withdrawal activity, and annual and other updates of the Company’s consumer privacy policies and procedures and (ii) all communications relating to the Manager (including, if applicable, its privacy policy and any other communication required under the Advisers Act, or otherwise) (collectively, “Company Information”) in electronic form, such as through a file attached to an email sent to the email address provided by the Subscriber, or over a private internet site, in lieu of sending such Company Information as hard copies via fax or mail. For the avoidance of doubt, Subscriber’s consent under this Section 11 to the electronic receipt of Schedule K-1 or other tax information must be confirmed by Subscriber separately by checking the appropriate box in Attachment D to this Agreement). If the Company Information is made available over the internet, the Subscriber may be notified of its availability through an email sent to the email address provided by the Subscriber. Please note also that email messages are not secure and may contain computer viruses or other defects, may not be accurately replicated on other systems, or may be intercepted, deleted or interfered with without the knowledge of the sender or the intended recipient. The Company and the Manager make no warranties in relation to these matters. Please note that the Company and the Manager reserve the right to intercept, monitor and retain email messages to and from their systems as permitted by applicable law. If Subscriber has any doubts about the authenticity of an email purportedly sent by the Company or the Manager, Subscriber would be required to contact the purported sender immediately. The Manager’s acceptance, on behalf of the Company, of the Subscriber’s Subscription is not conditioned on the Subscriber giving consent to electronic delivery of Company Information. The Subscriber agrees that it will be solely responsible for notifying the Company in writing of any change in its email address and that the Company may not seek to verify or confirm the Subscriber’s email address as provided. If the Subscriber does not have access to the internet or email, the Subscriber should not consent to electronic delivery of Company Information. The Subscriber may revoke its consent to electronic delivery of Company Information at any time upon written notice to the Company and receive all Company Information in paper format. The Subscriber may also request delivery of a paper copy of any Company Information by contacting the Company.

 

o            By checking this box, the Subscriber hereby agrees to receive Company Information in electronic form, at the Manager’s discretion, in lieu of a separate mailing of paper copies until such time as it no longer has the right to receive Company Information or it revokes its consent in writing.

 

 

The representations, warranties and agreements contained in this Agreement shall be binding on the respective successors, assigns, heirs and legal representatives of the Subscriber, and shall inure to the benefit of the respective successors and assigns of the Company and the Manager.

 

 

This Agreement is not intended to confer upon any person, other than the parties hereto, any rights or remedies. This Agreement may be executed online or in separate counterparts, each of which shall be deemed an original and all of which taken together shall constitute one and the same instrument. Counterparts may be delivered via facsimile, electronic mail (including pdf or any electronic signature complying with the U.S. federal ESIGN Act of 2000, e.g., www.docusign.com) or other transmission method and any counterpart so delivered shall be deemed to have been duly and validly delivered and be valid and effective for all purposes.

 

 

No failure by any party hereto to insist upon the strict performance of any covenant, duty, agreement or condition of this Agreement, or to exercise any right or remedy consequent upon a breach thereof, shall constitute a waiver of any such breach or any other covenant, duty, agreement or condition hereof.

 

 

This Agreement and the rights and obligations of the parties hereto shall be interpreted and enforced in accordance with and governed by the laws of Delaware applicable to agreements made and to be performed wholly within that jurisdiction, except to the extent superseded by federal law.

 

 

Whenever the context requires, the use of the singular number shall be deemed to include the plural and vice versa, each gender shall be deemed to include each other gender, and “person” shall be deemed to include a corporation, partnership, trust or other legal entity.

 

 

This Agreement, with the LLC Agreement and the provisions of any Side Letter or similar agreement entered into between Manager or the Company and the Subscriber, and all of the exhibits and appendices attached hereto and thereto, constitutes the entire agreement between the parties with respect to the subject matter hereof and thereof, and may be amended only by a writing executed by the Subscriber and the Manager.

 

 

If any provision of this Agreement or the application thereof to any person or in any circumstances shall be held to be invalid, unlawful or unenforceable to any extent, the remainder of this Agreement, and the application of such provision other than to the persons or in the circumstances deemed invalid, unenforceable or unlawful, shall not be affected thereby, and each remaining provision hereof shall continue to be valid and may be enforced to the fullest extent permitted by law.

 

[Remainder of page intentionally left blank]

 

SIGNATURE PAGE TO THE SUBSCRIPTION AGREEMENT

FOR

ALLIANCE MEDICAL FUND I LLC

 

IN WITNESS WHEREOF, the undersigned Subscriber has executed this Subscription Agreement for the purchase of the Company Interest as of the dates written below.

 

Individual Investor       (Name of Subscriber)	Investors other than individuals       (Name of Subscriber)
	By:
(Signature)
	Name:
	Title:
Date:	Date:
Co-Investors (spouses, etc.), if	Additional signatories, if applicable
applicable
	By:
(Print name of Co-Investor)	Name:
	Title:
(Signature)	Date:
Amount of Capital Commitment: $

 

 

[Please provide Subscriber Contact Information on Attachment A to this Agreement]

 

MEMBER SIGNATURE PAGE TO THE LLC AGREEMENT

OF

ALLIANCE MEDICAL FUND I LLC

 

 

The undersigned, desiring to become a Member of Alliance Medical Fund I LLC, a Delaware limited liability company, hereby becomes a party to the Limited Liability Company Agreement (the “LLC Agreement”). The undersigned hereby agrees to all the provisions of the LLC Agreement, and agrees that this signature page may be attached to any counterpart copy of the LLC Agreement.

 

 

 

	(Signature)
Member’s name and address:
Amount of Capital Commitment:
Member’s Social Security or Federal Tax Identification Number:
Dated:

 

ACCEPTANCE OF SUBSCRIPTION FOR

ALLIANCE MEDICAL FUND I LLC

 

The foregoing Subscription Agreement is hereby accepted upon the terms and conditions set forth herein.

 

 

 

 

Amount of Capital Commitment accepted by the Manager: $                         

 

If the Subscription Agreement is executed by the Company and the preceding line is left blank, the Manager has accepted the Subscriber’s subscription for a total Capital Commitment in the amount set forth on the Subscriber’s signature page to the Subscription Agreement.

 

ATTACHMENT A TO SUBSCRIPTION AGREEMENT

 

Subscriber Information
Name of Subscriber
Address of Subscriber
Country of Residence / State of Incorporation		Taxpayer Identification Number or Social Security Number
Total Amount of Subscription (in $)
Information pertaining to the financial institution from which the Subscriber’s capital contributions will be paid to the Company
Account Name
Name and Address of Financial Institution

 

Contact Information
Name of Contact and Position or Title of Contact / Relationship to Subscriber
Address of Contact
Telephone Number		Facsimile Number
E-Mail Address

 

  Distribution Information        

 

ACH Transfer

Bank/ABA Number

Account Name

Account Number

 

ATTACHMENT B TO SUBSCRIPTION AGREEMENT

 

Instructions for Certificate of Non-Foreign Status

 

Please complete the attached form based upon the Subscriber’s status to certify that the Subscriber is not a foreign person. A Subscriber that is a foreign person for U.S. federal income tax purposes should not complete the Certificate of Non-Foreign Status. If the Subscriber is a disregarded entity or a grantor trust, then the Certificate of Non-Foreign Status should be completed by the Subscriber’s owner.

 

ATTACHMENT B TO SUBSCRIPTION AGREEMENT

 

CERTIFICATE OF NON-FOREIGN STATUS

 

Section 1445 of the Internal Revenue Code provides that a transferee of a U.S. real property interest must withhold tax if the transferor is a foreign person. For U.S. tax purposes (including Section 1445), the owner of a disregarded entity (which has legal title to a U.S. real property interest under local law) will be the transferor of the property and not the disregarded entity. To inform a transferee that withholding of tax is not required upon the disposition of a U.S. real property interest by the Subscriber or the Subscriber’s Owner, as applicable, the undersigned hereby certifies the following:

 

 

 

 

 

 

 

 

 

The U.S. Taxpayer agrees to inform the Company if it becomes a foreign person at any time during the three years immediately following the date of this certificate. The U.S. Taxpayer understands that this certification may be disclosed to the Internal Revenue Service by the transferee and that any false statement contained herein could be punished by fine, imprisonment, or both.

 

[signature page follows]

 

ATTACHMENT B TO SUBSCRIPTION AGREEMENT

 

Under penalties of perjury I declare that I have examined this certification and to the best of my knowledge and belief it is true, correct and complete. If I am signing on behalf of a U.S. Taxpayer that is an entity, I further declare that I have the authority to sign this document on behalf of the U.S. Taxpayer.

 

Name of U.S. Taxpayer:

 

 

 

Name of Investor (print)

 

By:                                                                Signature, if Investor is an individual

 

 

By:                                                                Signature, if executing on behalf of entity

 

 

 

Dated:                                 

 

Name:                                                           Title:         

 

ATTACHMENT C TO SUBSCRIPTION AGREEMENT

 

Qualified Plan Investor Status

 

 

The Subscriber hereby represents and warrants, pursuant to Section 3(s) of the attached Subscription Agreement, that except as otherwise disclosed in writing to the Manager:

1. the Subscriber is not investing the assets of a participant-directed defined contribution plan and, at the time of the initial investment, neither the Company nor the Manager is a fiduciary or party-in-interest with respect to such Subscriber;
2. the Subscriber is not investing the assets of an employee benefit plan that is both voluntary and contributory;

 

 

 

 

 

 

 

1. the Subscriber has delivered to the Manager, and from time to time hereafter will deliver to the Manager, in writing, all of the information that the Manager may request in order to avoid violations of any provision of ERISA, the Code or other law to which the Subscriber is subject, and promptly will notify the Manager, in writing, of any change in the information so furnished.

 

ATTACHMENT D TO SUBSCRIPTION AGREEMENT

 

Consent to Receive Schedule K-1 Electronically

 

Alliance Medical Fund I Manager LLC, (the “Manager”) and Alliance Medical Fund I LLC (the “Company”) may, at their discretion, offer the opportunity for Investors of the Company to receive in electronic format in lieu of paper IRS Schedule K-1, “Partner’s Share of Income, Deductions, Credits, Etc.,” and other tax information relating to the Company otherwise required to be provided to you by the Manager in a paper format.

 

This Consent Statement provides the disclosures required by IRS Revenue Procedure 2012-17 (the “Revenue Procedure”). In accordance with the Revenue Procedure, if you return an executed version of this Consent Statement with your Subscription Agreement for the Company in accordance with the instructions accompanying the Subscription Booklet to which this Consent Statement is attached (including delivery of a PDF version by email), this statement will constitute your consent to receive in an electronic format Schedule K-1s and other tax information from the Manager relating to the Company.

 

Notice of affirmative consent requirement for electronic delivery of Schedule K-1s and other tax information

In order to receive electronic Schedule K-1s and other tax statements from the Manager relating to the Company (collectively, “tax statements”) via email, you must provide your acknowledgement and consent as set forth in this notice. However, if you would like to receive a paper copy of tax statements, please indicate in this same notice that you are declining the consent to receive tax statements and provide your mailing address.

 

Scope and duration of consent

Only one consent is required for your investment in the Company. The consent is applicable for the tax year ending December 31, 2022 and for all subsequent years until the consent is withdrawn.

 

Post-consent request for a paper statement

You may subsequently request a paper copy of any tax statements via email to the Manager. Such request will not be treated as a withdrawal of the consent.

 

Withdrawal of consent

You may request to withdraw the consent via letter or email to the Manager. The withdrawal of consent will be effective either on the date it is received by the Company or on a subsequent date determined by the Company. The Company will confirm the withdrawal and the date on which it takes effect via email. A withdrawal of the consent does not apply to tax statements furnished electronically to you before the date on which the withdrawal of consent takes effect.

 

Notice of termination

The consent will terminate for the Company upon your withdrawal from the Company or upon a dissolution or termination of the Company.

 

Updating information

You must inform the Company of any updated contact information, including email address, mailing address and phone number, as soon as possible.

 

ATTACHMENT D TO SUBSCRIPTION AGREEMENT

 

Consent to Receive Schedule K-1 Electronically

 

The Manager will inform you of any change in its contact information. If your contact information changes, you must promptly notify Manager in writing (electronically or in a paper format) at the following address: Alliance Medical Fund I LLC, 1616 W 12th St, Austin, TX 78703.

 

Hardware and software requirements

The electronic tax statements will be delivered via email in PDF format in a zip file. You should have appropriate computer hardware/software to access, print, and retain the tax statements. The tax statements may be required to be printed and attached to federal, state, or local income tax returns. Please consult your tax adviser.

 

 

 

[signature page follows]

 

ATTACHMENT D TO SUBSCRIPTION AGREEMENT

 

Consent to Receive Schedule K-1 Electronically

 

 

The undersigned has read and understands this Consent Statement and, by signing this document, consents to receive tax statements relating to the Company from the Manager in an electronic format from the date hereof until this Consent Statement is withdrawn.

 

 

 

 

Name of Investor (print)

 

By:                                                                Signature, if Investor is an individual

 

 

By:                                                                Signature, if executing on behalf of entity

 

Name:                                                          

 

Dated:                                                          Title:                                                   

 

ATTACHMENT E TO SUBSCRIPTION AGREEMENT

 

ACCREDITED INVESTOR VERIFICATION

 

The limited liability company interests (“Interests”) in Alliance Medical Fund I LLC, a Delaware limited liability company (the “Company”) are being sold only to “accredited investors” (“Accredited Investors”) as defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”). The purpose of the attached Accredited Investor Representation Letter (the “Letter”) is to collect information from you to determine whether you are an Accredited Investor and otherwise meet the suitability criteria established by the Company for investing in the Interests.

 

As part of verifying your status as an Accredited Investor, you must either access the online portal maintained by the Company’s third-party fund administrator to make certain statements and provide certain supporting information regarding your qualifications as an Accredited Investor or complete, sign, and return the Accredited Investor Representation Letter provided below.

 

The nature of this Company’s offering of Interests and the requirements of the exemption from registration of the Interests on which the Company is relying impose obligations on the Company to verify that each investor is in fact an Accredited Investor.

 

All of your statements in the Letter and all required supporting documentation delivered by you or on your behalf in connection with the Letter (collectively, the “Investor Information”) will be treated confidentially. However, you understand and agree that the Company may present the Investor Information to its legal, accounting, and financial advisors and such parties as it deems appropriate to establish that the issuance and sale of the Interests (a) is exempt from the registration requirements of the Securities Act or (b) meets the requirements of applicable state securities laws.

 

You understand that the Company, the Manager, and counsel engaged on behalf of the Company will rely on your representations and other statements and documents included in the Investor Information in determining your status as an Accredited Investor, your suitability for investing in the Interests, and whether to accept your subscription for the Interests.

 

The Company reserves the right, in its sole discretion, to verify your status as an Accredited Investor using any other methods that it may deem acceptable from time to time. However, you should not expect that the Company will accept any other such method. The Company may refuse to accept your request for investment in the Interests for any reason or for no reason.

 

[THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]

 

ALLIANCE MEDICAL FUND I LLC ACCREDITED INVESTOR REPRESENTATION LETTER

 

Alliance Medical Fund I LLC

c/o Alliance Medical Fund I Manager LLC 2201 Waukegan Rd. Suite 120

Bannockburn, IL 60015

 

Dear Alliance Medical Fund I Manager:

 

I am submitting this Accredited Investor Representation Letter (the “Letter”) in connection with the offering of limited liability company interests (the “Interests”) in Alliance Medical Fund I LLC (the “Company”). I understand that the Interests are being sold only to accredited investors (“Accredited Investors”) as defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”).

 

I hereby represent and warrant to the Company that I qualify as an Accredited Investor on the basis that:

(You must choose Part A OR B below AND check the applicable boxes.)

 

A.	I am a NATURAL PERSON and: (An investor using this Part A must check box (1), (2), OR (3).)
	[ ]	(1)	Income Test: My individual income exceeded $200,000 in each of the two most recent years or my joint income together with my spouse or spousal equivalent exceeded $300,000 in each of those years; and I reasonably expect to earn individual income of at least $200,000 this year or joint income with my spouse or spousal equivalent of at least $300,000 this year. To support the representation in A(1) above: (You must check box (a), (b) OR (c).)
			[ ]	(a)	I will deliver to the Company copies of Form W-2, Form 1099, Schedule K-1 of Form 1065 or a filed Form 1040 for each of the two most recent years showing my income or my joint income with my spouse or spousal equivalent as reported to the IRS for each of those years. I understand that I may redact such documents to avoid disclosing personally identifiable information, such as Social Security numbers, that is not necessary to confirm annual income. OR
			[ ]	(b)	My salary or my joint salary with my spouse or spousal equivalent is publicly available information that has been reported in a document made available by the U.S. government or any state or political subdivision thereof (for example, reported in a filing with the Securities and Exchange Commission) and I will deliver to the Company copies of such publicly available materials identifying me or me and my spouse or spousal equivalent by name and disclosing the relevant

 

		salary information for each of the two most recent years. OR
[ ]	(c)	In accordance with the procedures described below under the heading “Independent Third-Party Verification,” I will assist in arranging for a registered broker-dealer, SEC-registered investment adviser, licensed attorney, certified public accountant, or a nationally-recognized Accredited Investor verification service approved by the Company to deliver to the Company written confirmation of my status as an Accredited Investor based on my individual income or my joint income together with my spouse or spousal equivalent.

 

[ ]	(2)	Net Worth Test: My individual net worth, or my joint net worth together with my spouse or spousal equivalent, exceeds $1,000,000. For these purposes, “net worth” means the excess of: my total assets at fair market value (including all personal and real property, but excluding the estimated fair market value of my primary residence) minus my total liabilities.   For these purposes, “liabilities”: exclude any mortgage or other debt secured by my primary residence in an amount of up to the estimated fair market value of that residence; but include any mortgage or other debt secured by my primary residence in an amount in excess of the estimated fair market value of that residence.
		I confirm that my total individual liabilities, or my total joint liabilities together with my spouse or spousal equivalent, do not exceed $                           . I represent that all liabilities necessary to determine my individual net worth, or my joint net worth together with my spouse or spousal equivalent, for the purpose of determining my status as an Accredited Investor are reflected in the dollar amount in the preceding sentence.
		In addition, I confirm that I have not incurred any incremental mortgage or other debt secured by my primary residence in the 60 days preceding the date of the Letter, and I will not incur any incremental mortgage or other debt secured by my primary residence prior to the date of the closing for the sale of the Interests. I agree to promptly notify the Company if, between the date of the Letter and the date of the closing for the sale of the Interests, I incur any incremental mortgage or other debt secured by my primary residence. (NOTE: If the representation in the first sentence of this paragraph is untrue or becomes untrue prior to the date of the closing for the sale of the Interests, you may still be able to invest in the Interests. However, you must first contact the Company

 

for additional instructions on how to calculate your net worth for purposes of this offering.)
To support the representations in A(2) above: (You must check box (a) OR (b).)
			[ ]	(a)	I will deliver to the Company: Copies of bank statements, brokerage statements, other statements of securities holdings, certificates of deposit, tax assessments, and/or appraisal reports issued by independent third parties that show my individual assets or my joint assets together with my spouse or spousal equivalent; and A copy of a consumer credit report for me (or copies of consumer credit reports for me and my spouse or spousal equivalent) issued by TransUnion, EquiFax or Experian. I understand that each document described in paragraphs (i) and (ii) above must be dated no earlier than three months prior to the date of the closing for the sale of the Interests. I understand that I may redact any of these documents to avoid disclosing personally identifiable information, such as Social Security numbers, that is not necessary to confirm net worth.
					OR
			[ ]	(b)	In accordance with the procedures described below under the heading “Independent Third-Party Verification,” I will assist in arranging for a registered broker-dealer, SEC-registered investment adviser, licensed attorney, certified public accountant, or a nationally-recognized Accredited Investor verification service approved by the Company to deliver to the Company written confirmation of my status as an Accredited Investor based on my individual net worth or my joint net worth together with my spouse or spousal equivalent.
	[ ]	(3)	Company Insider or Verifiable Professional: [ ] I am a director, executive officer, knowledgeable employee of the Company, or manager of the Company or a director, executive officer, or manager of the Manager. [ ] I hold and maintain in good standing with a verifiable professional certification, designation, or credential as designated by the SEC via Commission Order or, any one of the following securities licenses: Series 7, Series 65, Series 82.
B.	I am a LEGAL ENTITY that is:

 

(An investor using this Part B must check at least one box below. NOTE: An investor that checks any of boxes B(1) through B(12) must contact the Company for additional instructions.)
[ ]	(1)	A bank as defined in Section 3(a)(2) of the Securities Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in its individual or fiduciary capacity.
[ ]	(2)	A broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended.
[ ]	(3)	An insurance company as defined in the Securities Act.
[ ]	(4)	An investment company registered under the Investment Company Act of 1940 (the “Investment Company Act”).
[ ]	(5)	A business development company as defined in Section 2(a)(48) of the Investment Company Act.
[ ]	(6)	A private business development company as defined in the Investment Advisors Act of 1940.
[ ]	(7)	A Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or 301(d) of the Small Business Investment Act of 1958.
[ ]	(8)	An organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or a partnership, not formed for the specific purpose of acquiring the Interests, with total assets in excess of $5,000,000.
[ ]	(9)	A plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000.
[ ]	(10)	Or is acting on behalf of, (i) an employee benefit plan within the meaning of Section 3(3) of ERISA, whether or not such plan is subject to ERISA, (ii) a plan described in Section 4975(e)(1) of the Code or (iii) an entity which is deemed to hold the assets of any such employee benefit plan pursuant to 29 C.F.R. § 2510.3-101. For example, a plan which is maintained by a foreign corporation, governmental entity or church, a Keogh plan covering no common-law employees and an individual retirement account are employee benefit plans within the meaning of Section 3(3) of ERISA but generally are not subject to ERISA (collectively, “Non-ERISA Plans”). In general, a foreign or U.S. entity which is not an operating company and which is not publicly traded or registered as an investment company under the Investment Company Act and in which 25% or more of the value of any class of equity interests is held by a benefit plan investor (including an entity which is deemed to hold the assets of any employee benefit plan or Non-ERISA Plan), would be deemed to hold the assets of one or more employee benefit plans pursuant to 29 C.F.R. § 2510.3-101. For purposes of determining whether this 25% threshold has been met or exceeded, the value of any equity interests held by a person (other than such a plan or entity) who has discretionary authority or control with respect to the assets of the entity, or any person who provides investment advice for a fee (direct or indirect) with respect to such

 

		assets, or any affiliates of such person, is disregarded.
[ ]	(11)	Or is acting on behalf of, an employee benefit plan that is subject to ERISA or is a plan described in Section 4975(e)(1) of the Code (including a trust described in Section 401(a) of the Code which forms part of a plan, or a plan described in Section 403(a) of the Code, which trust or plan is exempt from tax under Section 501(a) of the Code, an individual retirement account described in Section 408(a) of the Code, an individual retirement annuity described in Section 408(b) of the Code, an Archer MSA described in Section 220(d) of the Code, a health savings account described in Section 223(d) of the Code, or a Coverdell education savings account described in Section 530 of the Code), or are an entity deemed to hold the assets of any such plan or plans, if the investment decision is made by a plan fiduciary, as defined in such Act, which is either a bank, savings and loan association, insurance company, or registered investment advisor, or if the employee benefit plan has total assets in excess of $5,000,000, or if a self-directed plan, the investment decisions are made solely by persons that are Accredited Investors.
[ ]	(12)	Any of the following entities: [ ] A trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Interests, whose purchase is directed by a “sophisticated” person as described in Section 506(B)(b)(2)(ii) of the Code; and/or limited liability companies with $5 million in assets, SEC- and state-registered investment advisers, exempt reporting advisers, and rural business investment companies (RBICs); or   [ ] Indian tribes, governmental bodies, funds, and entities organized under the laws of foreign countries, that own “investments,” as defined in Rule 2a51-1(b) under the Investment Company Act, in excess of $5,000,000 and that was not formed for the specific purpose of investing in the securities offered; or   [ ] “Family Offices” with at least $5,000,000 in assets under management and their “family clients,” as each term is defined under the Investment Advisers Act.
[ ]	(13)	An entity in which all of the equity owners are Accredited Investors. (NOTE: If box (13) is checked, each equity owner of the entity must individually complete and submit to the Company its own copy of the Letter.)

 

SUPPORTING DOCUMENTATION

 

I understand that the Company may request additional supporting documentation from me in order to verify my status as an Accredited Investor and I hereby agree to promptly provide any such additional supporting documentation.

 

I further understand that, even if I complete and execute the Letter and provide all additional supporting documentation requested by the Company, the Manager may in its sole discretion refuse to accept my subscription for the Interests for any reason or for no reason.

 

RELIANCE ON REPRESENTATIONS; INDEMNITY

 

I understand that the Company, the Manager, and their respective counsels are relying upon my representations in the Letter and upon the supporting documentation to be delivered by me or on my behalf in connection with the Letter (collectively, the “Investor Information”). I agree to indemnify and hold harmless the Company, the Manager, and their respective officers, managers, partners, shareholders, members, directors, employees, and agents, and any person who controls any of the foregoing, against any and all loss, liability, claim, damage and expense (including reasonable attorneys’ fees) arising out of or based upon any misstatement or omission in the Investor Information or any failure by me to comply with any covenant or agreement made by me in the Investor Information.

 

SHARING OF INVESTOR INFORMATION

 

I understand and agree that the Company may present the Investor Information to its legal, accounting, and financial advisors and such parties as it deems appropriate to establish that the issuance and sale of the Interests (a) is exempt from the registration requirements of the Securities Act or (b) meets the requirements of applicable state securities laws.

 

 

INVESTOR’S SIGNATURE   Individual(s):       Print Name		Entity:       Print Name of Entity
Signature		Signature
Print Name of joint Investor, if applicable		Title or Capacity
Signature of joint Investor, if applicable
Date:		Date:

 

 

 

SPOUSE’S OR SPOUSAL EQUIVALENT’S SIGNATURE

 

(NOTE: The investor’s spouse need only sign the Letter if the investor is a natural person proving its Accredited Investor status based on joint income or joint net worth with such spouse under Part A(1)(a) or Part A(2)(a) above. A spouse who signs the Letter makes all representations set out in the Letter, including those relating to joint income or joint net worth, as applicable, on a joint and several basis.)

 

Spouse or Spousal Equivalent:       Print Name

Signature

Date:

 

 

 

 

 

 

 

UNITED STATES INTERNAL REVENUE SERVICE FORM W-9

[See attached]