Investment Provider Questionnaire

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The Investment Provider Questionnaire will help IRA Club learn more about your business and its offering(s). The information you provide may be used to create an investment research page on Investor’s Row within the IRA Club site. Please review for accuracy prior to submitting. For support, call (312) 795-0988. Office hours are Monday-Friday, 9:00 AM – 4:00 PM. Find information online at www.iraclub.com. ENTITY INFORMATION What is the name of the legal entity selling securities to investors?
What is Your Name?(Required)
ENTITY INFORMATION
What is the name of the legal entity selling securities to investors?
What is the legal classification of the entity that is raising capital?(Required)
Provide the names, title, and copy of a Government ID of the directors, managers, and owners of 10% or more of the company. If more space is needed, please include this information when uploading your business documentation.
Has any member of the ownership or management team declared bankruptcy in the past 10 years?(Required)
Has any member of the ownership or management team ever been investigated by the SEC or FINRA?(Required)
OFFERING INFORMATION
What is the Offering Name? This is the name of the securities offering the entity is selling to investors. If there is more than one investment offering, please complete a separate questionnaire for each.
Date(Required)
What is the security type?(Required)
Is a Form D notice filed on the SEC EDGAR system?(Required)
Form D is a brief notice that includes basic information about the company and the offering, such as the names and addresses of the company's executive officers, the size of the offering and the date of first sale. Generally, a company files this notice within 15 days after the first sale of the securities in the offering.
What is the Capital-Raising Exemption and Exclusion claimed? Select all that apply.(Required)
Does the offering accept non-accredited investors?(Required)
Does the offering issue capital calls?(Required)
Is this the first offering for this company?(Required)
Is the offering currently paying a dividend?(Required)
Is there an interest or dividend reinvestment?(Required)
Is there an interest or dividend distribution?(Required)
Do you work with a fund administrator that handles the offering accounting, reporting, valuation, capital calls and distributions?(Required)
Does your company use third party subscription software to assist investors in completing documents?(Required)
Please provide the company's legal firm and attorney information.
Please provide the bank information where investors are instructed to send funds. FUNDING INSTRUCTIONS FOR A WIRE TRANSFER
Are there additional banks prospective investors send funds to?(Required)
Do your IRA investors pay their own IRA Administration Fees?(Required)
Does your company intend to pay investor IRA Administration Fees to the IRA Club?(Required)
COMPANY SOCIAL MEDIA AND MARKETING INFORMATION
Who are your points of contact for prospective investors? i.e. Investor Relations, Salesperson, Account Executive
INVESTOR’S ROW PAGE FEE
Administration per Offering/Fund (includes monitoring) - $1,000 annually *billed upon acceptance and annually thereafter
Date(Required)
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Drop files here or
Max. file size: 50 MB.
    STATS
    EX: 3 YRS
    EX: 10%
    EX: $20M
    EX: $10,000
    EX: QUARTERLY
    Please do not close browser after filling out Hello Sign, and hit submit on the bottom of the page.
    Consent(Required)
    The representative signature, as authorized by the investment provider described herein, acknowledges the following:
    • IRA Club does not perform due diligence for investments and does not endorse investments.
    • IRA Club does not promote, sell, or distribute any investment, including the investment described in this questionnaire.
    • IRA Club does not provide tax, investment, or legal advice to any party including the issuer and/or the IRA account owners.
    • IRA Club is a self-directed IRA administrator and is not an investor.
    • Investment provider agrees to provide IRA Club with an annual valuation as required by the IRS.
    • Investment provider agrees to provide IRA Club with evidence of ownership of each investment including stock certificates or other written communication.
    • Investment provider agrees to notify IRA Club of any changes in address, phone, email, or company status.
    • Investment provider understands this questionnaire will be used to assist our compliance team in understanding the nature of the investment offerings and to determine administrative procedures.

    Hellosign Verification(Required)
    Pledge to the Investment

    The clearing broke that IRA Club uses does not support mutual funds. Please liquidate those positions before completing this ACATS transfer request. If you are not sure what your money is currently invested in, we highly suggest you contact your existing broker to find out.

    Ira Club will still Establish retirement account however if mutual funds are not liquidated transfer of funds will not be initiated.

    Disclaimer

    A. I currently hold (or am now in the process of opening) an account with IRA Club.
    B. The designated third party on this form may seek information regarding the above-captioned account.
    C. The designated third party may not transfer funds, transfer assets, or authorize investment transactions on behalf of the account owner.
    D. I now and forever hold harmless and release IRA Club and its employees for any and all errors in the execution of this agreement. I further understand and agree that IRA Club and its employees cannot be responsible for all actions that a third party may take.
    E. I understand disputes may arise from this agreement. IRA Club will settle disputes in Cook County, Illinois, and that the laws and regulations of Cook County, Illinois shall apply.
    F. Separation: I understand the IRA Club is an independent company and is not related to the third party.