Please be as complete as possible, so that it will not be necessary to ask for missing information later in the process.

Transcription

1 Questionnaire Instructions: This questionnaire is for internal use of Cornerstone only to help complete your various investment documents. It will not be forwarded or used for any official purpose. Please be as complete as possible, so that it will not be necessary to ask for missing information later in the process. If investing as husband and wife, please enter name and social security number for both husband and wife. To fill in the questionnaire electronically as a PDF: Please enter financial numbers as whole numbers with commas but no decimals or dollar signs. When the questionnaire is complete, save the file. **The most reliable and recommended way to save a completed PDF form is Print to File. Typical command would be File, Print; Print to File; select PDF as file format; then type document name, being sure to type your last name as part of the file name, such as SMITHQUESTIONNAIRE. To return the completed questionnaire, attach the file to an addressed to your Cornerstone representative. To print and fill out manually: Simply print like a normal file, fill out, and send as a scan to your Cornerstone representative or fax to the Cornerstone office. (Cornerstone fax: ) Please use large and dark print to fill out the form. Please contact your Cornerstone representative by phone or if you have any questions. R27-1

2 Account Title & Type Name of Individual(s) or Entity Investing (Note: For 1031 Exchange, name must exactly match that on title of ownership of relinquished property.) Social Security No. or Entity TIN Entity Formation Date & State Account Type (check one) Individual Account Single man or woman Husband and wife as joint tenants Husband and wife as community property Married man or woman as his or her sole and separate property Tenants-in-common As joint tenants with right of survivorship Revocable trust Irrevocable trust Partnership LLC Corporation IRA Type: 401K Type: Custodial/UGMA/UTMA 529 Plan/Coverdell "S" Corporation R27-2

3 INVESTOR SUITABILITY STANDARDS Accredited Investor Status (For purposes of determining net worth, exclude the value of your primary residence as well as the amount of indebtedness secured by your primary residence, up to the fair market value. ) If a Natural Person (check one) That I have an individual net worth, or joint net worth with my spouse (exclusive of the value of my primary residence) of more than $1,000,000; or That I have individual income in excess of $200,000, or joint income with my spouse in excess of $300,000, in each of the two most recent years and I have a reasonable expectation of reaching the same income level in the current year. If other than a Natural Person (check as appropriate) Revocable trusts, S corporations, partnerships, limited partnerships and limited liability companies can be accredited either as entities or as individuals, but if as individuals, each member must have accredited status. Irrevocable trusts and corporations must be accredited as entities only. Please contact me if you have any questions about accreditation standards. If investing as an entity, a copy of any pertinent entity documents will be required. An entity in which all of the equity owners are Accredited Investors (S Corp, LLC, Partnership, LP, etc.) A grantor revocable trust where the grantors meet the qualifications under Natural Persons above Entities with Total Assets in Excess of $5,000,000 (Rule 501(a)(3)). This category includes all Section 501(c)(3) tax-exempt organizations as well as most for-profit entities (corporations, partnerships, limited liability companies, and business trusts) with assets in excess of $5,000,000. However, if an entity was formed for the sole purpose of investing in the private offering in question, then it will not qualify as an accredited investor under Rule 501(a)(3). R27-3

4 A trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring an Interest and whose purchase is directed by a person who has such knowledge and experience in financial and business matters that he or she is capable of evaluating the merits and risks of an investment in an Interest A broker-dealer registered pursuant to section 15 of the Securities Exchange Act of 1934, as amended (the Exchange Act ) An investment company registered under the Investment Company Act of 1940, as amended (the Investment Company Act ) A business development company (as defined in section 2(a)(48) of the Investment Company Act) A Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1958 An employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 ( ERISA ), if the investment decision is made by a plan fiduciary (as defined in section 3(21) of ERISA), which is either a bank, savings and loan association, insurance company, or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons who are Accredited Investors A private business development company (as defined in section 202(a)(22) of the Investment Advisers Act of 1940, as amended) 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. Non-Accredited Investor If not an accredited investor, I have an income of $70,000 per year and a net worth of $70,000; or I have a net worth of $250,000. or If not an accredited investor, I have an income of $65,000 per year and a net worth of $250,000; or a net worth of $500,000. (This suitability standard applies to certain California-only investments.) R27-4

5 CONTACT INFORMATION Please complete Contact Information pages 5-7 for each Investor, Co- Investor, Spouse, Trustee, Partner etc. Name Please check one: Individual Trustee Partner Spouse Co-investor Corporate Officer Managing Director Mailing Address City State Zip Legal Address if Different (no PO Box) Check if you have been at current address for less than one year Phone Country of Residence USA PATRIOT ACT INFORMATION Date of Birth Citizenship (country) Social Security No. ID: Type Issuer ID Number Please send or attach a scan or photocopy of valid ID (cell phone photo is also OK) R27-5

6 Issue Date: Expiration Date Marital Status C Single Married Divorced Domestic Partner Ages of Dependents Employment Information (Check one) Currently Employed Self-Employed Retired Not Employed Student Other Occupation/Job Title Employer Years with current employer Business Address Education University Degree Graduate Degree Industry and Other Affiliations Are you, your spouse, or any other immediate family members, including parents, in-laws, siblings and dependents: 1. Employed by or associated with the securities industry? Yes No Name of entity Relationship: Self Spouse Parent Dependent Other R27-6

7 2. An officer, director or 10% or more shareholder in a publicly-owned company? Yes No Name of Company and Symbol Relationship: Self Spouse Parent Dependent Other 3. A senior military, governmental or political official in a non-us country? Yes No Name of Country: Relationship: Self Spouse Parent Dependent Other Release of Information (Check box to allow release of information): Information about performance of my investment may be released to my registered representative (Cornerstone)(optional). My contact information may be released to other investors in the DST (optional). R27-7

8 Financial Statement Please enter numbers with commas, no decimals. For the purposes of this financial statement, please round to the nearest $10,000. If you already have a current financial statement, you may provide that statement in lieu of this page. Name Assets Current Assets Cash & cash equivalents Checking/Savings $ As of (date) Liabilities Current Liabilities Notes/Accounts Payable Money market CDs Marketable Securities, Stocks, Bonds Mutual Funds Notes/Account Receivable (within 12 months) Other Current Assets Other Current Liabilities Total Current Assets $ Total Current $ Liabilities Long Term Assets Market value of primary $ residence Market Value of Real Estate Owned Net Worth of Other Businesses Direct Participation Programs: DSTs, TICs, funds, non-traded REITs, etc. including the amount being 1031 exchanged. Personal Property Long Term Liabilities Mortgage payable on Primary Residence $ Mortgage Payable on Real Estate Owned Debt Secured by Personal Property R27-8

9 Vehicles Furniture, Fixtures & Equipment Notes/Accounts Receivable Life Insurance Whole Term Variable Debt secured by Vehicles Total Long Term Assets Total Long Term Liabilities TOTAL ASSETS $ TOTAL LIABILITIES $ Annual Income from All Sources $ NET WORTH $ NET WORTH EXCLUDING PRIMARY RESIDENCE Tax Rate (highest marginal) Less than 10% 11-20% 21-30% 31-35% >35% I plan to use this account for the following (Check all that apply): Generate income for current or future expenses Steadily accumulate wealth over the long term Preserve wealth and pass it along to my heirs Receive tax advantages Market speculation Other R27-9

10 Please let us know your number of years of experience in each relevant category (select ALL that apply): Mutual Funds Bonds Stocks Annuities Options Alternatives * Years Experience Limited Moderate Extensive None *Real Estate, Limited Partnerships, Direct Participation Programs, TICs, DSTs, illiquid alternative funds, non-publically traded REITs, etc.) Do you currently have a margin account? Yes No Please describe in brief your investment experience: Funding this Account Please tell us how you intend to fund this account (check ALL that apply): Income Pension or retirement savings Inheritance Investment proceeds Sale of business or property Insurance payout Gift Social Security benefits Home equity line of credit/reverse mortgage Funds from another account Other: R27-10

11 Your 1031 Exchange Transaction My relinquished PROPERTY will close/has closed on Sale Price $ Debt in Property $ Cash Out $ Exchange Amount $ Adjusted Basis $ Type of Property Location (State) INVESTOR S QUALIFIED INTERMEDIARY (SECTION 1031 EXCHANGE INVESTORS ONLY) Company Name Contact Person Address Telephone No. Fax No. Address R27-11

12 INVESTOR DISTRIBUTION OPTIONS Please direct distributions (Select one) VIA MAIL TO MAILING ADDRESS OF RECORD VIA MAIL TO BANK OR BROKERAGE ACCOUNT (Please complete transfer information below.) VIA ELECTRONIC DEPOSIT (ACH) ( Please complete bank transfer information below and attach voided check or copy, scan or photo of voided check.) Bank Transfer Information Name of Bank, Brokerage Firm or Individual Mailing Address Bank ABA Number Account Number Checking Savings R27-12

13 CPA Information (if applicable) Name Company Address Telephone Fax Legal Counsel Information (if applicable) Name Company Address Telephone Fax R27-13