IMPORTANT: Verification of Accredited Investor Status

By completing this form the Investor represents and warrants that he or she is an “accredited investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended, (the “Securities Act”).

The Investor understands they have No Costs, No Commitments and No Obligations. This form is a requirement of Federal law in order to receive information on the alternative investment strategies represented by Mickelson Investment Management.

Contact Information

Please Check Applicable Statements:

The potential client is a natural person whose own net worth, or joint net worth with the Investor’s spouse, exceeds $1,000,000.
The potential client is a natural person who had an individual income in excess of $200,000 (or joint income with the Investor’s spouse in excess of $300,000) in each of the two previous years and who reasonably expects a gross income at the same level or greater in the current year.
The potential client is a registered investment advisor or other financial services professional.
The potential client is an employee benefit plan (under Title I of ERISA) whose investment decision is made by a qualified plan fiduciary or registered investment advisor, or whose total assets exceed $5,000,000, or is a self-directed plan where all investment decisions are made solely by accredited investors.
The Investor is a partnership, corporation, trust or other entity where all equity owners are accredited investors.
The Investor is a corporation, partnership, Massachusetts business or similar trust, or 501(c)(3) organization, with assets in excess of $5,000,000, not formed for the specific purpose of investing in the Fund.
The Investor is a trust with assets in excess of $5,000,000, formed independently and whose purchase decisions are directed by a person capable of objectively evaluating the merits and risks of any potential investment.
The Investor is a director, executive officer, or Manager of an Investment Fund or a director or executive officer of the Manager.
The Investor is a bank, savings and loan, registered broker/dealer, insurance company, registered investment company, business development company, or small business investment company.

Net Worth

Current net worth or joint net worth with spouse (note that “net worth” includes all of the assets owned by you and your spouse in excess of total liabilities, including the fair market value, less any mortgage, of your principal residence.)

 

 Prospective Investor’s Representations

The information contained in this Questionnaire is true and complete, and the undersigned understands that the Company and its counsel will rely on such information for the purpose of complying with all applicable securities laws as discussed above. The undersigned agrees to notify the Company promptly of any change in the foregoing information which may occur prior to any purchase by the undersigned of securities from the Company.