Marbach FormMarbach Form Step 1 of 234%Before we begin, let us take a moment to review this investmentInvest on Main StreetYou will be asked a series of questions to assist you in completing the documents and complying with securities law. You will be able to review your document before submitting them to Invest on Main Street A Private Placement Memorandum, any applicable additional documents, and accepted payment methods are viewable at any time during the questionnaire via the respective links near the top of the page.Email of Investor(Required)Please enter the email of the Investor :In order to assist us in collecting the appropriate information, could you please confirm whether the investor is an individual or an entity?(Required)In order to assist us in collecting the appropriate information, could you please confirm whether the investor is an individual or an entity ? A company, syndicate, partnership, trust, or unincorporated organization. Individual Corporation, trust, limited partnership or other entity A company, syndicate, partnership, trust, or unincorporated organization. Tips for the answering question An entity may include a government organization, charity, pension fund or regulated cintity. Click here for technical support and resources. Feel free to contact us if you have any question or require further assistance.Please enter the name of the Investor(Required) First Please enter the name of the authorized signing officer for {Please enter the name of the Investor : (First):38.3}(Required)Please enter the name of the authorized signing officer for First Please enter the title of the authorized officer for{Please enter the name of the Investor : (First):38.3} ( Including the General Partner of if applicable);(Required)Please enter the title of the authorized officer for ( Including the General Partner of if applicable); First Which of the following is {Please enter the name of the Investor : (First):38.3}?(Required)Which of the following is ? Corporation Trust Limited Partnership Estate Limited Liability Company Charitable Organization Investment Fund A Canadian or international finiancial institution A finiancial institution is a custodial institution, a depository institution, an investment entity, or a specified insurance company. An entity that is a tax resident of Canada can classify itself as a financial institution only if it is a Canadian financial institution. However, an entity that is a prescribed non-reporting financial institution in Canada can classify as a financial institution even if it is not a Canadian financial institution., government Entity A compnay, syndicate, partnership, trust or unincorporated organization., pension fund, registered fund company or subsidiary An issuer that is controlled directly or indirectly by another issuer and includes a subsidiary of that subsidiary one of these A Registered Advisor or Dealer OtherPlease enter the residential and beneficial address of Country(Required) Select CountryAfghanistanAlandAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscensionAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (DRC)Cook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (North Korea)Korea (South Korea)KosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territories (Gaza Strip and West Bank)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-Leste (East Timor)TogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweCountrySelect StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingAmerican SamoaVirgin Islands of the U.S.GuamNorthern Mariana IslandsPuerto RicoU.S. Minor Outlying IslandsStateAddress(Required) Street Address Address Line 2 City ZIP / Postal Code Tips for the answering question Tip: If the investor is an individual, this is typically their principal residence. If the investor is an entity, this is typically their principal place of business. If the investor is a "US Person" as defined by US securities law, this should be a US address. Please enter in your full mailing address, e.g. 220 Yonge St, Toronto, ON M5B 2H1, Canada OR 767 5th Ave, New York, NY 10153, USA Feel free to contact us if you have any questions or require further assistance.Mobile Number(Required)Enter the phone number of the Investor :✓ Valid number ✕ Invalid number✓ Valid number ✕ Invalid numberPlease enter the business number (or U.S Employer Identification Number/Tax Identification Number) of {Please enter the name of the Investor : (First):38.3}(Required)Please enter the Business Number (or U.S Employer Identification Number/Tax Identification Number) of : Tips for the answering question The Employeer identification Number (EIN), also known as the Federal Employer Idenfication Number(FEIN) or the Federal Tax Identification Number, is a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business entities operating in the United States for the purpose of Identification. In Canada, the Business Number is unique, nini-digit number and the standard identifier for businesses which is unique to a business or legal entity. You will have a Business Number if your register for programs with Canada Revenue agency, incorporate your business federally or register on incorporate your business in certain provinces od Canada. Feel free to contact us if you have any question or require further assistance.How many $1,000 units would you like to invest?(Required)Ex: 100 units would constitute a $100,000 total investmentHow many $1,000 units would you like to invest?Ex: 100 units would constitute a $100,000 total investmentNote: Any investment below $100,000 would be subject to prior approval. Enter a value above $100K or contact us to get approval: 1 (415) 347-6096. All investments must be in increments of $1,000 USD.Please indicate how{Please enter the name of the Investor : (First):38.3} will be holding the securities:(Required)Please indicate how will be holding the securities will be held: Jointly (with another individual) In a custodial (i.e. an IRA) As an individual investor Tips for the answering question If you do not have the correct information on hand, you can simply complete the registration as an individual, and your broker and the transfer agent can transfer them into the brokerage account after they have been issued. ONLY APPLICABLE TO CERTAIN OFFERINGS: To register your securities with an IRA, you will need to select "Custodial Account." When you choose to register your securities in a custodial IRA account, you are asked to provide the name of the custodian.This is the name of your Custodial IRA account provider, i.e. "Alto IRA" or E-Trade IRA You are then asked for EIN of the custodian which would be your IRA provider's EIN. We suggest reaching out to your IRA provider to confirm details before completing your subscription agreement, as if the shares are registered incorrectly, you will not able to deposit them. Feel free to contact us if you have any question or require further assistancePlease enter the full name of the partner with whom {Please enter the name of the Investor : (First):38.3} will jointly hold the securities(Required)Please enter the full name of the partner with whom will jointly hold the securities : First Who is the custodian of the IRA which the securities will be registered to?(Required)Who is the custodian of the IRA which the securities will be registered to?What is an EIN For %name%(Required)What is an EIN The EmployeerIdentification Number (EIN), aslso known as the Federal Employer Identification Number (FEIN) or the Federal Tax Identification Number, is a unique nine-didgit number assigned by the Internal Revenue Service(IRS) to business entities operating in the United States for the purpose of identification. for 's Which of the following best described how the securities will be held ?(Required) Joint Tenant Tenants-in-Common Community Property Tips for the answering question More information available here Feel free to contact us if you have any question or require further assistance.What is the address of {Please enter the name of the Investor : (First):38.3}(Required)What is the address of Street Address Tips for the answering question This is typically the head office of the account provider. Feel free to contact us if you have any question or require further assistance.As this is a 506c offering, you will be prompted, after submitting payment, to upload the applicable supporting documents required to verify eligibility. Please ensure that you are able to provide proof of accreditation prior to completing this agreement. If you are unable to do so, the investor will be rejected and liable for any associated costs.In addition, please ensure that you upload documents as soon as possible, as verification can take 5-10 business days. If signs a future subscription agreement for a 506c offering with the same or a new issuer using DealMaker, Deal Maker may share 's verified accredited investor An accredited investor is someone who meets certain financial net worth thresholds, is a registered securities dealer or financial institution status of status with the issuer and you may not need to provide proof of accreditation again.As this is a 506c offering, you will be prompted, after submitting payment, to upload the applicable supporting documents required to verify {Please enter the name of the Investor : (First):38.3} eligibility. Please ensure that you are able to provide proof of accreditation prior to completing this agreement. If you are unable to do so, the investor will be rejected and liable for any associated costs. In addition, please ensure that you upload documents as soon as possible, as verification can take 5-10 business days. If {Please enter the name of the Investor : (First):38.3} signs a future subscription agreement for a 506c offering with the same or a new issuer using Dealmaker, Dealmaker may share {Please enter the name of the Investor : (First):38.3} verified accredited investor status with the issuer and you may not need to provide proof of accreditation again(Required) I confirm that I will provide proof of accreditation after signing the subscription agreement Tips for the answering question A fast and simple way to submit proof of your eligibility is to have an accountant/lawyer/broker-dealer/investment advisor complete the form linked here. If you have them complete this, you will be able to upload to your account after submitting payment. For more information on why you are required to verify your accredited investor status, click here. Feel free to contact us if you have any questions or require further assistance.We are now going to ask you questions to determine the "accredited investor"An accredited investor is someone who meets certain financial net worth thresholds, is a registered securities dealer or financial institution. status of which is required under U.S. securities laws. Select the one of these categories that best describes the We are now going to ask you questions to determine the "accredited investor" An accredited investor is someone who meets certain financial net worth thresholds, is a registered securities dealer or financial institution. status of {Please enter the name of the Investor : (First):38.3} which is required under U.S. securities laws. Select the one of these categories that best describes the {Please enter the name of the Investor : (First):38.3} Net Worth Over $1,000,000 I have a net worth exceeding $1 million (excluding my primary residence) either individually or jointly with my spouse. Individual Income (Over $200,000) I have an individual income of more than $200,000 per year in the last two years and expect to reasonably maintain the same level of income in the current year. Joint Income (Over $300,000) I have combined income with my spouse exceeding $300,000 in each of the past two years and expect to reach the same this year. View More Tips for the answering question Note: For "Net Worth" in option two: (a) do not include primary residence as an asset; (b) do not include debt up to the value of the primary residence as a liability; (c) indebtedness over the fair market value of the primary residence at the time of sale should be included as a liability. Feel free to contact us if you have any questions or require further assistanceWe are now going to ask you questions to determine the "accredited investor" status of {Please enter the name of the Investor : (First):38.3} which is required under U.S. securities laws. Select the one of these categories that best describes the {Please enter the name of the Investor : (First):38.3}We are now going to ask you determine the "accredited investor"An accredited investor is someone who meets certain financial net worth thresholds, is a registered securities dealer or financial institution. status of Which is required by U.S securities laws. is one of the following? Executive officer of the Corporation or any director, executive officer or general partner of a general partner of that issuer A natural person whose individual net worth, or joint not worth with that person's spouse or spousal equivalent, at the date hereof exceeds US$1,000,000, excluding the value (if any) of such person's primary residence A natural person who had an individual Income in excess of US$200,000 in each of the two most recent years or joint income with that person's spouse or spousal equivalent in excess of US$300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year A broker or dealer registered pursuant to Section 15 of the United States Securities Exchange Act of 1934, as amended A natural person who is a "knowledgeable employee," as defined in rule 3-5(aX4) under the United States Investment Company Act of 1940 (17 CFR 270.3c 5kaX4)), of the issuer of the O securities being offered or sold where the issuer would be an investment company, as defined in Section 3 of such Act, but for the exclusion provided by either Section 3(c)(1) or Section 3(c)(7) of such Act: None of AboveWe are now going to ask you determine the "accredited investor" status of {Please enter the name of the Investor : (First):38.3} Which is required by U.S securities laws. Is{Please enter the name of the Investor : (First):38.3} one of the following?We are now going to ask you determine the "accredited investor"An accredited investor is someone who meets certain financial net worth thresholds, is a registered securities dealer or financial institution. status of Which is required by U.S securities laws. is one of the following? A broker or dealer pursuant registered to section 15 of the United states Securities Exchange of Act 1934, as amended An Entity with more than $5,000,000USD in net assets An Entity in which all of the equity owner meet the requirement of at least one of the accredited investor categories Show more optionsPlease select one of the following categories which best describes {Please enter the name of the Investor : (First):38.3}Please select one of the following categories which best describes An organization described in Section 501(c)(3) of the United States Internal Revenue Code, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of US$5,000,000 A trust, with total assets in excess of US$5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506bX2X) under the 1933 Act A corporation, Massachusetts or similar business trust, limited liability company or partnership, not formed for the specific purpose of acquiring the securities, with total assets of more than US$5 million An employee benefit plan within the meaning of the United States Employee Retirement Income Security Act of 1974 in which the investment decision is made by a plan fiduciary, as deed in Section 3(21) of such Act, which is either a bank, savings and loan association, insurance company or registered investment adviser, or an employee benefit plan with total assets in excess of US$5,000,000 or, if a self-directed plan, with investment decisions made solely by persons who are accredited investors A plan, established and maintained by a state, a political subdivision of a state, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, with total assets of more than US$5,000,000;Is {Please enter the name of the Investor : (First):38.3} one of the following? Is one of the following? A bank, as defined in Section 3(aX2) of the 1933 Act or a savings and loan association or other institution as defined in Section 3(aX5XA) of the 1933 Act, whether acting in its individual or fiduciary capacity An insurance company as defined in Section 2(13) of the 1933 Act An investment company registered under the United States Investment Company Act of 1940 A business development company as defined in Section 2(aX48) of the United States Investment Company Act of 1940 A small business investment company licensed by the U.S. Small Business Administration under Section 301 (c) or (d) of the United States Small Business Investment Act of 1958; A private business development company as defined in Section 202(aX22) of the United States Investment Advisers Act of 1940 A rural business investment company as defined in Section 384A of the Consolidated Farm and Rural Development Act; A "family client," as defined in rule 202(aX11XG)-1 under the United States Investment Advisers Act of 1940 (17 CFR 275.202(aX11XG)-1)), of a family office meeting the requirements in category 23 above and whose prospective investment in the issuer is directed by such family office;Please enter the Social Security Number (SSN) of {Please enter the name of the Investor : (First):38.3}(Required)Please enter the Social Security Number (SSN Social Security number (SSN) is a nine digit number issued to U.S. citizens, permanent residents, and temporary (working) residents under section 2059(c)(2) of the Social security Act ) of : Tips for the answering question Tax ID is required both for AML purposes and, for Regulation A offerings, to comply with broker-dealer requirements Feel free to contact us if you have any questions or require further assistance.{all_fields}
