Accredited Investor Verification Form

ACCREDITED INVESTOR VERIFICATION FORM
Regulation D, Rule 501 — Self-Certification
[Company Name / Fund Name]
[Sponsor Name]
[Address]
This form is being provided in connection with a potential investment in [Fund / Project Name] (the "Offering"). To participate in the Offering, each investor must qualify as an "Accredited Investor" as defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended.
Please complete all applicable sections, sign, and return to [Sponsor Name] at [Email Address].
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SECTION 1 — INVESTOR IDENTIFICATION
  Full Legal Name: ___________________
  Date of Birth: ___________________
  SSN (last 4 digits only for verification): XXX-XX-_____
  Address: ___________________
  City, State, ZIP: ___________________
  Phone: ___________________
  Email: ___________________
  ENTITY INVESTOR (complete if investing through an entity):
  Entity Name: ___________________

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[Section 3 — fill in your details...]

[Additional clauses and provisions apply...]