PROSPECTIVE PURCHASER QUESTIONNAIRE
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To: Prospective purchasers of Class B Units (the “Units”) offered by One Giant Leap, LLC, a
California Limited Liability Company, (the “Company”).
Information regarding securities investments offered by One Giant Leap, LLC is available to individuals and entities qualifying as Accredited Investors within the meaning of Rule 501 of Regulation D under the Securities Act of 1933, as amended (the “Securities Act”). Each prospective investor must complete the following questionnaire and return it to One Giant Leap, LLC.
The prospective investor will be given access to information upon determination of Accredited Investor status based upon the facts disclosed in this questionnaire and any other facts about the investor known by One Giant Leap, LLC.
1. My full name, primary residence address and telephone number are:
Name:
Address:
Telephone:
Facsimile:
My year of birth is:
E-mail Address:
I am registered to vote in (provide city and state):
My driver’s license is issued by the following state:
______________
______________
______________
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I am a citizen of the following country: ______________
My Social Security No. or Tax Identification No. is: ______________
Other Residences or Contacts: Please identify any other state(s) where you own a residence, are registered to vote, pay income taxes, hold a driver’s license or have any other contacts, and describe your connection with such state:
My Occupation/Title is:
My business address and telephone number are:
Company:
Address:
Telephone:
Facsimile: E-mail Address:
The highest level of education attained:
Previous Investment Experience:
(a) Do you have a brokerage account? Yes No
(b) Have you ever before bought securities which were exempt from federal and state registration (private placements)? Yes No
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(c) Have you ever invested in an issuer whose form of business was a limited partnership or limited liability company?
No Once Twice or More
Other Qualifications: Describe any other factors you believe are relevant to your financial experience and knowledge that enables you to understand the merits and risks of investments:
Do you have a pre-existing business or personal relationship with One Giant Leap, LLC? If so, please specify the nature and length of the relationship. If not, please specify how you became aware of the potential investment opportunity, including the name of the person and your relationship to that person:
Accredited Investor Status: Initial all appropriate spaces on the following pages indicating the basis upon which you would qualify as an accredited investor based on how you would hold an investment i.e. as an individual, in an IRA, trust or other form.
For Individuals Only
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(Initial)
(1) I hereby certify that I am an accredited investor because I have an individual net worth, or with my spouse have a joint net worth, in excess of $1,000,000. For purposes of this questionnaire, “net worth” means the excess of total assets at fair market value (including home, home furnishings and automobiles) over total liabilities.
(2) I hereby certify that I am an accredited investor because I have individual ________
(Initial) income (exclusive of any income attributable to my spouse) of more than
$200,000 in each of the past two years, or joint income with my spouse in excess of $300,000 in each of those years, and I reasonably expect to reach the same income level in the current year.
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(Initial)
(3) I am a Director, Executive Officer, or Manager of the Company.
For Corporations, Funds, Limited Partnerships, Limited Liability Companies or Limited
Liability Partnerships
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(Initial)
(4) The undersigned hereby certifies that it is an accredited investor because it has total assets in excess of $5,000,000 and was not formed for the specific purpose of acquiring securities.
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(Initial)
(5) The undersigned hereby certifies that it is an accredited investor because all of its equity owners are accredited investors. Information regarding the basis on which such equity owners are accredited may be requested.
For Individual Retirement Accounts, Self-Directed Benefit Plans and Keogh Plans
________
(Initial)
(6) The undersigned hereby certifies that it is an accredited investor because it is a self-directed plan (i.e., a tax-qualified defined contribution plan in which a participant may exercise control over the investment of assets credited to his or her account) in which all persons directing investments are accredited investors because each participant has a net worth of at least $1,000,000 or has had an individual income of at least $200,000 (or a joint income with spouse of at least $300,000) in each of the last two years. Information regarding the basis on which such participants are accredited may be requested.
For Not-for-Profit Entities (Including Endowments, Private Foundations and Charities)
________
(Initial)
(7) The undersigned hereby certifies that it is an accredited investor because it is an organization described in Section 501(c)(3) of the Internal
Revenue Code of 1986, as amended, was not formed for the specific purpose of acquiring securities, and has total assets in excess of
$5,000,000.
For Trusts
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(Initial)
(8) The undersigned hereby certifies that it is an accredited investor because it has total assets in excess of $5,000,000, was not formed for the specific purpose of acquiring securities, and its purchases are directed by a sophisticated person. As used in the foregoing sentence, a “sophisticated person” is one who has such knowledge and experience in financial and business matters that it is capable of evaluating the merits and risks of a prospective investment.
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(Initial)
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(Initial)
(9) The undersigned hereby certifies that it is an accredited investor because it is (i) a bank as defined in Section 3(a)(2) of the Securities Act of 1933, as amended, a savings and loan association, or other institution as defined in Section 3(a)(5)(A) of the Securities Act, (ii) acting in a fiduciary capacity and (iii) is acting on behalf of a trust account or accounts.
(10) The undersigned hereby certifies that it is an accredited investor because it is a revocable trust which may be amended or revoked at any time by the grantors thereof, the tax benefits of investments made by the trust pass through to the grantors and all of the grantors are accredited investors.
Information regarding the basis on which such grantors are accredited may be requested.
Signature page of Questionnaire
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________
(Initial)
(11) The undersigned hereby certifies that it is an accredited investor because it is an irrevocable trust with the following characteristics: (i) the trust is a grantor trust for federal tax purposes; (ii) the grantor was the sole funding source of the trust and would be taxed on all income of the trust during at least the first 15 years following an investment, would be taxed on any sale of trust assets during that period, and during that period, all of the assets of the trust would be includable in the grantor's estate for federal estate tax purposes; (iii) the grantor is a co-trustee of the trust and has total investment discretion on behalf of the trust; (iv) the terms of the trust provide that the entire amount of the grantor's contribution to the trust plus a fixed rate of return on the contribution would be paid to the grantor
(or his estate) before any payments could be made to the beneficiaries of the trust; (v) the trust was established by the grantor for family estate planning purposes to facilitate the distribution of his estate. In order to effectuate the estate planning goals, the trust was irrevocable; (vi) creditors of the grantor would be able to reach the grantor's interest in the trust at all times; and (vii) all of the grantors are accredited investors
Information regarding the basis on which such grantors are accredited may be requested.
10. Reliance on Exemptions: I understand that securities of the Company acquired by me are being offered in reliance upon specific exemptions from the registration requirements of United States federal and state securities laws and that the Company is relying upon the truth and accuracy of, and my compliance with, my representations, warranties, agreements, acknowledgments and understandings set forth herein in order to determine the availability of such exemptions and my eligibility to acquire the securities.
11. Experience of the Investor: I have, either alone or together with my representatives, such knowledge, sophistication and experience in business and financial matters so as to be capable of evaluating the merits and risks of the prospective investment in the Company’s securities, and have so evaluated the merits and risks of such investment. I am able to bear the economic risk of an investment in the Company ’s securities and, at the present time, am able to afford a complete loss of such investment.
12. General Solicitation: I am not acquiring the securities as a result of any advertisement, article, notice or other communication regarding the securities published in any newspaper, magazine or similar media or broadcast over television or radio or presented at any seminar or any other general solicitation or general advertisement.
By signing this Questionnaire, you affirm the truth and accuracy of the representations made above concerning your status as an accredited investor.
Dated: , 20
(Signature)
(Printed Name)
(Name of Entity, if applicable)
(Title, if applicable)
Signature page of Questionnaire
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