For Entities. 1. All of the beneficial equity owners of the undersigned qualify as accredited individual investors;
For Entities. The Holder is an entity and (please check all boxes that apply): ☐ is a corporation, partnership, limited liability company, Massachusetts or similar business trust or organization described in Section 501(c)(3) of the U.S. Internal
For Entities. The undersigned is an “Accredited Investor” because the undersigned falls within at least one of the following categories (Check all appropriate lines):
For Entities. ☐ The undersigned is an entity and (please check all boxes that apply): ☐ is a corporation, partnership, limited liability company, Massachusetts or similar business trust or organization described in Section 501(c)(3) of the U.S. Internal Revenue Code of 1986, as amended, not formed for the specific purpose of acquiring securities in the Company that has total assets in excess of $5,000,000; ☐ is a bank as defined in Section 3(a)(2) of the Securities Act, a savings and loan association, or other institution defined in Section 3(a)(5)(A) of the Securities Act acting in either its individual or fiduciary capacity (this includes a trust for which a bank acts as trustee and exercises investment discretion with respect to the trust’s decision to invest in the Company); ☐ is a broker dealer registered pursuant to Section 15 of the U.S. Securities Exchange Act of 1934, as amended (the “Exchange Act”); ☐ is an insurance company as defined in Section 2(a)(13) of the Securities Act; ☐ is an investment company registered under the U.S. Investment Company Act of 1940, as amended (the “Investment Company Act”), or a business development company as defined in Section 2(a)(48) of the Investment Company Act; ☐ is a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the U.S. Small Business Investment Act of 1958, as amended; ☐ is a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of employees, having total assets in excess of $5,000,000; ☐ is an employee benefit plan within the meaning of the U.S. Employee Retirement Income Security Act of 1974, as amended (“ERISA”), (a) for which the investment decision to acquire securities in the Company is being made by a plan fiduciary, as defined in Section 3(21) of ERISA, that is either a bank, savings and loan association, insurance company, or registered investment adviser, (b) which has total assets in excess of $5,000,000, or (c) which is self-directed, with the investment decisions made solely by persons who are Accredited Investors; ☐ is a private business development company as defined in Section 202(a)(22) of the U.S. Investment Advisers Act of 1940, as amended; ☐ is a trust not formed for the specific purpose of acquiring securities in the Company with total assets in excess of $5,000,000 and directed by a person who has such knowledge and experien...
For Entities. Form of entity (e.g., corporation, partnership, limited liability company, trust, etc.) Organized under the laws of: Address of principal office: Addresses of any other offices: Has the investing entity been organized for the specific purpose of acquiring securities of Chemesis Inc.? Yes _____ No _____
For Entities. Are you:
For Entities. ¨ The undersigned is an entity and (please check all boxes that apply): ¨ is a corporation, partnership, limited liability company, Massachusetts or similar business trust or organization described in Section 501(c)(3) of the U.S. Internal Revenue Code of 1986, as amended, not formed for the specific purpose of acquiring securities in the Company that has total assets in excess of $5,000,000; ¨ is a bank as defined in Section 3(a)(2) of the Securities Act, a savings and loan association, or other institution defined in Section 3(a) (5)(A) of the Securities Act acting in either its individual or fiduciary capacity (this includes a trust for which a bank acts as trustee and exercises investment discretion with respect to the trust’s decision to invest in the Company); ¨ is a broker dealer registered pursuant to Section 15 of the U.S. Securities Exchange Act of 1934, as amended (the “Exchange Act”); ¨ is an insurance company as defined in Section 2(a)(13) of the Securities Act; ¨ is an investment company registered under the U.S. Investment Company Act of 1940, as amended (the “Investment Company Act”), or a business development company as defined in Section 2(a)(48) of the Investment Company Act; ¨ is a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the U.S. Small Business Investment Act of 1958, as amended; ¨ is a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of employees, having total assets in excess of $5,000,000; ¨ is an employee benefit plan within the meaning of the U.S. Employee Retirement Income Security Act of 1974, as amended (“ERISA”), (a) for which the investment decision to acquire securities in the Company is being made by a plan fiduciary, as defined in Section 3(21) of ERISA, that is either a bank, savings and loan association, insurance company, or registered investment adviser, (b) which has total assets in excess of $5,000,000, or (c) which is self-directed, with the investment decisions made solely by persons who are Accredited Investors; ¨ is a private business development company as defined in Section 202(a)(22) of the U.S. Investment Advisers Act of 1940, as amended; ¨ is a trust not formed for the specific purpose of acquiring securities in the Company with total assets in excess of $5,000,000 and directed by a person who has such knowledge and experie...
For Entities. ☐ The undersigned is an entity and (please check all boxes that apply): ☐ is a corporation, partnership, limited liability company, Massachusetts or similar business trust or organization described in Section 501(c)(3) of the U.S. Internal Revenue Code of 1986, as amended, not formed for the specific purpose of acquiring securities in the Company that has total assets in excess of $5,000,000; ☐ is a bank as defined in Section 3(a)(2) of the Securities Act, a savings and loan association, or other institution defined in Section 3(a)(5)(A) of the Securities Act acting in either its individual or fiduciary capacity (this includes a trust for which a bank acts as trustee and exercises investment discretion with respect to the trust’s decision to invest in the Company); ☐ is a broker dealer registered pursuant to Section 15 of the U.S. Securities Exchange Act of 1934, as amended (the “Exchange Act”); ☐ is an insurance company as defined in Section 2(a)(13) of the Securities Act; By: Name: Title:
For Entities. Were you formed for purposes of investing in the Fund? □ Yes □ No Note: If you checked Yes, you must check Box 10 on Exhibit B (Accredited Investor Status) and list your beneficial owners Are you, or but for the exception under Section 3(c)(1) or 3(c)(7) of the Investment Company Act would you be, an investment company? □ Yes □ No Are you investing 40% or more of your total assets and committed capital in the Fund? □ Yes □ No If you checked "Yes" to any of 3 questions above, how many "beneficial owners" of your outstanding interests are there?
For Entities. (iii) ¨ a bank as defined in Section 3(a)(2) of the 1933 Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the 1933 Act whether acting in its individual or fiduciary capacity or an insurance company as defined in Section 2(a)(13) of the 1933 Act.
