Investment Direction Form
for
Private Investments
Instructions: Please complete this form in its entirety. In addition, please be sure to read this entire form prior to completing to avoid any
processing delays. This form contains important disclosures about YOUR responsibilities in regards to investing and holding a private equity
investment. The Kingdom Trust Company does not conduct any investigation and does not make any express or implied representations
whatsoever as to the validity, strength, appropriateness, legality or tax effect (including interest and penalties) of this investment (the
"investment"). By signing this form you consent to all terms and conditions outlined within this document.
Section 1: Account Holder Information
Account Holder Name:
IRA Account #
Name of Investment Entity:
Amount of Investment
$
Number of shares/units:
%
Ownership to be acquired:
Type of Investment:
Price Per share/units
Private Common Stock
Limited Liability Company
Private Preferred Stock
Limited Partnership
Other:
Section 2: Processing Instructions
Send above $ amount via check regular mail
UPS
Send above $ amount via overnight delivery service
FedEx
Payee name:
Address:
City:
Billing Account number
State:
Zip:
3rd party billing zip:
Send above $ amount via wire (wire fee will apply)
Bank Name:
ABA Routing #
For Credit to (FCT):
Bank Phone Number
(must be a 9 digit number)
Account Number:
Send investment via ACH
Bank Name:
Bank Phone No:
Account No:
Routing No:
Copyright The Kingdom Trust Company 2011
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Investment Related and Incidental Fees:
See fee schedule for complete list of fees due and date to which you are expected to provide payment.
Deduct from available cash in account (Please note that there must be sufficient cash in the account to avoid additional charges.)
Bill Credit Card:
Visa
Master Card
Discover
American Express
Name as it appears on card:
Card Number:
Expiration date:
Credit card billing address:
By checking this box you authorize The Kingdom Trust Company to bill the above credit card for all fees and expenses.
Account Holder Signature:
Section 3: Representations
I represent that I am NOT an officer, director, owner, manager, member or affiliate of the entity, nor am I related to an
officer, director, owner, manager or member of the entity or any affiliate of the entity. I am also indicating that my total
ownership interest, directly or directly, in the entity is less than 50%. This includes my ownership combined with that of all
my family member(s), affiliated entity(ies), and other disqualified persons, as defined in the Internal Revenue Code.
I represent that I am an officer, director, owner, manager or member of the entity or one or more of its affiliates or that I
am related to an officer, director, owner, manager or member of the entity or one or more affiliates of the entity. The
combined percentage of ownership of the entity, directly and indirectly, by me, my family member(s), affiliated entity(ies),
and other disqualified persons as defined in the Internal Revenue Code currently is:
Relationship:
Total Percentage of Ownership %
Section 4 : Signature
I understand that fees will apply to this request. I also understand that The Kingdom Trust Company does not complete any due diligence on this or any other
investments, and the decision to make this investment is solely at my direction. I agree to indemnify, hold harmless and defend The Kingdom Trust Company
and its respective officers, directors, managers, members, employees, representatives, agents, owners, affiliates, successors and assigns from any liability,
loss, damage, injury or expense of any nature, including attorneys' fees, which may occur or arise in connection with the investment directed hereby and
holding such equity ownership investment on an ongoing basis.
Account Holder Signature:
Date:
The Kingdom Trust Company does not provide tax, legal or investment advice. It does not endorse or recommend any agent, company, or
specific investment. Any information communicated by The Kingdom Trust Company is solely for educational purposes and should not be
construed as tax, legal, or investment advice. Consultations with tax, legal and investment professionals is advised prior to making any
decisions regarding your retirement account.
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