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Bad Actor Questionnaire

Do you have any aliases?
No
Yes

1-123-555-5555

Best method of contact
Phone
Email
Homes Address
Business Address
Other
State you are registered to vote? (not required)
Employed since (not required)
Month
Day
Year

Question 1

Have you been convicted, within ten (10) years of the date hereof (or five (5) years, in the case of the Issuer, its predecessors and affiliated issuers), of any felony or misdemeanor:

• in connection with the purchase or sale of any security;

• involving the making of any false filing with the SEC; or

• arising out of the conduct of the business of an underwriter, broker, dealer, municipal securities dealer, investment advisor or paid solicitor of purchasers of securities?

Answer to question 1
No
Yes

Question 2

Are you subject to any order, judgment or decree of any court of competent jurisdiction,

enteredwithin five (5) years of the date hereof, that, on the date hereof, restrains or enjoins you

from engaging or continuing to engage in any conduct or practice?

• in connection with the purchase or sale of any security;

• involving the making of any false filing with the SEC; or

• arising out of the conduct of the business of an underwriter, broker, dealer, municipal securities dealer, investment adviser or paid solicitor of purchasers of securities?

Answer to question 2
No
Yes

Question 3

Are you subject to a final order of a state securities commission (or an agency or officer of a state performing like functions); a state authority that supervises or examines banks, savings associations, or credit unions; a state insurance commission (or an agency or officer of a state performing like functions); an appropriate federal banking agency; the Commodity Futures Trading Commission; or the National Credit Union Administration that on the date hereof, bars you from:

• association with an entity regulated by such commission, authority, agency or officer;

• engaging in the business of securities, insurance or banking; or

• engaging in savings association or credit union activities; or

• constitutes a final order, entered within ten (10) years of the date hereof, that is based on a violation of any law or regulation that prohibits fraudulent, manipulative, or deceptive conduct? A "final order" is a written directive or declaratory statement issued by any of the regulators listed in this question under applicable statutory authority that provides for notice and an opportunity for a hearing, which constitutes a final disposition or action by that regulator.

Answer to question 3
No
Yes

Question 4

Are you subject to an order of the SEC entered pursuant to Section 15(b) or 15B(c) of the Securities Exchange Act of 1934 (the "Exchange Act") or Section 203(e) or 203(f) of the Investment Advisers Act of 1940 (the "Advisers Act") that, on the date hereof:

• suspends or revokes your registration as a broker, dealer, municipal securities dealer or investment adviser;

• places limitations on your activities, functions or operations; or

• bars you from being associated with any entity or from participating in the offering of any penny stock?

Answer to question 4
No
Yes

Question 5

Are you subject to any order of the SEC, entered within five (5) years of the date hereof, that, on the date hereof, orders you to cease and desist from committing or causing a violation of or future violation of: • any scienter-based anti-fraud provision of the federal securities laws, including, but not limited to, Section 17(a)(1) of the Securities Act, Section 10(b) of the Exchange Act and Rule 10b-5 thereunder, Section 15(c)(1) of the Exchange Act and Section 206(1) of the Advisers Act, or any other rule or regulation thereunder; or • Section 5 of the Securities Act

Answer to question 5
No
Yes

Question 6

Have you been suspended or expelled from membership in, or suspended or barred from association with a member of, a securities self-regulatory organization (e.g., a registered national securities exchange or a registered national or affiliated securities association) for any act or omission to act constituting conduct inconsistent with just and equitable principles of trade?

Answer to question number 6
No
Yes

 Question 7

Have you filed (as a registrant or issuer), or were you named as an underwriter in, any registration statement or Regulation A offering statement filed with the SEC that, within five (5) years of the date hereof, was the subject of a refusal order, stop order, or order suspending the Regulation A exemption, or are you, on the date hereof, the subject of an investigation or proceeding to determine whether a stop order or suspension order should be issued?

Answer to question 7
No
Yes

Question 8

Are you subject to a United States Postal Service false representation order entered within five (5) years of the date hereof, or are you, on the date hereof, subject to a temporary restraining order or preliminary injunction with respect to conduct alleged by the United States Postal Service to constitute a scheme or device for obtaining money or property through the mail by means of false representations?

Answer to question 8
No
Yes
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