Family Risk and Accreditation – Ascent Capital Partners

Family Risk and Accreditation Form

Family Risks and Accreditation

Step 1 of 5 - Personal Information

Your Name*
Spouse's Name
Daytime Phone*
Cell Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Your Birth Date*
Date Format: MM slash DD slash YYYY
Spouse's Birth Date
Date Format: MM slash DD slash YYYY
Number of Dependents (excl. spouse)*

Current/Former Occupation*
Annual Household Income*
Total Portfolio Value*
Cash/Liquid Reserves Value*
Value of illiquid assets (limited partnerships, REITs, etc)*
What best describes your current income?*
- I am retired with a fixed income which must be supplemented by earnings from my investments.
- I am retired and have a steady source of income that does not need to be supplemented from my investments.
- I am employed but my source of income must be supplemented with earnings from my investments.
- I am employed and my major source of income is adequate, predictable, and I expect it to grow.

Other Important Information*
Is there any other information about your investment objectives, financial condition, or other investments that would help us better evaluate your financial situation? If so, please explain here:
Investor Status (check all that apply)*
- Accredited Investor: An Accredited Investor is generally, a) Any natural person whose individual net worth, or joint net worth with that person’s spouse, at the time of purchase exceeds $1,000,000, excluding the value of their primary residence*, or b) Any natural person who had an income in excess of $200,000 in each of the two most recent years or joint income with that person’s spouse in excess of $300,000 (both spouses should sign) in each of those years and has a reasonable expectation of reaching the same income level in the current year.
- Qualified Client: A Qualified Client is generally a natural person whose individual net worth, or joint net worth with that person’s spouse, at the time of purchase exceeds $2,100,000, excluding the value of their primary residence*.
- Qualified Purchaser: A Qualified Purchaser is generally a natural person whose individual net worth, or joint net worth with that person’s spouse, at the time of purchase exceeds $5,000,000, excluding the value of their primary residence*.
**When calculating net worth, you should (i) exclude your primary residence as an asset, (ii) exclude debt secured by your primary residence, up to the fair market value of your residence, (iii) include the amount of any increase on the debt secured by your primary residence incurred within the last 60 days of making a purchase of the securities, unless related to the acquisition of your primary residence, and (iv) include debt in excess of the fair market value of your primary residence.
Your Affirmation*

Checking this box affirms that the information you have provided is accurate as of the date listed, and fairly and completely represents your current financial condition. By checking this box, you also acknowledge that you understand recommendations made by Ascent Private Client will be based on this information, plus any subsequent information you may provide orally or in writing.

Family Risk and Accreditation Form

Family Risks and Accreditation

Step 1 of 5 - Personal Information

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