3001 Countryside Blvd Clearwater, FL 33761

Corporation, Partnership, Trust, or other Entity

First Name *

Last Name *

Office Phone *

Email *

Principle Office Address

Address

Street Address

City

State

Country

Postal code

State of Incorporation or Organization

Date of Incorporation or Organization

Taxpayer Identification Number

Nature of Business

Name and Title

Name and Title of Authorized Individual to Execute the Questionnaire

Name of record and beneficial owners of entity (10% ownership or more)

Please list name and percentage of ownership. One name per line.

For All Investors

Relationship to the Company or Manager of the Company

Is the undersigned an officer or director of a publicly-held company?

Yes

No

I ______ personally invested in investments sold by means of private placements within the past five years.

have

have not

Do you consider yourself to have such knowledge and experience in financial and business matters to enable yourself to evaluate the merits and risks of investment in the Company?

Yes

No

Listed below are the categories of accredited investors, as defined by Regulation D, promulgated under the Securities Act of 1933, as amended. Please check the appropriate space provided below if the Investor falls within one or more of these categories.

Any natural person whose individual net worth or joint net worth with that person's spouse, at the time of his purchase, exceeds $1,000,000. Net worth includes homes, furnishings and automobiles.

Any natural person who had an individual 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 in each of those years and has a reasonable expectation of reaching the same income level in the current year.

A bank, insurance company, registered investment company, employee benefit plan if the investment decision is made by a bank, insurance company or registered investment adviser, or an employee benefit plan with more than $5 million of assets.

Any private business development company as defined in Section 202(a) (22) of the Investment Advisers Act of 1940.

Any organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose or acquiring the securities offered, with total assets in excess of $5,000,000.

Any director, executive officer or general partner of the issuer of the securities being offered or sold, or any director, executive officer or general partner of a general partner of that issuer.

Any trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii).

Any entity in which all of the equity owners are accredited investors.

The Investor does not qualify in any accredited category as indicated above.

Please indicate whether you intend to have an attorney, accountant, investment advisor or other consultant act as its Purchaser Representative in connection with this investment

Yes

No

Investor Acknowledgement

The Investor hereby certifies that the information contained herein is complete and accurate and the Investor will notify the Company promptly of any change of information. Specifically, the Investor hereby certifies that the information contained above concerning the residency of the Investor is true and correct. The Investor realizes and understands that, but for the truth of the information contained herein, the Investor would not receive consideration by the Company pertaining to this investment. If the Questionnaire is completed on behalf of a corporation, partnership, trust, or estate, I, the person executing on behalf of the Investor, represent that I have the authority to execute and deliver the Questionnaire on behalf of such corporation, partnership, trust, or estate.

Date

Signature for Corporation, Partnership, Trust, or other Entity

Name of Investor

By

Signature

Full Name

Title

Digital Signature

By checking this box, you agree and understand that using an "electronic signature" is legal and binding. By filling in the field labeled "Signature," you are agreeing that all the information given is to the best of your abilities true.

*DEFINITION OF ACCREDITED INVESTOR

You qualify as an Accredited Investor if you meet any of the following criteria: a) You earn over $200,000 in annual income, b) You, together with your spouse earn over $300,000 in joint annual income, c) You have a net worth, exceeding $1,000,000 (excluding the value of your primary residence), individually or together with your spouse.

DISCLAIMER

All information contained herein is for informational purposes only and should not be construed as a securities offering of any kind. Prior to making any decision to contribute capital, all investors must review and execute all private offering documents, including the project prospectus and the Private Placement Memorandum. Access to information about our investments is limited to investors who qualify as accredited investors within the meaning of the Securities Act of 1933, as amended, and Rule 501 of Regulation D promulgated therefrom.

Corporation, Partnership, Trust, or other Entity

*DEFINITION OF ACCREDITED INVESTOR

DISCLAIMER

ADDRESS

3001 Countryside Blvd Clearwater, FL 33761

PH 727.270.8866