Worthy

Investor Questionnaire

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Investor Information
Place of Issuance of Passport
Investment Information
Information for the Secondary
Place of Issuance of Passport
Provide Information for Entity

Provide Information for all Beneficial Owners
(1) Each individual, if any, who owns, directly or indirectly, 25 percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a corporation; and
(2) An individual with significant responsibility for managing the legal entity customer (e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer).


First Beneficial Owner
Place of Issuance of Passport
2nd Beneficial Owner Information
Place of Issuance of Passport
3rd Beneficial Owner Information
Place of Issuance of Passport
4th Beneficial Owner Information
Place of Issuance of Passport
5th Beneficial Owner Information
Place of Issuance of Passport
Investor Qualifications
in USD
in USD
Investment Amount
You will get: 0 shares
Share Price: $0
Minimum amount: $0
Price is rounded up to $0 to get a non-fractional amount of shares.
Payment Method
An email will be sent to you regarding the account details.
This option is.
Wire Instructions
One Boca Commerce Center
551 NW 77th Street
Suite 212
Boca Raton, FL 33487

Truist
515 E. Las Olas Blvd. 7th Floor
Fort Lauderdale, FL 33301
954-233-0459

Business Checking Account
ABA Routing & Wire Transfer #: 263191387
Account Number#: 1100022797040

Reference: Worthy Financial, Inc. - test investor displayname
Check Instructions
Make check payable to: “ test llc
Send check through FedEx, UPS or via regular mail to:
One Boca Commerce Center
551 NW 77 Street, Suite 212
Boca Raton, FL 33487
I understand that I may only cancel my commitment to purchase up to 48 hours before the offering period expires.
I understand that the securities being offered are restricted and may only be resold under certain circumstances.
I understand that investing in securities involves risks and I should not invest unless I can bear the loss of risk, including a 100% loss.

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Individual
  Valid Government ID
  Proof of Accreditation
Joint
  Valid Government ID
  Proof of Accreditation
Trust
  Valid Government ID
  Trust Agreement
  Proof of Accreditation
Companies/Institutions
  Valid Government ID
  Tax ID Letter (SS4)
  Articles of Incorporation
  Proof of Accreditation

Proof of accreditation for companies or trusts can be any of these documents:
  1. a bank, insurance company, registered investment company, business development company, or small business investment company;
  2. an employee benefit plan, within the meaning of the Employee Retirement Income Security Act, if a bank, insurance company, or registered investment adviser makes the investment decisions, or if the plan has total assets in excess of $5 million;
  3. a charitable organization, corporation, or partnership with assets exceeding $5 million;
  4. a director, executive officer, or general partner of the company selling the securities;
  5. a business in which all the equity owners are accredited investors;

Investor accreditation documents, can be any of the following:
Investor accreditation documents, can be any of the following:
For the Equity owners, investor accreditation documents, can be any of the following:
  1. An accreditation letter signed by a licensed attorney or CPA;
  2. Proof of assets worth more than 1mil by reviewing specific types of documentation dated within the prior three months, such as:
    • bank statements
    • brokerage statements
    • certificates of deposit
    • tax assessments
    • credit report from at least one of the nationwide consumer reporting agencies, and obtaining a written representation from the investor
  3. Individual Proof of income for 2 years of at least 200k by reviewing copies
    of any Internal Revenue Service form that reports income, such as:
    Form W-2, Form 1099, Schedule K-1 of Form 1065, and a filed Form 1040;
  4. Joint Proof of income for 2 years of at least 300k by reviewing copies
    of any Internal Revenue Service form that reports income, such as
    Form W-2, Form 1099, Schedule K-1 of Form 1065, and a filed Form 1040;
  5. Proof of income for 2 years of at least 200k by reviewing copies
    of any Internal Revenue Service form that reports income, such as:
    Form W-2, Form 1099, Schedule K-1 of Form 1065, and a filed Form 1040;

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