Accredited Investor Application
SECTION 1 — INTRODUCTION
This Accredited Investor Verification Form (“Form”) is designed to collect information necessary to determine whether an individual or entity qualifies as an “accredited investor” under Rule 501(a) of Regulation D of the U.S. Securities Act of 1933, as amended.Completion of this Form is required prior to participation in certain private investment offerings conducted pursuant to Rule 506(c), which mandates that issuers take reasonable steps to verify accredited investor status.
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SECTION 2 — PERSONAL INFORMATION
Required for all applicants
PRIMARY APPLICANT INFORMATION
Full Legal Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Must match your government-issued identification.
Social Security Number
*
00-000-0000
Email
*
Ex: example@example.com [This email will be used for secure communications and delivery of verification results.]
Phone Number
*
Provide a valid phone number, including country code if outside the United States.
Format: (000) 000-0000.
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country of Residence
*
Country of Citizenship
*
CO-APPLICANT INFORMATION
Only applicable if applying based on joint-income
Full Legal Name (Co-Applicant)
Prefix
First Name
Middle Name
Last Name
Suffix
Date of Birth (Co-Applicant)
-
Month
-
Day
Year
Must match your government-issued identification.
Social Security Number (Co-Applicant)
00-000-0000
Email (Co-Applicant)
Ex: example@example.com [This email will be used for secure communications and delivery of verification results.]
Phone Number (Co-Applicant)
Provide a valid phone number, including country code if outside the United States.
Format: (000) 000-0000.
Residential Address (Co-Applicant)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country of Residence (Co-Applicant)
Country of Citizenship
Government ID Upload Requirement
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Provide a clear copy of a valid, non-expired government-issued ID (Driver’s License or Passport).
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SECTION 3 — ACCREDITATION METHOD
Required for all applicants
Select the method by which you qualify:
*
Income-Based Qualification
Net-Worth Based Qualification
Professional Certification (Series 7, 65, or 82)
Entity Qualification (LLC., C-Corp, S-Corp, Sole Proprietorship, Trust)
Third-Party Qualification
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SECTION 4 — INCOME-BASED QUALIFICATION
Required for all applicants
Type of Income
*
Individual
Joint
Entity-Based
Net-Worth Based
Individual Income (2024)
*
USD
Joint Income (2024)
USD [if applicable]
Proof of Income - 2024
*
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IRS Tax Returns (Form 1040) - 2024
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Individual Income (2025)
*
USD
Joint Income (2025)
USD [if applicable]
Proof of Income - 2025
*
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IRS Tax Returns (Form 1040) - 2024
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Choose all that apply - You must reasonably expect to exceed:
$200,000 (Individually)
$300,000 (Jointly)
All Pay Stubs 2025 and/or 1099's
*
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Required Documentation
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2025 1099 and/or W2
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Required Documentation
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Bank Statements - Last 3 months
*
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All applicable bank statements showing income activity
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SECTION 5 — NET WORTH-BASED QUALIFICATION
Required for all applicants
Estimated Total Assets
*
USD [if applicable]
Estimated Total Liabilites
*
USD [if applicable]
All Bank Statements - Last 6 months
*
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All applicable bank statements
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Brokerage/Investment Account Statements - Last 3 months
*
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All applicable Brokerage/Investment statements
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Real Estate Documentation (excluding primary residence)
*
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Property Valuation, Proof of Title/Deed
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SECTION 6 — CREDIT REPORTING
Required for all applicants
How would you like American Business Capital Group, Inc. to obtain your most recent credit report? (Must choose one)
Upload my own credit report
Authorize ABC to securely obtain my credit report on my behalf
Credit Report Request (Liability Verification)
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We need most recent Experian, Equifax, TransUnion 3-bureau report
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Fair Credit Reporting Act (FCRA) Authorization
I hereby authorize American Business Capital Group of Companies (a DBA of American Business Capital Group, Inc.) to obtain, review, and evaluate my consumer credit report for the limited purpose of verifying my financial liabilities in connection with my accredited investor verification. I understand this authorization constitutes written consent under applicable law and may result in a soft credit inquiry that does not impact my credit score.
Initials
Initials (Co-Applicant)
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SECTION 7 — PROFESSIONAL CERTIFICATION
Only required if applicable / please leave blank if it doesn't apply to you
Please choose all professional investing certifications you hold currently
Series 7 - General Securities Representative
Series 65 - Investment Advisor Representative
Series 82 - Private Securities Offerings Representative
Proof of active license status
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CRD Number
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SECTION 8 — ENTITY INVESTOR
Only applicable to investors applying as an entity
Entity Legal Name
Entity Type
Limited-Liability Company
C-Corp
Sole Proprietorship
Limited Partnership
General Partnership
Irrevocable Trust
Revocable Trust
Family Office
EIN /FTIN
00-0000000
State of Formation
Country of Formation
Qualification requires: (Select all that apply)
$5,000,000+ in assets OR
All equity owners are accredited investors
All Entity Formation Documents
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Articles of Incorporation, Certificate of Formation, Operating Agreement, or Partnership Agreement confirming legal entity structure and existence. This may include Articles of Incorporation, Certificate of Formation, Operating Agreement, Partnership Agreement, or Trust Agreement. These documents help verify the existence of the entity, ownership structure, and authorized decision-makers.
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Financial Statements
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Ownership Structure / Cap Table
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Last 3 months balance sheets, income statements, or other financial records demonstrating assets, liabilities, and overall financial position.
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SECTION 9 — THIRD-PARTY VERIFICATION
Only applicable to investors applying with third-party verification only
Verifier Type (please select one)
Certified Public Accountant (CPA)
Attorney / Counsel
Registered Broker-Dealer
Investment Advisor
Verifier Full Name
Prefix
First Name
Middle Name
Last Name
Suffix
Firm / Company / Entity Name
Verifier Email Address
example@verifier.com
Verifier Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Verification Letter
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1.) Must be signed by the verifier- 2.)Must be dated within the past 90 days- 3.)Must clearly state that you meet accredited investor criteria under applicable U.S. securities laws
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Verifier Authorization
By initialing below, I confirm that the information provided is accurate and that the verification letter is valid and issued by a qualified professional.
Verifier Initials
*
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SECTION 10 — INVESTOR PROFILE
Required for all applicants
Intended Investment Amount (12-month period)
*
Under $25,000
$25,001 - $50,000
$50,001 - $100,000
$100,001 - $250,000
$250,001 - $500,000
$500,001 - $750,000
$750,001 - $999,999
>$1,000,000
Source of Funds
*
Employment
Business Income
Investment Income (Stocks, Bonds, Dividends)
Sale of Assets
Inheritance / gift
Retirement / savings
Other
If 'Other' was selected please specify
*
Investment Experience (Please select one)
*
None
Limited (1-3 investments)
Moderate (4-10 investments)
Extensive (10+ investments)
Prior Private Investment Participation (Select one)
*
None
Limited (1-3 investments)
Moderate (4-10 investments)
Extensive (10+ investments)
Please describe anything else you'd like us to know about your investment history
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SECTION 11— LEGAL DISCLOSURE & CERTIFICATIONS
Required for all applicants
Please review and confirm the following
I represent and certify that I meet the definition of an “accredited investor” as set forth in Rule 501(a) of Regulation D under the Securities Act of 1933, as amended. I understand that this determination is based on my financial condition, professional qualifications, or entity status, and that I may be required to provide documentation to verify such status.
I confirm that all information provided in this form is true, accurate, and complete
I understand that this verification is conducted in accordance with Rule 506(c) of Regulation D under the Securities Act of 1933, as amended, which requires issuers to take reasonable steps to verify that investors qualify as accredited investors. I acknowledge that this process may involve the review of financial information, documentation, or third-party verification, and that such verification is necessary to comply with applicable securities laws.
I acknowledge that submission does not guarantee approval
I understand that this form does not constitute an offer to sell securities
I acknowledge that additional documentation may be required
I understand that verification may expire and require renewal
I acknowledge that issuers and verification providers may rely on this information
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SECTION 12 - DATA PRIVACY & SECURITY POLICY
Required for all applicants
Data privacy & security policy acknowledgement
I acknowledge and agree to the Data Privacy & Security Policy, including the use of encryption, secure storage, and limited data sharing as required for verification and compliance purposes
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SECTION 13- — AML / KYC CERTIFICATION
Required for all applicants
AML / KYC CERTIFICATION
I certify that all funds used for investment are derived from lawful sources
I confirm that I am not currently listed on, nor have I ever been listed on, any sanctions, embargo, or restricted party lists, including but not limited to those maintained by the U.S. Department of the Treasury’s Office of Foreign Assets Control (OFAC)
I confirm that I am not a politically exposed person (PEP), or if I am, I have disclosed such status and understand additional review may be required
I confirm that I am not acting on behalf of any undisclosed third party, nominee, or beneficial owner, and that all information provided reflects the true beneficial ownership of any investment
I acknowledge that the issuer and its representatives may rely on the information provided for purposes of complying with applicable anti-money laundering (AML), know-your-customer (KYC), and counter-terrorism financing laws and regulations
I understand and agree that additional AML/KYC verification procedures, identity verification, and compliance checks may be conducted at any time, including after submission of this form
I agree to promptly provide any additional information or documentation reasonably requested to satisfy AML/KYC compliance requirements
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SECTION 14- — BACKGROUND CHECK AUTHORIZATION
Required for all applicants
To comply with applicable laws and protect the integrity of the verification process, authorization may be required to conduct background and compliance checks.
I authorize American Business Capital Group of Companies (a DBA of American Business Capital Group, Inc.), and its authorized service providers, to conduct background checks, identity verification, and compliance screenings, including but not limited to sanctions screening, regulatory checks, and verification of information provided in this form
I understand that such checks may include review of publicly available records, regulatory databases, and other lawful sources for the purpose of verifying my identity and compliance with applicable laws
I acknowledge that this authorization is provided in accordance with applicable laws and is limited to verification, compliance, and risk management purposes
I understand that additional consent may be required if any consumer report or credit report is obtained under the Fair Credit Reporting Act (FCRA)
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SECTION 15 — ELECTRONIC CONSENT (ESIGN)
Required for all applicants
Please check all boxes below
I agree that my electronic signature is legally binding
I consent to receiving documents electronically
I confirm that I have the ability to access and retain electronic records
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SECTION 16 — RISK DISCLOSURE
Required for all applicants
Please check all boxes below
I understand that private investments are speculative and involve risk
I acknowledge that I may lose some or all of my investment
I understand that investments may be illiquid and not readily transferable
I acknowledge that no guarantees or assurances of returns are provided
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SECTION 17 — RECORD KEEPING DISCLOSURE
Required for all applicants
Please check box below
I acknowledge that all submitted information may be retained for compliance, audit, and regulatory purposes
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SECTION 18 — SIGNATURE
Required for all applicants
Applicant / Signer 1
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Type a question
*
Co-Applicant / Signer 2
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Type a question
FINAL CERTIFICATION
Applicant
APPLICANT / SIGNER 1
*
I certify under penalty of perjury that all information provided is true, complete, and accurate, and I agree to all legal, compliance, and privacy terms outlined in this form
CO-APPLICANT / SIGNER 2
I certify under penalty of perjury that all information provided is true, complete, and accurate, and I agree to all legal, compliance, and privacy terms outlined in this form
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