Santa Monica Partners Asset Management
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SANTA MONICA PARTNERS ASSET MANAGEMENT

INVESTOR QUESTIONNAIRE

INSTRUCTIONS: The purpose of this Questionnaire is to assist the Fund in complying with the requirements of the Securities Act of 1933, as amended (the "Securities Act"), the Investment Company Act of 1940, as amended (the “Investment Company Act”), and state securities laws. The limited partnership interest which may be sold to you pursuant to a subscription agreement has not been, and will not be, registered under the Securities Act and is being sold in reliance upon an exemption from the registration requirements of the Securities Act and an exemption from the applicable state securities laws. The information to be supplied herein will be relied upon in connection with the offering and sale of the limited partnership interests in compliance with the aforesaid exemption.

Santa Monica Partners and its associated funds are available only to accredited investors. This form is required before we are able to furnish you information about our firm and funds.

All information supplied will be treated in confidence, except that this InvestorQuestionnaire may be presented to such parties as deemed appropriate or necessary to establish the availability of an exemption from registration under the Act and under state securities laws.

ONCE COMPLETED
PLEASE FAX THIS FORM TO
SANTA MONICA PARTNERS
(914) 833-1068

PLEASE ANSWER EACH QUESTION. If the answer to any question is "None" or "Not Applicable", please so state. [all fields are required fields]

Please Select One:

Legal Name of Investor or Business:

Address:

Home Phone:

Business Phone:

Email Address:

Please choose one:
Please enter SSN/TID number:

Occupation:

If you are a business, what is the nature of the business, please describe:

Business Address:

Please respond to the following questions by selecting next to the appropriate answer. The primary purpose of these questions is to determine whether you are an “accredited investor” under Rule 501(a) of Regulation D under the Securities Act and a “qualified purchaser” for the purposes of Section 3(c)(7) of the Investment Company Act.

A. Identify the nature of ownership of the proposed investment in the Fund:
    Single ownership
    Tenancy by the entirety (spouses only)
    Joint tenancy with the right of survivorship
    Tenancy in common
    Other (please specify) 

B. Is your current net worth (or joint net worth with that of your spouse, if applicable) as of the date of this subscription in excess of $1,500,000 excluding homes, furnishings, personal automobiles?

C. Did your individual income without regard to that of your spouse exceed $200,000 in each of the last two full calendar years and do you reasonably expect such individual income to exceed $200,000 in the current year? For the purpose of this question, income includes earned income, as well as other items of ordinary income, such as dividends, interest and royalties, but excludes capital gains.

D. Did your joint income with your spouse exceed $600,000 in each of the last two full calendar years and do you reasonably expect such joint income to exceed $600,000 in the current year? For the purpose of this question, income includes earned income, as well as other items of ordinary income, such as dividends, interest and royalties, but excludes capital gains.

E. List in the space provided below the state(s) in which you have maintained a residence during the past two years and the dates during which you resided in each state, and the state(s), if any, in which you are required to pay income taxes:
   
   

F. Do you own at least $5,000,000 in investments (net of any currently outstanding indebtedness incurred in connection with acquiring such investments) including, if applicable, any investments held jointly by your spouse or investments in which you share with your spouse a community property or similar shared-ownership interest. For this purpose, the term "investments" includes: (i) securities of public companies, securities of non-public companies that have shareholders’ equity of at least $50 million, or securities of other non-public companies that you do not control, shares in registered investment companies such as mutual funds and publicly-traded closed-end funds, and shares in private investment companies such as private investment funds that are exempt from registration under the Investment Company Act, (ii) real estate, commodity futures contracts, options on commodity futures contracts, physical commodities, options on physical commodities, or cash or cash equivalents held for investment purposes, and (iii) certain financial contracts entered into for investment purposes. In addition, the term "investment" specifically excludes real estate used for personal purposes such as a residence, property used as a place of business or in connection with a trade or business, and other investments such as jewelry, antiques and artwork. You can include investments held in your IRA or 401(k) accounts, or other retirement accounts, if you make the investment decisions with respect to those accounts. You may also include investments held by a so-called “alter ego” or wholly-owned entity.

I hereby represent that all the information supplied herein is true, correct and complete as of the date hereof . I agree to notify Santa Monica Partners Asset Management immediately of any material change in the foregoing answers.

IN WITNESS WHEREOF, the undersigned has executed this Investor Questionnaire on and declares that it is truthful and correct.
 
Type Name
** Please print out this document, sign below and fax to Santa Monica Partners Asset Management at (914) 833-1068 **




____________________________________
Signature

Information contained on this website is based on sources we believe to be reliable but we do not guarantee its accuracy or completeness. Everything contained on this website is for informational purposes only and is neither an offer nor solicitation to buy or sell securities. All expressions of opinion reflect judgments as of this date and are subject to change without notice. Our principals and associates may own securities of the issuers mentioned herein and may make purchases or sales of these securities at any time. Additional information is available upon request.

“Stocks overlooked or ignored by otherwise intelligent investors” ®  is a registered trademark.

 
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