Investor Input Form – Brynes Capital

investor input form

Brynes Capital

Name(Required)

First Middle Last

Email Address to Send Documents(Required)

Address to List on Documents(Required)

Street Address City State ZIP Code

Phone(Required)

Date of Birth(Required)

Marital Status(Required)

Are You Investing as a Company, Individual, or Fiduciary?(Required)

Because You're Investing as an Individual, Please Provide Your Social Security Number(Required)

Because You're Investing as a Fiduciary, Please Provide Your Fiduciary Name(Required)

Because You're Investing as a Fiduciary, Please Provide Your Fiduciary Phone Number(Required)

Because You're Investing as a Fiduciary, Please Provide Your Fiduciary Address(Required)

Street Address Address Line 2 City State ZIP Code

Because You're Investing as a Company, Please Provide Your Company Name(Required)

Because You're Investing as a Company, Please Provide Your EIN(Required)

College Graduate(Required)

Please Provide Your College/University(Required)

Please List Your Graduate Degree(Required)

Do You Have an Advanced College Degree?(Required)

Please Provide Your Advanced Degree College/University(Required)

Please List Your Advanced Graduate Degree(Required)

Occupation(Required)

Have You Participated in a Private Offering?(Required)

What is Your Investment Type?(Required)

Type of IRA(Required)

Because You Chose "Other", Please Explain.(Required)

Exact Name of IRA(Required)

IRA Account Number(Required)

IRA Investor Has Previously Participated in Other Private Offerings of Securities(Required)

IRA Investor was Previously Verified as an Accredited Investor in One of the Issuer’s Prior Offerings and is Currently One of the Issuer’s Investors(Required)

With CamaPlan or Other Custodian(Required)

IRA Transaction Fees Paid By Credit Card or Cash in IRA?(Required)

IRA Investor is a Citizen of the United States(Required)

IRA Investor is a Resident of the United States(Required)

Exact Name of Investing Entity(Required)

Entity EIN(Required)

What State was the Entity Formed In(Required)

Entity Address(Required)

Street Address City State ZIP Code

Entity Phone Number(Required)

Who Will Be Signing the Investment Documents(Required)

Signer's Title(Required)

Are You an Accredited Investor?(Required)

How are You Accredited?(Required)

Because You Chose "Other Accredited Investor", Please Explain.(Required)

Total Investment Amount Into Brynes Capital Life Settlement Wealth Fund 2021(Required)

*A Subscription Fee of 2% will be added to your Total Investment Amount. $25,000 minimum investment. Possible Custodial Fee/Minimum Balance Requirement.