EPSTEIN
page 2 / 1960 . OCR, unverified
Client Account Number:
FFC (if applicable):
Reference (if applicable):
If your account is with a non-U.S. bank, please provide the additional information below:
U.S. Correspondent/Intermediary Bank Name:
U.S. Correspondent/Intermediary ABA Number (if applicable):
U.S. Correspondent/Intermediary Swift Code (if applicable):
International Bank Account Number (IBAN):
Source of Funds. Please indicate the source of the funds being invested in the Partnership:
K
Salary
K
Savings
K
Inheritance
K
Gift
K
Retirement / Redundancy Payment
K
Windfall / Compensation Payment
Other:
PROPRIE'fARY AND CONFIDEN77AL
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
DB-SDNY-0099874
CONFIDENTIAL
SDNY_GM_00246058
EFTA01393970
--- SOURCE: IMAGES__0062__EFTA01393971.txt ---
METADATA_SOURCE: IMAGES0062
METADATA_FILENAME: EFTA01393971.pdf
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GLDUS137 Forrestal Capital LLC
Exhibit B
FOR INDIVIDUALS
INVESTOR STATUS
The Investor hereby represents and warrants that the answers provided below completely and accurately
describe the Investor.
The Investor is a natural person whose net worth, either individually or jointly with such person's spouse,
at the time of purchase, equals (exclusive of the value of the Investor's primary residence):
K
Less than $500,000
K
$500,000 - $999,999
K
$1,000,000 - $4,999,999
K
$5,000,000 - $9,999,999
K
$10,000,000 or more
The Investor is a natural person who had individual income on the amounts specified below, or joint income
with that person's spouse in the amount specified below, in the previous two calendar years and reasonably
expects to reach the same income level in the current calendar year:
2016 Income:
2017 Income:
K
$199,999 or less
K
$199,999 or less
K
$200,000-$299,999
K
$200,000-$299,999
K
$300,000-$499,999
K
$300,000-$499,999
K
$500,000 or greater
K
$500,000 or greater
The above amounts are calculated:
K
Individually
K
Together with my spouse
The Investor is a natural person (including a person who will hold a joint, community property or similar
shared ownership interest in the Partnership with that person's qualified purchaser spouse) who owns
investments' worth:
K
Less than $5,000,000
K
$5,000,000 - $ I 0.000,000
K
More than $ I 0,000,000
For definition of "invesunents." see Rule 2a51-1 promulgated under the Investment Company Act.
PROPRIETARY AND CONFIDEN71AL
B-I
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
DB-SDNY-0099877
CONFIDENTIAL
SDNY_GM_00246061
EFTA01393971
--- SOURCE: IMAGES__0062__EFTA01393972.txt ---
METADATA_SOURCE: IMAGES0062
METADATA_FILENAME: EFTA01393972.pdf
----------------------------------------
GLDUS137 Forrestal Capital LLC
4.
Please indicate whether the Investor is investing the assets of any retirement plan, employee benefit
plan or other similar agreement that is subject to Section 4975 of the United States Internal Revenue Code
of 1986, as amended (the "Code") (such as an IRA or "Keogh" plan) (a "Plan Investor"):
K
Yes
K
No
(a) If the Investor answered "Yes", to Question 4 above, please indicate what percentage of the
Investor's assets invested in the Partnership arc the assets of a plan. individual retirement account
or other arrangement that is described in Section 4975 of the Code, whether or not such plan,
account or arrangement is subject to Section 4975 of the Code:
o
Less than 25% and the percentage is
%.
25% or more and the percentage is
%.
(b) If the Investor answered "Yes", to Question 4 above, please indicate whether or not the Investor
is, or is acting (directly or indirectly) on behalf of, (A) an employee benefit plan (within the
meaning of Section 3(3) of the United States Employee Retirement Income Security Act of 1974,
as amended ("ERISA")) that is subject to Title I of ERISA. (B) an insurance company using general
account assets, if such general account assets are deemed to include the assets of any of the
foregoing types of plans, accounts or arrangements, for purposes of Tide I of ERISA or Section
4975 of the Code under Section 401(c)(1XA) of ERISA or the regulations promulgated thereunder,
or (C) an entity which is deemed to hold the assets of any of the foregoing types of plans, accounts
or arrangements:
K
Yes
K
No
5.
Please indicate whether or not the Investor is subject to any other federal, state, local, non-U.S. or
other laws or regulations that could cause the underlying assets of the Partnership to be treated as assets of
the Plan Investor by virtue of its investment in the Partnership and thereby subject the Partnership and the
General Partner (or other persons responsible for the investment and operation of the Partnership's assets)
to laws or regulations that are similar to the fiduciary responsibility or prohibited transaction provisions
contained in Title I of ERISA or Section 4975 of the Code.
K
Yes
K
No
If the Investor answered "Yes" above, please contact the General Partner immediately.