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Medalist Diversified REIT
Fill out the form below to submit your investment.
Step
1
of
5
20%
Investor Vesting Information
I wish to invest as
*
Individual(s)
Company
Trust
Self-Directed IRA
Name
*
First
Last
Vesting Name
*
Custodian Name
*
First
Last
Social Security #
*
Birth Date
*
DD slash MM slash YYYY
Company Name
*
Company EIN
*
Trust Name
*
Trust EIN
*
Custodian EIN
*
State of Formation
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Company Information
Trust Information
Custodian Information
Contact Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Is this a joint account?
*
Yes
No
Invest Amount
*
Payment Method
*
ACH (easiest)
Wire
Check
Financial Adviser (optional)
SEC Statements
This information is needed for us to comply with SEC and state securities regulations.
Are you an "accredited" investor (meaning do you earn over $200,000 per year, have a net worth of $1m or more, or are an institutional investor)?
*
Yes
No
I qualify as an accredited investor as follows (Check all that apply)
*
I have an individual net worth, or joint net worth with my spouse, that exceeds $1 million including any IRA's, 401K's and other retirement accounts, but excluding the net value of my primary residence.
I am an individual with income of over $200,000 in each of the last two years, or joint income with my spouse exceeding $300,000 in those years, and I reasonably expect at least the same this year.
The SEC requires that investors in 506(c) offerings be “reasonably” confirmed as to their accredited status. SEC 17 CFR Parts 230, 239 and 242 — Section 3. A, B & C (starting on page 26). There are a number of ways to do this. Please help us get this done by letting us know whichever is easiest for you (check all that apply):
*
Google me and you’ll find enough information about me to see that it’s reasonable to assume I’m an accredited investor.
Look at our website and you’ll see it contains information that will show it’s reasonable to consider us accredited:
Call my accountant, he/she will tell you I’m accredited — Their contact info:
Call my broker/registered investment adviser, he/she will tell you I’m accredited — Their contact info:
Call my lawyer, he/she will tell you I’m accredited — Their contact info:
I’ll send you proof and email or fax my tax returns (most recent 2 years, only gross income page(s) necessary). Send them to info@crowdfundbuilder.com or upload below.
I’ll send you proof and email or upload my bank statement, my securities statement, my IRA or 401K statement(s), my financial statement (prepared by a CPA), or other document(s) showing that my net worth exceeds $1 million (excluding my primary residence, but including any secondary or investment real estate). I will also send you a list of all my liabilities (other than those associated with my primary residence) and hereby certify and attest that I am disclosing all liabilities so you can make a reasonable calculation that my net worth exceeds the Rule 506(c) requirement. I further authorize RealtyXE, LLC and its third-party providers to obtain a credit report to confirm my liabilities as required by SEC rules. Send documents to info@crowdfundbuilder.com or upload below.
Name
*
First
Last
Company
Phone
Email
File
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, doc, docx, ppt, Max. file size: 50 MB, Max. files: 10.
Other notes and things to consider (optional):
Substitute Form W-9 Statement: Under penalty of perjury, by accepting the agreement below I certify that I have provided my correct taxpayer identification number, and
*
I am a US citizen, US resident, or other US person.
I am not a US citizen, US resident, or other US person.
Investor Suitability
Are you retired?
*
Yes
No
Employer
*
Occupation
*
Date of Retirement
*
Prior Occupation
*
Annual Household Income — last year
*
Annual Household Income — est. current year
*
Annual Average Living Expenses
*
Net Worth
*
Liquidity (cash, assets easily convertible into cash and marketable securities, minus current expenses due and payable):
*
Do you have any planned, large expenses in the future (greater than 50% of your average annual income)?
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Yes
No
Have you ever invested in real estate (excluding your principal residence)?
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Yes
No
Have you ever borrowed money or used margin to take advantage of an investment opportunity?estate (excluding your principal residence)?
*
Yes
No
Commercial Real Estate
*
Extensive
Moderate
None
Investor Qualifications
I am an accredited Investor
*
Yes
No
Check all that describe the investor's status (select at least one)
*
Income Great than $200,000 or $300,000
New Worth Greater than $1,000,000
Financial Resources
Is the financial information below joint?
*
Yes
No
Individual's Total Assets
*
< $1,000,000
$1,000,000 - $2,999,999
$3,000,000 - $4,999,999
$5,000,000 - $9,999,999
$10,000,000 - $24,999,999
$25,000,000 - $49,999,999
> $50,000,000
Individual's Investment Holdings
*
< $1,000,000
$1,000,000 - $2,999,999
$3,000,000 - $4,999,999
$5,000,000 - $9,999,999
$10,000,000 - $24,999,999
$25,000,000 - $49,999,999
> $50,000,000
Individual's Investment Holding Period (Select all that are applicable)
*
1-3 Years
3-5 Years
5-7 year
Investment Experience
Have you ever invested in real estate (excluding your principal residence)?
*
Yes
No
Have you ever borrowed money or used margin to take advantage of an investment opportunity?
*
Yes
No
Commercial Real Estate
*
Extensive
Moderate
None
Real Estate Development Projects
*
Extensive
Moderate
None
Bridge Loans
*
Extensive
Moderate
None
Risk Tolerance and Investment Objectives
What is your risk tolerance for your investments through SKB? Real estate investments involve substantial risk. Economic and market forces and unforeseen costs may adversely affect the ability of an investor to recoup such investor's initial investment. Funds invested in real estate should not be invested for such purposes as emergency savings, home purchase, education funding, dependent care, safety of principal, or any other short-term purpose.
Risk Tolerance
*
Conservative - I seek real estate investments that have a lower risk of loss of principal and are more likely to preserve principal. Note: If this is your level of risk tolerance, you should not participate in real estate development investments.
Moderate - I seek real estate investments that have a greater potential for appreciation of principal and/or generation of income and I am willing to accept a moderate risk of loss of principal, or invest in a balanced portfolio of conservative, moderate, and aggressive investments.
Aggressive - I seek real estate investments, such as development projects, that have the greatest potential for appreciation of principal and/or generation of income and I am willing to accept a higher degree of risk of loss of principal.
What are your investment goals? (Select all that are applicable
*
Income
Growth & Income
Growth
Aggressive Growth
ACH Form
Name on Account
*
First
Last
Nine Digit Bank Routing Number
Bank Account Number
Account Type
Checking
Savings
Account Type
Checking
Savings
Confirmation of Terms
*
By submitting this form, the undersigned acknowledges they have read and understood the
Privacy Policy, Terms of Use and Terms of Service
and agree to be bound thereby.
Check Type
Personal
Business
IMPORTANT: Please read before completing, signing and submitting. Direct Payment via ACH is a transfer of funds from (or to) a bank account for the purposes of making a payment. I (we) hereby authorize Crowdfund Builder, LLC (“Crowdfund Builder”), to electronically initiate credit and debit entries to my (our) account at the financial institution listed below (hereinafter “Bank”), and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority authorizes Crowdfund Builder to credit my (our) account to correct errors and with payments, refunds, reimbursements, and other funds, and to debit my (our) account for exact amount of investments I make, and will remain in effect until such time that Crowdfund Builder is notified by me (us) in writing to cancel it, with such notice provided at least 3 business days in advance, delivered via overnight courier to Crowdfund Builder, LLC, attention Financial Operations Principal, at 7315 Wisconsin Ave. Suite 400, Bethesda, MD 20814. I agree that the ACH transactions I (we) authorize comply with all applicable law.
ACH Authorization Signature
Please type your name here to sign ACH Authorization.
Offering Agreement
I certify that
*
I am the investor and the authorized signer.
Offering Agreement Signature
*
Please type your name here to sign this agreement.
Comments
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