Jacobs Asset Management - Investors in Financial Services

OVERVIEW

JAM SPECIAL
OPPORTUNITIES FUNDS

ACCREDITED INVESTOR QUESTIONNAIRE

Information regarding any fund managed by Jacobs Asset Management, LLC (“JAM”) is only available to individuals and entities qualifying as Accredited Investors within the meaning of Rule 501(a) of Regulation D of the Securities Act of 1933.

All potential investors must provide the following information prior to receiving material regarding the funds:

Full Name:
Entity Name: (if applicable)
Your Position: (if applicable)
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-mail Address:
Password:
Are you an accredited investor?:	Yes No

If Yes, please complete the answer the question below.

The undersigned represents and warrants that the undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D of the Securities Act of 1933, because the undersigned meets at least one of the following criteria (please check one):

FOR INDIVIDUALS: The undersigned is
		a natural person whose individual net worth, or joint net worth with his or her spouse, exceeds $1,000,000, excluding the value of the primary residence of such natural person; or
		a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with the undersigned’s spouse in excess of $300,000 in each of those years and who reasonably expects to reach the same income level in the current year
FOR ENTITIES: The undersigned is
		any entity in which all of the equity owners are accredited investors.
		a corporation, partnership, business trust or an organization described in Section 501(c)(3) of the Internal Revenue Code, with total assets in excess of $5,000,000 that was not formed for the specific purpose of investing in funds managed by JAM
		a bank as defined in Section 3(a)(2) of the Securities Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act whether acting in its individual or fiduciary capacity, any broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934
		an insurance company as defined in Section 2(13) of the Securities Act
		an investment company registered under the Investment Company Act of 1940 or a business development company as defined in Section 2(a)(48) of such Act
		a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958
		an employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974, if the investment decision is made by a plan fiduciary, as defined in Section 3(21) of such Act, which plan fiduciary is either a bank, savings and loan association, insurance company or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons who are accredited investors
		The undersigned is a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940; or
		The undersigned is a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of in funds managed by JAM, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D of the Securities Act

The undersigned agrees to promptly notify JAM of any changes to their status as an “Accredited Investor”.

NAME
TITLE (if signing on behalf of an Entity)
ENTITY (if signing on behalf of an Entity)
DATE

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