Onboarding Data Gathering Form

The following form helps us prepare your subscription documents.

The more complete and accurate the information you provide, the smoother and more efficient the onboarding process should be for the Zynergy Digital Innovation Fund (ZDIF) and any other investment opportunities we may offer.

Important Note: Some fields may be pre-selected with the most common response. Please review and confirm that each selection is accurate before submitting.

Please don’t hesitate to contact us with any questions, or if you would prefer to walk through this together.

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Basic Contact & Subscription Information

Your Legal Name

First

Middle

Last

Preferred Email Address

The email address you would like for all communication about your account.

Preferred Cell Phone

What investment are you subscribing to?

What type of account would you like to setup?

Are you a resident of the United States?

o or omission

Your Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

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ERISA Related Status

A. The Subscriber represents that the Subscriber is, or is investing on behalf of (please select one (and only one) category):

1. A plan or trust (an “ERISA Plan”) within the meaning of, and subject to the provisions of, the U.S. Employee Retirement Income Security Act of 1974, as amended (“ERISA”);
2. A plan subject to Section 4975 of the U.S. Internal Revenue Code of 1986, as amended (the “Code”), including a Keogh plan or an individual retirement account (an “IRA”) which is not subject to ERISA;
3. An insurance company’s general account assets or the assets of an insurance company’s separate account or bank common or collective trust that has investors described in one or more of Items 1 and 2 of this Paragraph A. Such investors include (please select all that apply and indicate the applicable percentage owned by such investors):
4. An entity in which 25% or more of any class of its equity interests is held in the aggregate by one or more of the below, excluding from the 25% computation non-benefit plan interests of any individual or entity (and affiliates thereof) with discretionary authority or control over the Subscriber’s assets (please select all that apply and indicate applicable percentage owned by such investors):
5. A U.S. person or entity that (i) is exempt from U.S. federal income taxation (other than unrelated business taxable income) such as a private foundation, public charity or school endowment, a government plan or trust not subject to ERISA, or a “pass-through” entity whose investors are all U.S. tax-exempt and (ii) is not described in Items 1 through 4 of this Paragraph A; or
None of the above

C. The Subscriber represents (please select one of the following Investment Company Act Representations):

Representations Pertaining to Non-Participant-Directed Plans (please select if both Representations Pertaining to Non-Participant-Directed Plans listed below are true):

1. Plan participants are not permitted to decide whether or how much to invest in particular investment alternatives.

2. The decision to invest the assets of the plan in the Fund was made by the plan trustee or other fiduciary that makes investment decisions for the plan.
Representations Pertaining to Participant-Directed Plans (please select if all five Representations Pertaining to Participant-Directed Plans listed below are true):

1. The decision to invest the assets of the plan in the Fund and the amount and timing of such investment was, and any withdrawals of capital from the Fund will be, made solely by plan fiduciaries without direction from or consultation with any plan participant, other than plan trustees acting in their capacity as fiduciaries.

2. Other than plan trustees acting in their capacity as plan fiduciaries, a plan participant’s investment discretion, if any, is limited to allocating his account among a number of investment options, each of which has only an identified generic investment objective.

3. No representation is made to plan participants that any specific portion of their contributions to or account balances under the plan, or any specific portion of the relevant investment option, will be invested in a fund relying on the exclusion from the definition of an investment company pursuant to Section 3(c)(1) or Section 3(c)(7) of the 13 U.S. Investment Company Act of 1940, as amended (the “1940 Act”).

4. Immediately following the plan’s investment in the Fund, at least 50% of the relevant investment option under the plan will consist of securities or property other than securities issued by any private investment fund not registered under the 1940 Act in reliance on the exemptions contained in Section 3(c)(1) or Section 3(c)(7) thereof.

5. If the plan delivers information to plan participants that mentions an investment in the Fund, it is and will continue to be accompanied by a disclaimer to the effect that no assurances can be given that the investment option will continue to invest its assets, or the same portion of its assets, in the Fund.

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Onboarding Data Gathering Form

Basic Contact & Subscription Information

Basic Subscription Information

ERISA Related Status

Accredited & Qualified Investor Status

Accredited Investor Status

Qualified Client Status

Investment Company Status

Allocations of New Issues

Bad Actor Representation

Anti-Money Laundering Representation