GLDUS127 Annandale Capital
Eachprospective Investor is required to complete either the column titled "ForIndividuals" or the column
titled "For Entities -. as applicable.
I am investing as an: ❑ Individual ❑ Entity
I am an IndiN aka! m Entity that is a U.S. Person': ❑ Yes ❑ No
FOR INDIVIDUALS: FOR ENTITIES:
Type of Individual: Type of Entity:
State/Province and Country of Residence of Jurisdiction of Organization:
Investor for Tax Purposes:
Domicile:
Social Security No. or Tax Identification Tax Identification No.:
No:
Permanent Address: Permanent Address:
Mailing Address (if different from above): Mailing Address (if different from above):
Date of Birth: Date of Formation:
Telephone No: Telephone No:
Email Address: Email Address:
6 For definition of "U.S. Person'. please see Rule 902(k) of Regulation S under the Securities Act
PROPRIETARY AND CONF7DEN77AL
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CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0040282
CONFIDENTIAL SDNY GM_00188488
EFTA01355269