Form of Subscription Agreement
Exhibit 4.2
SUBSCRIPTION BOOKLET
FOR
SHARES OF COMMON STOCK
IN
JEFFERIES CREDIT PARTNERS BDC INC.
(a Maryland Corporation)
CAREFULLY REVIEW AND FOLLOW THE SUBSCRIBER’S INSTRUCTION SHEET IMMEDIATELY FOLLOWING THIS COVER PAGE
NOTE TO INVESTORS:
Please note that Jefferies Credit Partners BDC Inc. reserves the right to obtain, and that you will be required to provide, additional information and documentation if you are not a U.S. person (as defined below) and, accordingly, do not provide a U.S. Internal Revenue Service (“IRS”) Form W-9. Please contact Investor Relations at ***@*** for additional information in this regard.
INSTRUCTIONS TO SUBSCRIBERS
These instructions are provided to assist you with completing the attached Subscription Agreement (the “Agreement” or the “Subscription Agreement”). The Subscription Agreement is complicated, so we encourage you to go one step at a time with these instructions as your guide.
IF YOU HAVE ANY QUESTIONS OR NEED ASSISTANCE IN COMPLETING YOUR SUBSCRIPTION, PLEASE CONTACT THE FOLLOWING VIA EMAIL:
Attention: Investor Relations
Email: ***@***
with a copy to
Paul Hastings LLP
200 Park Avenue
New York, NY 10166
Email: ***@***
A. SUBSCRIPTION AGREEMENT
To subscribe, please follow these steps:
1 As set forth in the instructions to IRS Form W-9, a “U.S. person” for IRS purposes generally includes (i) a citizen or resident of the United States, (ii) a partnership, corporation or other entity created or organized under the laws of the United States or any State thereof, and (iii) an estate the income of which is subject to U.S. federal income tax regardless of its source, or any trust if a court within the United States is able to exercise primary supervision over the administration of the trust and one or more U.S. persons have the authority to control all of the substantial decisions of the trust.
THE SUBSCRIPTION AGREEMENT AND ATTACHMENTS, WHERE APPLICABLE, SHOULD BE DELIVERED VIA EMAIL TO
Jefferies Credit Partners BDC Inc.
c/o Jefferies Credit Management LLC
520 Madison Avenue, 12th Floor
New York, NY 10022
Attention: Investor Relations
Email: ***@***
with a copy to
Paul Hastings LLP
200 Park Avenue
New York, NY 10166
Email: ***@***
B. PURCHASE PAYMENT
The BDC Share Purchase Obligation required to be paid under the Subscription Agreement must be paid by wire transfer in same day funds in accordance with the terms thereof and the account instructions set forth below.
Bank: The Bank of New York Mellon
Bank Address: 500 Ross St.
Pittsburgh, PA 15262
ABA Number: 021 000 018
SWIFT: IRVTUS3NXXX
Account Name: JCP BDC Custody
Account Number: 6016718400
Reference: JCP BDC Subscription
END OF INSTRUCTIONS
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JEFFERIES CREDIT PARTNERS BDC INC.
(a Maryland Corporation)
SUBSCRIPTION AGREEMENT
THE BDC SHARES REFERRED TO IN THIS SUBSCRIPTION AGREEMENT HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), NOR UNDER ANY APPLICABLE STATE SECURITIES LAWS. SUCH BDC SHARES ARE BEING OFFERED AND SOLD UNDER THE EXEMPTION PROVIDED BY SECTION 4(A)(2) OF THE SECURITIES ACT AND/OR PURSUANT TO REGULATION D, RULE 506, THEREUNDER. NEITHER THE U.S. SECURITIES AND EXCHANGE COMMISSION NOR ANY STATE SECURITIES COMMISSION HAS PASSED ON ANY ASPECT OF THE OFFERING OF SUCH BDC SHARES AND ANY REPRESENTATION TO THE CONTRARY IS ILLEGAL.
A PURCHASER OF BDC SHARES SHOULD BE PREPARED TO BEAR THE ECONOMIC RISK OF THE INVESTMENT FOR AN INDEFINITE PERIOD OF TIME BECAUSE THE BDC SHARES HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT AND, THEREFORE, CANNOT BE SOLD UNLESS THEY ARE SUBSEQUENTLY REGISTERED OR AN EXEMPTION FROM REGISTRATION IS AVAILABLE. THERE IS NO OBLIGATION OF THE ISSUER TO REGISTER THE BDC SHARES UNDER THE SECURITIES ACT OR UNDER ANY APPLICABLE STATE SECURITIES LAWS.
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JEFFERIES CREDIT PARTNERS BDC INC.
SUBSCRIPTION AGREEMENT
TO: Jefferies Credit Partners BDC Inc.
c/o Jefferies Credit Management LLC
520 Madison Avenue, 12th Floor
New York, NY 10022
Ladies and Gentlemen:
THIS SUBSCRIPTION AGREEMENT (together with all attachments hereto, the “Subscription” or the “Subscription Agreement”) is entered into by Jefferies Credit Partners BDC Inc., a Maryland corporation ( the “BDC”) and the undersigned (the “Purchaser”) in connection with the Purchaser’s agreement to purchase shares of common stock, par value $0.001 per share, of the BDC (the “BDC Shares”).
The BDC is to be operated in accordance with its Articles of Amendment and Restatement, Amended and Restated Bylaws, registration statement on Form 10 (the “BDC Form 10”), the companion Confidential Private Placement Memorandum (the “BDC PPM”), and the Investment Advisory Agreement (the “BDC IAA”) by and between the BDC and Jefferies Credit Management, LLC (the “Adviser”) (collectively, the “BDC Governing Documents”).
If the Purchaser’s Subscription is accepted by the BDC, the Purchaser will become a stockholder of the BDC.
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The Purchaser hereby represents and warrants to the BDC and the Adviser as follows:
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2 A “Related Person” is, with respect to any entity, an interest holder, director, senior officer, trustee, beneficiary or grantor of such entity; provided that, in the case of an entity that is a Publicly Traded Company or a Qualified Plan, the term “Related Person” shall exclude any interest holder holding less than 5% of any class of securities of such Publicly Traded Company and beneficiaries of such Qualified Plan. “Publicly Traded Company” means an entity whose securities are listed on a recognized securities exchange or quoted on an automated quotation system in the U.S. or country other than a Non-Cooperative Jurisdiction or a wholly-owned subsidiary of such an entity. “Qualified Plan” means a tax qualified pension or retirement plan in which at least 100 employees participate that is maintained by an employer that is organized in the U.S. or is a U.S. government entity.”
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3 A “Foreign Shell Bank” is a Foreign Bank without a Physical Presence in any country; does not include a Regulated Affiliate. A “Foreign Bank” is an organization that does not have a Physical Presence in any country and (a) is organized under the laws of a country outside the United States; (b) engages in the business of banking; (c) is recognized as a bank by the bank supervisory or monetary authority of the country of its organization or principal banking operations; (d) receives deposits to a substantial extent in the regular course of its business; and (e) has the power to accept demand deposits, but does not include the U.S. branches or agencies of a foreign bank. “Physical Presence” means a place of business that is maintained by a Foreign Bank and is located at a fixed address, other than solely a post office box or an electronic address, in a country in which the Foreign Bank is authorized to conduct banking activities, at which location the Foreign Bank: (a) employs one or more individuals on a full-time basis, (b) maintains operating records related to its banking activities and (c) is subject to inspection by the banking authority that licensed the Foreign Bank to conduct banking activities. “Regulated Affiliate” means a Foreign Shell Bank that: (a) is an affiliate of a depository institution, credit union, or Foreign Bank that maintains a Physical Presence in the U.S. or a foreign country, as applicable; and (b) is subject to supervision by a banking authority in the country regulating such affiliated depository institution, credit union, or Foreign Bank.
4 A “Non-Cooperative Jurisdiction” is any foreign country or territory that has been designated as non-cooperative with international anti-money laundering principles or procedures by an intergovernmental group or organization, such as the Financial Action Task Force (“FATF”), of which the United States is a member and with which designation the United States representative to the group or organization continues to concur. For FATF’s list of non-cooperative countries and territories, see http://www.fatf-gafi.org/topics/high-riskandnon-cooperativejurisdictions/.
5 A “Senior Foreign Political Figure” is a current or former senior official in the executive, legislative, administrative, military or judicial branches of a non-U.S. government (whether elected or not), a senior official of a major non-U.S. political party, a senior executive of a non-U.S. government-owned corporation or other persons entrusted with prominent public functions. In addition, a Senior Foreign Political Figure includes any corporation, business or other entity that has been formed by, or for the benefit of, a Senior Foreign Political Figure.
6 With respect to a Senior Foreign Political Figure, “Immediate Family” typically includes the political figure’s parents, siblings, spouse, children and in-laws.
7 “Close Associate” means, with respect to a Senior Foreign Political Figure, a person who is widely and publicly known internationally to maintain an unusually close relationship with the Senior Foreign Political Figure; includes a person who is in a position to conduct substantial domestic and international financial transactions on behalf of the Senior Foreign Political Figure.
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The foregoing representations and warranties and all information in this Subscription Agreement (including, without limitation, all attachments hereto) are true, correct, complete and accurate as of the date hereof and shall be true, correct, complete and accurate as of the Purchase Date. If any portion of any such representations and warranties or any other information in this Subscription Agreement (including, without limitation, all attachments hereto) shall not be true and accurate prior to the Purchase Date (or, in the case of any tax representations and warranties or tax information, at any time), the Purchaser shall give immediate notice of such fact to the Adviser by email, specifying which representations and warranties or information or portions thereof are not true and accurate and the reasons therefor; provided, however, that under no
8 The Treasury Department’s Financial Crimes Enforcement Network (“FinCEN”) issues advisories regarding countries of primary money laundering concern. FinCEN’s advisories are posted at http://www.fincen.gov/pub_main.html.
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circumstances whatsoever shall any such notice diminish or disparage in any way or to any degree whatsoever or result in the waiver of any rights the Adviser or the BDC may have by virtue of the circumstances causing delivery of such notice.
The BDC hereby represents, warrants and covenants to the Purchaser as follows:
The Purchaser acknowledges that it understands the meaning and legal consequences of the representations and warranties made by the Purchaser herein, and agrees to indemnify and hold harmless the BDC, its affiliates and the Adviser and its partners and each officer, director, employee and agent of the Adviser or its general partner and any affiliates of the Adviser from and against any and all loss, damage, liability, cost or expense (including without limitation reasonable attorneys’ and accountants’ fees) which the BDC or any of them may incur
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by reason of or in connection with any misrepresentation made by the Purchaser or any breach of any representation or warranty of the Purchaser contained in this Subscription Agreement, or any failure by the Purchaser to fulfill any of its covenants or agreements under this Subscription Agreement.
Except as otherwise set forth in the BDC Governing Documents, each of the Purchaser and the BDC agrees not to transfer or assign this Subscription Agreement, or any interest herein , and further agrees that the assignment and transferability of the BDC Shares acquired pursuant hereto shall be made only in accordance with this Subscription Agreement and the BDC Governing Documents.
This Subscription Agreement will terminate upon agreement in writing of each of the parties hereto to terminate this Subscription Agreement.
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The BDC, the Adviser and each of their respective affiliates are committed to complying with legal requirements designed to combat money laundering and terrorist financing. Each of the foregoing consults the list of Specially Designated Nationals and Blocker Persons compiled by the U.S. Department of Treasury’s Office of Foreign Assets Control (OFAC) to verify that no prospective client’s name appears on the list.
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You will not receive paper copies of these electronic materials unless specifically requested, the delivery of electronic materials is prohibited or the BDC, in its sole discretion, elects to send paper copies of the materials.
By consenting to electronic access, you (i) will be responsible for your customary internet service provider charges and may be required to download software in connection with access to these materials and (ii) confirm that you have access to email and agree to notify the BDC or Computershare if you no longer have access. To unsubscribe or revoke your consent for electronic delivery in the future, to make changes to some or all of your delivery preferences, or to request a paper copy of the aforementioned documents at no cost, please contact the BDC or Computershare.
NO ACTION IS REQUIRED FOR ELECTRONIC DELIVERY.
Check here if you do NOT consent to electronic delivery
_______________________________________________
Email (If blank, the email provided in Item 14 of Attachment I will be used)
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IN WITNESS WHEREOF, the undersigned has executed this Subscription Agreement this ____________ day of _____________________, 20___.
_________________________________ (Signature of Subscriber)
| _________________________________ (Signature of Subscriber)
|
_________________________________ (Printed Name of Subscriber)
| _________________________________ (Printed Name of Subscriber)
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_________________________________ (Signature of Subscriber) | _________________________________ (Signature of Subscriber)
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_________________________________ (Printed Name of Subscriber)
| _________________________________ (Printed Name of Subscriber)
|
Account Name: ________________________________________________________________
If the Purchaser is an individual retirement account, Keogh Plan or other self-directed plan, the custodian or trustee of the Purchaser must also execute this Subscription Agreement below:
_________________________________ (Signature of Custodian or Trustee)
_________________________________ (SSN/EIN/ITIN of Custodian or Trustee)
| _________________________________ (Date)
|
_________________________________ (Printed Name of Custodian or Trustee)
|
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ACCEPTED:
JEFFERIES CREDIT PARTNERS BDC INC.
BY: ___________________________________
Name:
Title:
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BROKER/FINANCIAL ADVISOR INFORMATION
The broker (“Broker”) or financial advisor (“Financial Advisor”) of the Purchaser must sign below to complete the order. The Financial Advisor hereby warrants that he/she they are duly licensed and may lawfully sell shares in the state designated as the investor’s legal residence.
_________________________________ (Broker) | _________________________________ (Financial Advisor Name) |
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_________________________________ (Financial Advisor Mailing Address) | _________________________________ (City/State/Zip Code) |
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_________________________________ (Financial Advisor Number) | _________________________________ (Branch Number) |
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_________________________________ (Telephone Number)
| _________________________________ (Email Address) |
_________________________________ (Operations Contact Name) | _________________________________ (Operations Contact Email Address) |
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_________________________________ (Financial Institution)
| _________________________________ (Financial Institution CRD Number)
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Please note that unless previously agreed to in writing by the BDC, all sales of securities must be made through a broker, including when a registered investment adviser has introduced the sale. In all cases, this Broker/Financial Advisor Information form must be completed.
The undersigned Broker/Financial Advisor confirm(s), which confirmation is made on behalf of the Broker with respect to sales of securities made through the Broker, that they (i) have reasonable grounds to believe that the information and representations concerning the investor identified herein are true, correct and complete in all respects; (ii) have discussed such investor’s prospective purchase of shares with such investor; (iii) have advised such investor of all pertinent facts with regard to the lack of liquidity and marketability of the shares; (iv) have delivered or made available a current prospectus and related supplements, if any, to such investor; (v) have reasonable grounds to believe that the investor is purchasing these shares for his or her own account; (vi) have reasonable grounds to believe that the purchase of shares is a suitable investment for such investor, that such investor meets the suitability standards applicable to such investor set forth in the prospectus and related supplements, if any, and that such investor is in a financial position to enable such investor to realize the benefits of such an investment and to suffer any loss that may occur with respect thereto; and (vii) have advised such investor that the shares have not been registered and are not expected to be registered under the laws of any country or jurisdiction outside of the United States except as otherwise described in the prospectus. The undersigned Broker or Financial Advisor listed herein further represents and certifies that, in connection with this subscription for shares, they have complied with and has followed all applicable policies and
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procedures of his or her firm relating to, and performed functions required by, federal and state securities laws, rules promulgated under the Securities Exchange Act of 1934, as amended, including, but not limited to Rule 151-1 (“Regulation Best Interest”) and FINRA rules and regulations including, but not limited to Know Your Customer, Suitability and PATRIOT Act (Anti Money Laundering, Customer Identification) as required by its relationship with the investor(s) identified on this document.
If you want to receive financial advice regarding a prospective investment in the shares, contact your broker-dealer or other financial intermediary.
_________________________________ (Signature of Financial Advisor) | _________________________________ (Date)
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_________________________________ (Printed Name of Financial Advisor)
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_________________________________ (Branch Manager Signature) (If required by Broker) | _________________________________ (Date)
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_________________________________ (Printed Name of Branch Manager)
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ATTACHMENT I
Account Information
________________________________________________________________________
________________________________________________________________________
Individual Benefit Plan Investor (check one)
Joint Tenancy/ Tenancy in Common ERISA Title I Plan
LLC (Taxed as Corporation) IRA / KEOGH Section 4975 Plan
LLC (Taxed as Partnership) Custodian Name: ______________
LLC (Single Member) Account Number: ______________
Beneficial Owner Name: __________ Plan Assets Entity - ERISA 3(42)
Beneficial Owner Tax ID: _________ Estate
LLP Corporation
Limited Partnership S-Corporation
Charitable Trust Governmental Benefit Plan
Grantor Trust
Trust (Other: ____________ )
Exempt Organization
YES NO
The Purchaser should complete all questions below with reference to the beneficial owner for whom the Purchaser is subscribing. You must answer questions 4(b) through 4(e) below regardless of your answer to 4(a).
I-1
YES NO
YES NO
YES NO
YES NO
Note: If any of the above questions under this Question 4 were answered “Yes,” please provide identifying information or contact the Adviser.
___________________________________________________________
5. Accredited Investor. The Purchaser hereby represents and warrants to the Adviser and the BDC that the Purchaser is an Accredited Investor within the meaning of Regulation D, and is included within the Accredited Investor category or categories checked below:
(1) Any bank as defined in section 3(a)(2) of the Act, or any savings and loan association or other institution as defined in section 3(a)(5)(A) of the Act whether acting in its individual or fiduciary capacity; any broker or dealer registered pursuant to section 15 of the 1934 Act; any investment adviser registered pursuant to section 203 of the Investment Advisers Act of 1940 or registered pursuant to the laws of a state; any investment adviser relying on the exemption from registering with the Commission under section 203(l) or (m) of the Investment Advisers Act of 1940; any insurance company as defined in section 2(a)(13) of the Act; any investment company registered under the Investment Company Act of 1940 or a business development company as defined in section 2(a)(48) of that act; any 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; any Rural Business Investment Company as defined in section 384A of the Consolidated Farm and Rural Development Act; any plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of
9 “Affiliated Investor” means any investor who would be deemed to be a Controlling Person with respect to the Units held by the Purchaser or who would have an indirect Controlling Person in common. A “Controlling Person” with respect to a security includes any person who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, has or shares, or is deemed to have or share, (i) voting power, which includes the power to vote, or to direct the voting of, such security; and/or (ii) investment power which includes the power to dispose, or to direct the disposition of, such security and any person that has the right to become a Controlling Person as described in (i) or (ii) within 60 days, including through the exercise of an option, the termination of a contract or otherwise.
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$5,000,000; any employee benefit plan within the meaning 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 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 that are accredited investors.
(2) Any private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended (the “Advisers Act”).
(3) Any organization described in Section 501(c)(3) of the U.S. Internal Revenue Code of 1986, as amended (the “Code”), as a corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000.
(4) Any director, executive officer, or general partner of the issuer of the securities being offered or sold, or any director, executive officer, or general partner of a general partner of that issuer.
(5) Any natural person whose individual net worth, or joint net worth with that person’s spouse, at the time of his purchase exceeds $1,000,000 (not including such person’s primary residence nor indebtedness thereon, except to the extent such indebtedness exceeds the value of the residence).
(6) Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person’s spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
(7) Any trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose Purchase is directed by a person who has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of an investment in the BDC.
(8) Any entity in which all of the equity owners are accredited investors.
(9) Any entity, of a type not listed in paragraphs (a)(1), (a)(2), (a)(3), (a)(7), or (a)(8), not formed for the specific purpose of acquiring the securities offered, owning investments in excess of $5,000,000.
(10) Any natural person holding in good standing one or more professional certifications or designations or credentials from an accredited educational institution that the Commission has designated as qualifying an individual for accredited investor status. In determining whether to designate a professional certification or designation or credential from an accredited educational institution for purposes of this paragraph (a)(10), the Commission will consider, among others, the following attributes:
(i) The certification, designation, or credential arises out of an examination or
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series of examinations administered by a self-regulatory organization or other industry body or is issued by an accredited educational institution;
(ii) The examination or series of examinations is designed to reliably and validly demonstrate an individual’s comprehension and sophistication in the areas of securities and investing;
(iii) Persons obtaining such certification, designation, or credential can reasonably be expected to have sufficient knowledge and experience in financial and business matters to evaluate the merits and risks of a prospective investment; and
(iv) An indication that an individual holds the certification or designation is either made publicly available by the relevant self-regulatory organization or other industry body or is otherwise independently verifiable.
(11) Any natural person who is a “knowledgeable employee,” as defined in rule 3c-5(a)(4) under the Investment Company Act of 1940, of the issuer of the securities being offered or sold where the issuer would be an investment company, as defined in section 3 of such act, but for the exclusion provided by either section 3(c)(1) or section 3(c)(7) of such act.
(12) Any “family office,” as defined in rule 202(a)(11)(G)-1 under the Investment Advisers Act of 1940:
(i) With assets under management in excess of $5,000,000;
(ii) That is not formed for the specific purpose of acquiring the securities offered; and
(iii) Whose prospective investment is directed by a person who has such knowledge and experience in financial and business matters that such family office is capable of evaluating the merits and risks of the prospective investment.
(13) Any “family client,” as defined in rule 202(a)(11)(G)-1 under the Investment Advisers Act of 1940, of a family office meeting the requirements in paragraph (a)(12) of this section and whose prospective investment in the issuer is directed by such family office pursuant to paragraph (a)(12)(iii).
6. Entities.
(a) If the Purchaser is an entity, the Purchaser hereby represents and warrants as follows (check the appropriate response to each of the following statements):
True / False | The Purchaser is excepted from the definition of “investment company” by virtue of either Section 3(c)(1) or Section 3(c)(7) of the Investment Company Act. |
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True / False | The Purchaser has made investments prior to the date hereof or intends to make investments in the near future and each beneficial owner of interests in the Purchaser has and will share in the same proportion to each such investment. |
True / False | The Purchaser’s investment in the BDC will not constitute more than 40% of the value of the assets of the Purchaser (exclusive of government securities and cash items) on an unconsolidated basis. |
True / False | The governing documents of the Purchaser require that each of its beneficial owners participates in all of its investments and that the profits and losses from such investments are shared among such beneficial owners in the same proportions as all other investments of the Purchaser. |
True / False | Shareholders, partners or other holders of equity or beneficial interests in the Purchaser have been provided the opportunity to decide individually whether or not to participate, or the extent of their participation, in the Purchaser’s investment in the BDC. |
(b) Jurisdiction of Organization (Country):
(c) Year of Organization:
(d) Principal place of business (City, State):
7. Government Entities. Is the Purchaser a government entity or an officer, agent or employee thereof acting in his or her official capacity?
YES NO
Note: For the purposes of this question only, government entities include all state and local governments, their agencies and instrumentalities, and any investment programs, defined benefit plans as defined in Section 414(j) of the Code, state general funds, pools of assets or plans sponsored or established by state and local governments, including all public pension plans and any participant-directed plan or program of a government entity, such as ‘‘qualified tuition plans’’ authorized by Section 529 of the Code and retirement plans authorized by Section 403(b) or 457 of the Code.
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8. Regulated Institutions.
(a) Is the Purchaser a regulated institution that is subject to legal or regulatory restrictions or limitations on the nature of its investments (such as a bank or insurance company)?
YES NO
(b) If the answer is “Yes,” has the Purchaser verified that the proposed subscription is in compliance with applicable laws and regulations?
YES NO
(c) Is the Purchaser an insured depositary institution, as defined in the Federal Deposit Insurance Act or a company that controls directly or indirectly an insured depositary institution?
YES NO
(d) Is the Purchaser treated as a bank holding company for the purposes of Section 8 of the International Banking Act of 1978?
YES NO
(e) Is the Purchaser a direct or indirect subsidiary or affiliate of an entity described in (c) or (d) above?
YES NO
9. Category of Purchaser (check one box that best describes the beneficial owner(s) for whose account an Interest is being acquired):
Individual that is a US Person10 (or a trust of such person)
Individual that is not a US Person (or a trust of such person)
Broker-dealer
Non-profit
Private Fund11
Banking or Thrift Institution (Proprietary)
Insurance Company
Investment Company Registered with the SEC
Non-governmental Pension Plan
ERISA Title I Plan
IRA / KEOGH Section 4975 Plan
Plan Assets Entity - ERISA 3(42)
10 A “US Person” for purposes of this question 10 only has the meaning in Rule 203(m)-1 under the Investment Advisers Act of 1940, as amended, and includes any natural person that is resident in the United States of America (including its territories or possessions).
11 A “private fund” means an issuer that would be an “investment company” (as defined by Section 3 of the Investment Company Act of 1940, as amended) but for Section 3(c)(1) or 3(c)(7) thereof.
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State or Municipal Government Entities (Excluding Governmental Pension Plans)12
10. Tax Status.
(a) U.S. Taxpayer Identification Number
SSN/EIN/ITIN: __________________
Please state your state of residence for tax purposes:
__________________
Indicate the annual date on which your taxable year ends for U.S. federal income tax reporting or information return filing purposes:
__________________
To the extent the Purchaser is an individual, are you a United States citizen or otherwise a tax resident of the United States?
YES NO N/A
If you are subscribing jointly with another person (e.g., joint tenancy, tenancy in common, or purchase jointly with spouse), is such other person a United States citizen or otherwise a tax resident of the United States?
YES NO N/A
(b) Other Tax Information
(1) Please indicate whether, for U.S. federal income tax purposes, you file now or have ever filed a tax or information return, as a “partnership” (including a limited liability company treated as such), as a “grantor” trust or as an “S corporation” under Sections 1361 1379 of the Code?
YES NO N/A
If “Yes,” please indicate:
(i) whether more than 50 percent of the value of the ownership interest of any of your beneficial owners is (or may at any time during the term of the
12 “Government entity” means any state or political subdivision of a state, including (i) any agency, authority, or instrumentality of the state or political subdivision; (ii) a plan or pool of assets controlled by the state or political subdivision or any agency, authority, or instrumentality thereof; and (iii) any officer, agent, or employee of the state or political subdivision or any agency, authority, or instrumentality thereof, acting in their official capacity.
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BDC be) attributable to your (direct or indirect) interest in the BDC?
YES NO
(2) To the extent the Purchaser is an entity, does the entity have, or is it deemed to have, only a single owner for U.S. federal income tax purposes?
YES NO N/A
If “Yes,” has the Purchaser elected to become, or is it deemed to be, an entity that is disregarded from its owner for U.S. federal income tax purposes?
YES NO N/A
(3) Is the Purchaser exempt from U.S. federal income tax (e.g., a qualified employee benefit plan or trust, retirement account, charitable remainder trust, or a charitable foundation or other tax-exempt organization described in Section 501(c)(3) of the Code)?
YES NO
(c) ERISA Information
(1) Please indicate whether or not the subscriber is (i) a Plan, (ii) a Plan Asset Entity, or (iii) an entity that otherwise constitutes a “benefit plan investor” within the meaning of any Department of Labor regulation promulgated under Section 3(42) of ERISA.
YES NO
If no, please skip the following and go to Question 11 – FOIA or Similar Law.
(2) Is the subscriber a Plan that is both involuntary and non-contributory?
YES NO
(3) Have beneficiaries of the Plan been provided the opportunity to decide individually whether or not to participate, or the extent of their participation, in the Plan’s investment in the BDC (i.e., have beneficiaries of the Plan been permitted to determine whether their capital will form part of the specific capital invested by the Plan in the BDC)?
YES NO
(4) Is the subscriber either (i) an insurance company general account the underlying assets of which include “plan assets” for purposes of ERISA or (ii) a Plan Asset Entity?
YES NO
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If “Yes”, the maximum percentage of the Purchaser constituting “plan assets” will be _____%.
(Note that the subscriber has an obligation under the Subscription Agreement to promptly notify the BDC if this percentage is exceeded in any calendar month.)
11. FOIA or Similar Law. Is the Purchaser subject to the Freedom of Information Act (5 U.S.C. Section 552), or any similar open public records laws of any state, municipality or foreign government that could result in the disclosure of confidential information relating to the Adviser, the BDC or any of its investments?
YES NO
If the answer is “Yes,” please provide a citation to the relevant law.
12. Source of Funds. Please identify the source of funds to be invested:
Business Income Gift
Employment Inherited
Investments Other Investors
Other: ________________________________________________
13. Line of Business. Provide a brief description of your occupation or line of business:
____________________________________________________________________
14. Primary Account Owner:
Contact Person: _________________________________________
Mailing Address: _________________________________________
_________________________________________
_________________________________________
Permanent Address (if not different from above, write “N/A”):
_________________________________________
_________________________________________
_________________________________________
Home Telephone: _________________________________________
Work Telephone: _________________________________________
Mobile Telephone: _________________________________________
Email Address: _________________________________________
I-9
If Applicable, _________________________________________
Principal Place of _________________________________________
Business: _________________________________________
Personal (Optional):
Birth Date: _________________________________________
Marital Status: _________________________________________
Children: _________________________________________
The Purchaser acknowledges and agrees that all statements, reports, forms and notices will be sent via electronic delivery, unless Purchaser specifically directs otherwise in writing.
Please note that only the contact provided above as primary account owner will receive shareholder portal access from Computershare. All relevant investment communications will be sent from Computershare to only the primary account contact.
15. Wiring Instructions for Distributions.
Please provide wiring instructions below for distributions from fund investments:
Bank Name: _________________________________________
Bank ABA: _________________________________________
Account Name: _________________________________________
Account Number: _________________________________________
For Further Credit
Account Name: ________________________________________
Account Number: ______________________________________
Reference: _________________________________________
If International wire, continue below
Beneficiary Address: _________________________________________
_________________________________________
_________________________________________
Bank SWIFT: _________________________________________
Beneficiary Bank
Account Number: ______________________________________
Intermediary Bank
Account Number: ______________________________________
Intermediary Bank Name: _____________________________________
Intermediary Bank ABA: ______________________________________
I-10
Intermediary Bank SWIFT: ____________________________________
Additional Info
(i.e., IBAN, BSB, etc.): _________________________________
I-11
ATTACHMENT II
DRIP Enrollment Form
Instructions to Attachment II
Please fill out and sign the DRIP Enrollment Form on the following page, except for the Account Number, which will be provided by the Fund’s transfer agent, Computershare Inc. (“Computershare”), when the BDC Shares are issued. The Account Number should be left blank.
Please ensure inclusion of the completed and signed DRIP Enrollment Form with this Subscription Agreement.
II-1
DRIP Enrollment Form
DIVIDEND REINVESTMENT PLAN
FOR
JEFFERIES CREDIT PARTNERS BDC INC.
ENROLLMENT APPLICATION
| Please enroll this account as allows: Check one box only ☒ If you do not check any box, then NO DISTRIBUTION REINVESTMENT will be assumed ☐ FULL DISTRIBUTION REINVESTMENT Reinvest all distributions for this account. ☐ 50% DISTRIBUTION REINVESTMENT Reinvest distribution on 50% of shares held by me in book form and pay distributions in cash on all remaining shares held by me in book form. ☐ NO DISTRIBUTION REINVESTMENT All distributions will be paid in cash. |
I (We) hereby appoint Computershare Inc.as my (our) Agent under the terms and conditions of the Plan, as described in the prospectus of the Plan which accompanied this form, to receive cash distributions and apply them to the purchase of JEFFERIES CREDIT PARTNERS BDC INC. Common Stock as indicated above.
NO INTEREST WILL BE PAID ON THE FUNDS HELD PENDING INVESTMENT.
Please complete requested information below for the exact account registration.
ACCOUNT’S REGISTRATION (NAME): __________________________________________________
ACCOUNT NUMBER: _____________________________________________________________
ACCOUNT ADDRESS: _____________________________________________________________
SIGNATURE(S): _________________________________________________________________
SIGNATURE(S) __________________________________________________________________
All Joint Owners
Must Sign
ATTACHMENT III
Investor Type | Registration | Document/Information Required |
Individual | Individual Traditional IRA Rollover IRA Roth IRA Roth Conversion SEP IRA | 1. Tax Form (W-9 or W-8) a. Individual's name, address and social security number is used. b. Form is signed by individual. 2. Individual's valid government issued ID (passport, license).* 3. Subscription document is completed and signed by the individual. |
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Individual | JTWRO JTTEN | 1. Tax Form (W-9 or W-8) a. Main taxpayer's name, address and social security number is used. b. Form is signed by main taxpayer. 2. Both individual's valid government issued ID (passport, license).* 3. Subscription document is completed and signed by both individuals. |
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Custodian FBO |
| 1. Custodian Tax Form (W-9 or W-8). a. Custodian's name, address and tax identification number is used. b. Form signed by Custodian, usually accompanied by a Medallion Signature Guarantee. 2. Beneficiary's valid government issued ID (passport, license).* 3. Subscription document is completed and signed by the individual using Custodian's tax identification number. |
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Trust | Revocable Irrevocable Testamentary | 1. Trust Tax Form (W-9 or W-8). a. Trust name, address and tax identification number is used. b. Form is signed by current Trustee. 2. Trustee's and Controlling Party's valid government issued ID (passport, license).* 3. Complete and current Trust Agreement or Trustees Certification. 4. Subscription document is completed and signed by the Trustee. |
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ERISA | Employee Benefit Plan Keough Plan | 1. Custodian Tax Form (W-9 or W-8). a. Custodian's name, address and tax identification number is used. b. Form is signed by an authorized signer. 2. Valid government issued ID (passport, license)* of the individual(s) authorized to make the investment on the plan's behalf. 3. Plan Document. 4. Percentage of Plan assets owned. 5. Subscription document is completed and signed by an authorized signer |
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Entity | (i.e. Limited Liability Company Limited Partnership Corporation General Partner) | 1. Entity Tax Form (W-9 or W-8). a. Entity's name, address and tax identification number is used. b. Form is signed by beneficial owner. 2. Signed Certification of Beneficial Owners (see attached)*** 3. Filed formation document*** 4. Certificate of Good Standing (if entity is over 1 year old. Certificate must be dated within 1 year of date of investment)*** 5. Cayman AML Checklist** 6. Subscription document is completed and signed by an authorized signer |
* If using ID without address please submit proof of address (i.e. utility bill). Expired IDs will not be accepted.
** Required if entity is organized in the Cayman Islands
*** Denotes items not required of publicly traded companies. Please provide proof of listing (i.e. ticker actively trading) if you are a publicly traded company.