CONFIDENTIAL

Rule 506 Disqualification Event Questionnaire
INSTRUCTIONS
Please complete this Questionnaire if you are

(the “Issuer”); the Issuer’s predecessor or affiliated issuer; a director, manager, officer, general partner or managing member of the Issuer; a beneficial owner of 20% or more of any class of the Issuer’s equity securities; a Promoter connected with the Issuer in any capacity during the sale of any securities; or a “Compensated Solicitor” (or such Compensated Solicitor’s director, officer, general partner or managing member that is  participating in the Issuer’s Offering).

 

The Issuer is furnishing this Questionnaire to you to obtain information in connection with the Issuer’s Offering under Rule 506 of the Securities Act. As used in this Questionnaire, “you” also refers to any entity on whose behalf you are responding. Capitalized terms are defined on the attached addendum. Please refer to the definitions when responding to questions.

 

Please answer every question. If the Issuer has completed portions of the Questionnaire for you, confirm that the information is accurate. If your answer to a question is “Yes,” provide details in the explanation. Unless otherwise stated, give your answers as of the date you sign the Questionnaire. If you are not sure whether to include something in your response, please err on the side of over-inclusion. The Issuer may have follow-up questions for you in connection with the Offering. 

 

After completing the Questionnaire, sign it to indicate that:  (i) you consent to the Issuer relying upon the information in this Questionnaire; (ii) you acknowledge the SEC or applicable regulations may require the Issuer to publicly disclose such information, and you consent to such disclosure; (iii) you will promptly notify the Issuer of any changes in the information that occur after the date you sign the Questionnaire; and (iv) you confirm that such information is true and correct, to the best of your knowledge after a reasonable investigation, as of the date you sign the Questionnaire.

Please return the completed Questionnaire to

of the Issuer, at

THIS QUESTIONNAIRE AND YOUR ANSWERS ARE CONSIDERED CONFIDENTIAL AND PROPRIETARY BY THE ISSUER AND SHOULD BE TREATED ACCORDINGLY. 

SHATTERED GLASS EQUITY

401 Grand Ave. West Des Moines, Iowa

515-277-0042

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