ESCROW APPLICATION AND REQUIRED SETUP INFORMATION

Complete and submit this form along with a Certificate of Incorporation (or similar) and PPM (or similar) to apply for an escrow account for your crowdfunding Issue. Please email Certificate of Incorporation and Offering Documents to:  [email protected]

(e.g. Corporation, LLP, LLC, etc.)
(e.g. Sole Proprietor, Corporation, LLP, LLC, etc.)
**Only if Sole Proprietor or Sole Member LLC
Company Phone Number *
Company Phone Number
http://
$
Can be set at the same amount as the total amount you want to raise or a lesser amount.
$
Effective Date of the Offering *
Effective Date of the Offering
The day you plan to start taking investment funds.
Escrow Termination Date *
Escrow Termination Date
The last day funds will be accepted (maximum is 6 months from the Effective Date without renewing the escrow).
Name of Bank
Name exactly as it appears on bank statement.
Account Type *
506(b), 506(c), Intrastate, etc.
$
leave blank if no maximum
$
What will the proceeds from the offering will be used for?
Offering Type *
(select one)
Will investors receive periodic payments? *
Frequency of investor payments *
Description of how investors are repaid if debt/lending or % equity they are receiving, etc.
Note: GoldStar cannot do K-1 reporting.
BUSINESS PRINCIPAL(S)
(First / MI / Last) - Primary Owner/Account Manager
Principal #1 Phone Number *
Principal #1 Phone Number
Principal #1 Date of Birth
Principal #1 Date of Birth
ADDITIONAL BUSINESS PRINCIPALS: INCLUDE ALL INDIVIDUALS LISTED ON THE OFFERING DOCUMENTS.
(First / MI / Last) - additional authorized partner, member, officer, etc.
Principal #2 Date of Birth
Principal #2 Date of Birth
ADDITIONAL BUSINESS PRINCIPALS: INCLUDE ALL INDIVIDUALS LISTED ON THE OFFERING DOCUMENTS.
(First / MI / Last) - additional authorized partner, member, officer, etc.
Principal #3 Phone Number
Principal #3 Phone Number
Principal #3 Date of Birth
Principal #3 Date of Birth
ADDITIONAL BUSINESS PRINCIPALS: INCLUDE ALL INDIVIDUALS LISTED ON THE OFFERING DOCUMENTS.
(First / MI / Last) - additional authorized partner, member, officer, etc.
Principal #4 Phone Number
Principal #4 Phone Number
Principal #4 Date of Birth
Principal #4 Date of Birth
Acknowledgement *
By checking 'I agree', you acknowledge that the information provided on this form will be used by GoldStar Trust Company to run a background check on each business principal.