Quote Request - Kevin Kaplan

Securities-based Credit Line Quote Request Form (secure)

Please answer all questions, attach picture ID and brokerage statement (required)
and any other support documents you wish using the attachment buttons below

Full Name:

Company:

Address:

Telephone:

Fax:

Email:

Purpose of this financing?
(For what purpose will it be used?)

Securities Information

1) Are you an employee, director, insider, or owner of 5% or more of any of the securities being pledged?
If yes, please provide details.

2) Are any of your securities currently in Certificate ("Cert") form? If yes, please provide details.

3) Are the securities you will be using for the Credit Line all free trading - e.g., no liens or restrictions that you are aware of?If no, please provide details.

4) Are any of your securities currently being used as collateral for a loan? If yes, please explain.

5) Are there currently any third party claims to any of your securities? (i.e.,tax lien, divorce settlements etc)
If yes, please explain.

6) Are your securities part of an IRA or Keogh Plan? If yes, they cannot used for this financing program

Important: Please attach the following as PDF or JPG files. Please note that a copy of a brokerage statement and photo ID is required to receive a firm quote. Please attach:
1) A copy of a valid current brokerage statement no more than 30 days old indicating shares proposed for credit line; and
2) a clear and legible copy of a picture ID (driver's license, passport, etc.).

Please note that all documents are held in strict confidence per our privacy policy, a copy of which is available upon request, and that thse documents shall be used solely and exclusively for the purpose of institutional lender review for securities-backed financing analysis.

Stock Ticker Symbols or Description

Number of Shares or Description

Who will be the signatory
to this credit line account?
(LLC, Corporation, or Trust signatories may require up to two weeks additional due diligence per regulation.)

Would you be interested in debt/equity financing as well?

Yes, I would like to also be considered for PlusLoan debt/acquisition financing if I am eligible. No, I would not like to be considered for PlusLoan financing.

Upload picture ID (Passport or Driver's License)

Upload brokerage statement

Upload additional document

Are you the legal owner of these shares, or do you have power of attorney over them?

I attest by my electronic signature below that the information given in this application is truthful and accurate. I further recognize and accept that no financial advice, tax advice, or securities purchase or sale advice has been provided to me. I agree that no funding through this program shall be used as a tax shelter or tax avoidance method and that I shall consult a licensed tax professional for guidance as necessary. (Note please: IP addresses are captured with this form for authentication).

Signature

Security Code: