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efta-01452241DOJ Data Set 10Other

EFTA01452241

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DOJ Data Set 10
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efta-01452241
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EFTA Disclosure
Text extracted via OCR from the original document. May contain errors from the scanning process.
SOF III - 1081 Southern Financial LLC 2. Please indicate whether or not the Investor is, or is acting on behalf of, (i) an "employee benefit plan" within the meaning of Section 3(3) of ERISA, and subject to Title I of ERISA, (ii) a plan to which Section 4975 of the Internal Revenue Code of 1986, as amended, applies (including without limitation, an individual retirement account) (iii) an entity whose underlying assets include plan assets by reason of a plan's investment in such entity or (iv) an entity that otherwise constitutes a "benefit plan investor" within the meaning of Section 3(42) of ERISA and the Department of Labor Regulation 2510.3-101, 29 C.F.R. Section 2510.3-101, or any successor regulation (together. the "Plan Asset Provisions"), including but not limited to certain insurance company general accounts (each of (i), (ii), (iii) or (iv), a "Benefit Plan Investor"). Yes No 3(a). If the Investor checked "Yes" to question 2, please check all boxes that describe the Investor or the entity that the Investor is acting on behalf of: L an "employee benefit plan" within the meaning of Section 3(3) of ERISA or a "plan" as described in Section 4975(e) of the Code that is subject to Title I of ERISA or Section 4975 of the Code (e.g., a 401(k) plan). O an individual retirement account ("IRA") or an individual retirement annuity. O an entity or fund whose underlying assets include -plan assets" by reason of a plan's investment in such entity (e.g., an insurance company separate account or an entity in which 25% or more of a class of equity interest is held by Benefit Plan Investors (calculated in accordance with the Plan Asset Provisions)). Please indicate the maximum expected percentage of the entity or fund that will constitute "plan assets" for purposes of Title I of ERISA: %. An Investor that cannot provide the foregoing percentage hereby acknowledges that for purposes of determining whether Benefit Plan Investors own less than 25% of the outstanding Interests, 100% of the assets of the Investor shall be treated as "plan assets." I an insurance company general account. Please indicate the maximum expected percentage of the general account that will constitute "plan assets" for purposes of Title I of ERISA: %. An Investor that cannot provide the foregoing percentage hereby acknowledges that for purposes of determining whether Benefit Plan Investors own less than 25% of the outstanding Interests, 100% of the assets of its general account shall be treated as "plan assets." O Other. Investor Questionnaire - 9 Confidential CONFIDENTIAL — PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0109158 CONFIDENTIAL SDNY_GM_00255342 EFTA01452241

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