Step 1 of 7 14% If you have been invited to complete this form, CoPeace is considering a custom investment in your company. In order to proceed with the consideration, CoPeace needs to collect certain information from your company using this form. NOTE: Please fill out this form in its entirety before closing your browser to avoid losing data. Some of the data and documentation we will require: Business Description Social Impact Description Historical & Projected Financials Complete & Execution-Ready Investment Documents Organization Logo Your information is protected via secure SHA-2 2048-bit encryption. For details on our privacy policy, please visit the "Privacy Policy" page, which can be found in the footer of the website. If you have any questions about the form, please contact info@copeace.com or call (720) 233-4215. Section 1 - Tell Us About Your CompanyCompany Name* Enter the name of the company that will be the recipient of the recommended investment. Company Type*Choose legal structure from the list below. C Corp S Corp B Corp LLC LP Company Summary*Enter a short (600 characters max) description of your company's mission and purpose. Impact Sector*Choose the main impact sector for the proposed investment from the list below. Advocacy & Social Justice Animal Welfare Arts & Culture Civic Engagement Clean Tech Disaster Relief Economic Opportunity Education & Charter Schools Environment & Sustainable Development Global Health Nutrition, Health & Wellness Housing & Community Development Human Rights Media, Tech & Mobile Microfinance Sustainable Agriculture Small & Medium Business Development Water & Sanitation Youth Development Impact Regions* East Asia & Pacific Europe & Central Asia Latin America & the Caribbean Middle East & North Africa North America South Asia Sub-Saharan Africa Choose the main geographic region the investment will be targeting from the list below. Incorporation Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Section 2 - Contact InformationPlease fill out the information below for the point of contact that we will be communicating with throughout the process. Name* First Last Business Title* Phone*Email* Will the signatory for your company be the same as the point of contact from above?* Yes No Signatory Name* First Last Signatory Title/Position* Signatory Phone Number*Signatory Email* Who may our auditors contact with questions about this investment?* Primary point of contact listed above Investment signatory (if different from POC) Is this incorporation address the same as the company's mailing address?* Yes No Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Step 3 - Investment DetailsUse of Proceeds*Briefly (1000 characters max) please describe the intended use of funds. Upload additional documents as neccessaryIf you have additional documents or need more space for the Use of Proceeds section, upload those documents here (5 files max, 4 MB max size). Drop files here or Select files Accepted file types: pdf, doc, docx, rtf, txt, Max. file size: 4 MB, Max. files: 5. Investment Date (Target)*Please set a date at least 10 business days in the future to allow for minimum processing times. MM slash DD slash YYYY Investment Amount*Investment at Close*Portion of the investment amount needed at close (if not 100%)Investment Type* Debt Equity Fund Convertible Debt Other Terms (if applicable)Describe below. Section 4 - Reference Checks & OFAC ComplianceDepending on whether or not your organization has been operating for less than three years, reference checks may be required. Please answer the following questions, and if prompted, complete the request reference information. My organization is a U.S.-based entity.* Yes No My organization has 3+ years operating experience.* Yes No Name of CEO* First Last CEO's Email* Is the CEO a U.S. citizen?* Yes No Name of CEO* First Last CEO's Email* Is the CEO a U.S. citizen?* Yes No Name of CEO* First Last CEO's Email* Is the CEO a U.S. citizen?* Yes No Name of CFO (or Equivalent)* First Last CFO's Email* Is this individual a U.S. citizen?* Yes No Name of CFO (or Equivalent)* First Last CFO's Email* Is this individual a U.S. citizen?* Yes No Authorization*By checking this box, the investee consents to background screening(s) of the individuals listed above. Authorization*By checking this box, the investee consents to background screening(s) of the individuals listed above. Authorization*By checking this box, the investee consents to background screening(s) of the individuals listed above. Section 5 - OFAC ComplianceAs a U.S. organization, CoPeace is required to comply with U.S. federal law, which requires that all individuals and organizations within the United States are responsible for ensuring that they do not undertake business dealings with an individual or entity listed on the U.S. Treasury Department's Office of Foreign Assets Control (OFAC) Specialty Designated Nationals (SDN) and Blocked Persons List. We use third-party tools to check the names of the following: Management Team Members Board Members Investors/Shareholders/OwnersAdditional Management*Are there any additional management team members not already listed on this form? Yes No Additional Management Team Member #1* First Last Additional Management Team Member #2 First Last Additional Management Team Member #3 First Last Additional Management Team Member #4 First Last Additional Management Team Member #5 First Last Board Members*Does your organization have a Board? Yes No Board Member #1* First Last Board Member #2 First Last Board Member #3 First Last Board Member #4 First Last Board Member #5 First Last Board Member #6 First Last Investors and Percentage*In the next section, you will be asked to upload certain documents. Is there a list of investors and % interest included in the transaction documents you will be uploading/forwarding? If "no" you will be prompted to enter their names below. Yes No InvestorsIf your company is NOT incorporated in the United States, please list the names of all individuals or entities with a percentage interest in the organization. If your company IS incorporated in the United States, please only list the names of individuals or entities with great than 20% interest. If you need to list more than five investors/members/owners, please use the "Additional Documents" field in the next section to upload a complete list.Investor/Owner/Member #1 First Last Investor/Owner/Member #2 First Last Investor/Owner/Member #3 First Last Investor/Owner/Member #4 First Last Investor/Owner/Member #5 First Last Section 6 - Files to UploadBusiness Description PlanPlease upload any organizational brochures, PPT decks, business plans or other similar material. (32MB total upload limit) Drop files here or Select files Accepted file types: jpg, ppt, doc, docx, pdf, rtf, txt, png, Max. file size: 32 MB. Social Impact DescriptionPlease upload any social impact description if not included as part of the Business Description Plan (16MB total upload limit) Drop files here or Select files Accepted file types: jpg, ppt, doc, docx, pdf, rtf, txt, png, Max. file size: 16 MB. Historical & Projected FinancialsPlease upload any financials. It is preferred to include at least three years of historical financials (if available), and a minimum of five years pro forma financials. If your company has not been in business long enough to have three years of historical financials, upload the most complete projected and/or historical information you have. (16MB total upload limit) Drop files here or Select files Accepted file types: jpg, ppt, doc, docx, pdf, rtf, txt, png, Max. file size: 16 MB. LogoPlease upload a high-resolution image/images of your organization's logo. (32MB total upload limit) Drop files here or Select files Accepted file types: jpg, png, gif, tiff, pdf, Max. file size: 32 MB. Additional Financial FilesIf you need to upload additional financial files, please upload them here. (16MB total upload limit) Drop files here or Select files Accepted file types: jpg, ppt, doc, docx, pdf, rtf, txt, png, Max. file size: 16 MB. Are your financials routinely audited?* Yes No Investment DocumentsInstructions: CoPeace uses DocuSign to complete investment signatures. Please send the executable version of the investment documents. Please make sure that the signature listed earlier in this form is the one who will be signing on behalf of your company. "CoPeace PBC" listed throughout the signatory information as follows: By: Name: Title: All Investment notice information should be as follows: CoPeace PBC Attn: Address: Phone: Fax: Email: If you have any questions about this form, please contact XXXX or cal XXXX. Investment Documents UploadIf applicable in your discussions with CoPeace, please upload complete and execution-ready documents (no blanks, all dates and amounts complete). (32MB total upload limit) Drop files here or Select files Accepted file types: jpg, ppt, doc, docx, pdf, rtf, txt, png, Max. file size: 32 MB. Section 7 - Reporting RequirementsAgreeing with and adhering to CoPeace's reporting standards is a condition of investment and to be considered an investee in good standing. Annual Financial Reporting for Companies A. The company will submit its complete audited financial statements, including but not limited to its balance sheet, its income statement, and its cash flow statement, all submitted within three months of the fiscal year end. B. If the company does not yet submit to an annual audit, the company will submit its unaudited financial statements, including but not limited to its balance sheet, its income statement, and its cash flow statement, all submitted within three months of the fiscal year end. C. If the company does not yet have the ability to produce financial statements, the company will submit a narrative summary of key financial milestones reached or challenges faced within three months of the fiscal year end. Annual Impact Reporting for Companies CoPeace will require companies to comply with annual collection of impact data and conformity with certain impact metrics and/or submit a written narrative impact report that details the social and/or environmental impact of the company and its activities or the fund and its investments, which may include analysis of impact metrics, anecdotes related to company or fund impact, case studies, changes in impact thesis or criteria, and other related impact outputs and outcomes. Compliance*Please check to confirm that you understand and agree to comply with the requirements above. My company will comply with the reporting requirements.Consent* By using this form you agree to our Privacy PolicyPhoneThis field is for validation purposes and should be left unchanged.
