Accredited Investor Form

ACCREDITED INVESTOR QUESTIONNAIRE

J.W. Hager & Assoc, Inc.

ALL INFORMATION FURNISHED IS FOR THE SOLE USE OF J.W. Hager & Assoc, Inc. THE "CORPORATION") AND ITS COUNSEL AND WILL BE HELD IN CONFIDENCE BY THE CORPORATION AND ITS COUNSEL, EXCEPT THAT THIS QUESTIONNAIRE MAY BE FURNISHED TO SUCH PARTIES AS THE CORPORATION AND COUNSEL DEEM NECESSARY TO ESTABLISH COMPLIANCE WITH FEDERAL OR STATE SECURITIES LAWS OR TO THE EXTENT REQUIRED BY LAW.

The shares of Common Stock being offered (the "Shares") by the Corporation are not registered under the Securities Act of 1933, as amended (the "Act"), in reliance upon certain exemptions from registration provided by the Act. One of the exemptions being relied upon is provided by Section 4(2) of the Act and Regulation D of the Securities and Exchange Commission. Regulation D requires, among other things, that prior to making a sale of any Shares, the Corporation must have reasonable grounds to believe, and shall believe after reasonable inquiry, that the offeree is an "accredited investor" (as defined). The Corporation intends to limit the purchase of the Shares to accredited investors. In order to obtain the facts needed to determine whether the Corporation may accept a purchaser's investment, it is necessary for the purchaser (the "Purchaser") to complete this Accredited Investor Questionnaire. Additional information and verifications may be sought from banks and other sources. The form should be signed, dated and forwarded to the Corporation.

Answer all questions. Write "N/A" if not applicable.

A. PLEASE PROVIDE THE FOLLOWING INFORMATION.

1. Name: ______________________________________

(Check preferred mailing address)

2. Residence address: ________________________________

3. Business address: ____________________________

4. Residence telephone: ( )

Business telephone: ( )

5. Year of birth (or date of organization or incorporation): _____________________

B. THE FOLLOWING INFORMATION IS TO BE PROVIDED SO THAT THE CORPORATION CAN DETERMINE IF THE PURCHASER IS AN ACCREDITED INVESTOR.

Please indicate, by initialing, one or more of the following categories which are applicable to you. If no category is applicable, please initial "None.

"Under Regulation D, an "accredited investor" is defined as any person who comes within any of the following categories, or who the issuer reasonably believes comes within any of the following categories, at the time of the sale of the securities to that person:

1. A bank as defined in Section 3(a)(2) of the Act, or a savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Act, whether acting in its individual or fiduciary capacity.

2. Any broker or dealer registered pursuant to Section 15 of

the Securities Exchange Act of 1934.

3. An insurance company as defined in Section 2(13) of the Act.

4. An investment company registered under the Investment Company Act of 1940.

5. A business development company as defined in Section 2(a)(48) of the Investment Company Act of 1940 [a closed‑end company, operated for the purpose of investing in securities described in Section 55(a)(l)‑(3) of such Act and which makes available "significant managerial assistance" with respect to the issuers of such securities to the extent required by the Investment Company Act of 1940 and has elected to be regulated pursuant to Sections 55‑65 of such Act as a business development company].

6. A small business investment company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958.

7. An employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974 ("ERISA"), (i) if the investment decision is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (ii) if the employee benefit plan has total assets in excess of $5,000,000, or (iii) if a self directed plan, with investment decisions made solely by persons that are accredited investors.

8. A private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940.

9. A corporation, partnership, Massachusetts or similar business trust, or organization described in Section 501(c)(3) of the Internal Revenue Code, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000.

10. A director or executive officer of the Corporation. [An executive officer" means the president, any vice president in charge of a principal business unit, division, or function (such as sales, administration or finance), any other officer who performs a policy making function, or any other person who performs similar policy making functions for the Corporation.

11. A natural person whose individual net worth, or joint net worth with that person's spouse, at the time of his purchase exceeds $1,000,000.[For purposes of calculating net worth, any assets may be considered, including the fair market value of one's principal residence and automobiles. The principal residence owned by an individual should be valued either at (i) cost, including the cost of improvements, net of current encumbrances upon the property, or (ii) the appraised value of the property as determined upon a written appraisal used by an institutional lender making a loan secured by the property, including the cost of subsequent improvements, net of current encumbrances upon the property.

12. A natural person who had an individual income (not including income of spouse) in excess of $200,000 in each of the two most recent years (12. A natural person who had an individual income (not including income of spouse) in excess of $200,000 in each of the two most recent years (20 and 20 ) or joint income with that person's spouse in excess of $300,00 in each of those years and who reasonably expects an income in excess of the s= ame income level in the current year (19 ).

["Income" may include amounts normally excluded from "adjusted gross income" such as long‑term capital gain deductions, depletion deductions, interest exclusions and losses allocated to a limited partner. However, "income" is not necessarily synonymous with "revenue"; for example, a self employed person should deduct operating expenses to give an accurate indication of income.]

13. Any trust, with total assets in excess of $5,000,000, not form= ed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii)of Regulation D.

14. An entity in which all of the equity owners are "accredited investors" as defined in one or more of categories B1 through B13 immediately above. (If this item is checked, please complete the "Accredited Investor Certificate" below.)

15. None.

C. THE FOLLOWING INFORMATION IS TO BE PROVIDED BY PURCHASERS WHO ARE INDIVIDUALS OR BY THE PERSON MA= KING THE INVESTMENT DECISION ON BEHALF OF CORPORATIONS, PARTNERSHIPS, TRUSTS OR OTHER ENTITIES.

1.

(a) Name of employer: _____________________________

(b) Position or title:

(c) Length of time with present employer:

(d) Other business affiliations and experience if with current employer less than one year:

2. College education; business or professional training:

Field of = Dates of

School study attendance Degree

3. (a) Name of Purchaser's commercial bank:

(b) Bank's branch address, if applicable:

(c) Name of bank officer familiar with the purchaser:

4. (a) Purchaser's 4. (a) Purchaser's 20 [two years prior to current year] tax rate: %

(b) Purchaser's 20 [year prior to current year] tax rate:

(c) Purchaser's anticipated 20 [current year] tax rate: %

5. (a) Purchaser's 20 [two years prior to current year] taxable income: $

(b) Purchaser's 19 [year prior to current year] taxable income:

(c) Purchaser's estimated 19 [current year] taxable income:

$

6. Purchaser's assets:

Liquid (including cash, marketable securities, personal notes, accounts receivable, and cash value of

insurance policies): $

Real estate

(a) Describe type(s) ence $

(b) Principal residence $

Other (Describe. Do not include furnishings or

automobiles.): $

Total assets: $7. Purchaser's liabilities:

Current (including notes and accounts payable,

margin accounts, unpaid income tax, etc.): $

Other debts

(a) Mortgage on principal residence: $

(b) Other mortgages: $

(c) Other debts: $

Total liabilities: $

Current net worth: $

8 Do you have knowledge and experience in financial and business matters sufficient to evaluate the merits and risks associated with investing in the Corporation?

(a) Prior investment experience:

Type of Name of partnership, common stock Year of Amount

investment issuer in computer company, etc.) investment invested

(b) Other financial experience:

Please describe any 9. In connection with your proposed investment, will you rely Yes _____ No (If "yes", please complete the "Purchaser Representative" form below.)

10. Are you aware of the fact that you= (or your Purchaser Representative, if you have one) have the opportunity to question a representative of the Corporation about this investment, the Corporation, the Corporation's properties, the Corporation's operations and= the Corporation's methods of doing business?

11. (a) Do you understand the merits and risks associated with investments in closely held companies.?

(b) Do you understand the merits and risks associated with an investment in the Corporation?

12. Do you understand that there is no guarantee of any financial return on this investment and that you run the risk of losing your entire investment?

13. Do you understand that this investment is illiquid?

14. Do you understand that you may purchase an interest in the Corporation for investment only, and not with a view to the sale or other distribution thereof?

D. THE FOLLOWING INFORMATION IS TO BE PROVIDED BY PURCHASERS WHO ARE INDIVIDUALS.

1. Marital status: Number of dependents: Social Security number:

Are all of the answers which you have provided to the questions above true and correct to the best I hereby represent to the Corporation that I will notify it immediately of any material adverse change in any of the information contained herein occurring prior to my purchase of the Shares.

Date: , 20Signature of Investor (or person acting on the Investor's behalf)

Name of Investor (please print)

ACKNOWLEDGMENT AND DISCLOSURE OF THE CORPORATION

On the basis of the foregoing, the Corporation believes the above person is an accredited investor and is otherwise qualified to purchase an interest in the Corporation because it believes that the Offeree, either alone or together with his Purchaser Representative, has sufficient knowledge and experience in financial and business matters to be capable of evaluating the merits and risks of an investment in the Corporation. Further, to the extent that there is a material relationship between the Corporation and the Purchaser Representative (or his affiliates), the Corporation, in compliance with Regulation D, affirms and adopts the foregoing disclosures of the Purchaser Representative with respect to such material relationships and the compensation received the reform, and states that the same are true and correct in all material respects.

Date: , 20

J.W. Hager & Assoc, Inc.

By:________________________________

Print name:____________________________

Title:________________________________

[COMMENT1]

This form is designed to allow issuance of securities to non-residence of Georgia = (when the intra-state exemption fails to apply) and qualify for exemption from registration. The exemption is based on the definition of "Accredited Investor" under S.E.C. Regulations. Use the form with extreme caution. MSL 3-27-96