Private Placement Application Form

Please complete this form to begin the Larson Financial Securities, LLC private placement application process. Additionally, during our meetings, we may give you a variety of recommendations regarding topics such as financial planning, investment strategies, wealth management, etc. When making these types of recommendations, we want to make sure you understand our relationship to you as our client. Click here to review our Customer Relationship Summary ("Form CRS").

1Fund and Ownership Info

2Client

3Co-Client

4Finances and Investments

5Payment Info

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Advisor's Salesforce User ID

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Advisor's Name

First Last

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Advisor's Email

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CSM's Salesforce User ID

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CSM's Name

First Last

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CSM's Email

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Opportunity ID

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Account Type

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Hidden: Subscription Checkbox for IRA

Larson Capital Real Estate Fund IQ, LLC, a Delaware limited liability company ("LCREF IQ")

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Hidden: Product Type Checkbox for IRA

Larson Capital Real Estate Fund IQ

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Hidden: Product Type for IRA

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Hidden: Subscription Checkbox for NOT IRA

Larson Capital Real Estate Fund I, LLC, a Delaware limited liability company ("LCREF I")

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Hidden: Product Type Checkbox for NOT IRA

Larson Capital Real Estate Fund I

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Hidden: Product Type for NOT IRA

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Hidden: Benefit Plan & Non-Profit Subscribers: IRA Checkbox

If IRA, this option is automatically selected in a hidden field

Subscriber is a plan, trust or account that is subject to Code §4975, including a plan which is exempt from tax under Section 501(a) of the Code because it meets the requirements described in Code §401(a), an individual retirement account (an “IRA”), or any other trust, plan, account or annuity that is subject to Code §4975.

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Hidden: Benefit Plan & Non-Profit Subscribers: TRUST Checkbox

If Trust, this option is automatically selected in a hidden field

Subscriber is a plan or trust that is subject to the fiduciary provisions under Part 4 of title I of ERISA.

Fund and Ownership Information

Fund Name(Required)

Please select the option indicating how the Interests will be held by the Investors:(Required)

If Other, please specify:(Required)

Name of Trust(Required)

Date Trust Formed(Required)

State of Incorporation, Formation or Organization(Required)

Name of Trustee(s)(Required)

Is this Trust a Grantor Trust?(Required)

Grantor's Name(Required)

First Last

Grantor's Social Security Number / Tax ID(Required)

Grantor's Address(Required)

Street Address City State ZIP Code

Name of Custodian for IRA(Required)

If Other, please insert the IRA Custodian(Required)

IRA Name(Required)

IRA Number(Required)

Will this investment be held directly at a Custodian?(Required)

Please select the Custodian this investment will be held at:(Required)

If Other, please insert the name of your Custodian:(Required)

Account Name(Required)

Account Number(Required)

Direct Payment Information

The subscriber hereby authorizes Larson Capital Management to initiate credit/debit entries to my Checking or Savings selected below at the Financial Institution indicated, to credit/debit such account:

Name of Financial Institution(Required)

Telephone Number of Bank(Required)

Branch Location(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

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Hidden: Will the money you use to invest in this fund come from bank accounts outside the United States? YES Checkbox

Yes

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Hidden: Will the money you use to invest in this fund come from bank accounts outside the United States? NO Checkbox

Check Layout

Routing Number(Required)

Account Number(Required)

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Please attach an image of a voided check:

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

Do you want distributions to be paid to the same account that you're funding this investment with?(Required)

Payment of Distributions

The subscriber hereby requests that the applicable fund pay any cash distributions to the following account, unless Subscriber otherwise notifies the Manager in writing:

Name of Financial Institution(Required)

Telephone Number of Bank(Required)

Account Number(Required)

Routing Number(Required)