CONVERTIBLE PROMISSORY NOTE

 

THIS NOTE AND ANY SHARES OF STOCK ISSUABLE UPON THE CONVERSION HEREOF HAVE NOT
BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE
STATE SECURITIES LAWS. THIS NOTE·AND ANY SHARES OF STOCK ISSUABLE UPON THE
CONVERSION HEREOF MAY NOT BE SOLD, OFFERED FOR SALE, MORTGAGED, PLEDGED,
HYPOTHECATED OR OTHERWISE TRANSFERRED IN THE ABSENCE OF AN EFFECTIVE
REGISTRATION STATEMENT COVERING THIS NOTE OR SUCH SHARES UNDER SAID ACT AND
APPLICABLE STATE SECURITIES LAWS OR THE DELIVERY OF AN OPINION OF COUNSEL THAT
SUCH REGISTRATION IS NOT REQUIRED. THIS NOTE IS ALSO SUBJECT TO RESTRICTIONS ON
TRANSFER.

 

REGEN BIOPHARMA, INC.

 

Issue Date: September 22, 2017   Principal Amount: $50,000

 

 

1.      Terms. For value received, the Regen BioPharma, Inc., a Nevada
corporation (the "Company") hereby absolutely and unconditionally promises to
pay to the order of________, an individual (the "Lender") ON DEMAND AT ANY TIME
AFTER September 21, 2020 {the "Maturity Date"), the principal amount of Fifty
Thousand Dollars ($50,000) and interest on the :whole amount of said principal
sum outstanding and remaining from time to time unpaid (the "Note"), commencing
from the date hereof and continuing until payment in full of this Note or
conversion as hereinafter provided, at an annual rate equal to ten percent (I
0%) simple interest. Interest shall be payable quarterly upon demand or upon
conversion pursuant to Section 2 hereunder. Interest shall be computed on the
basis of the actual number of days elapsed divided by 365. Principal and
interest shall be payable in lawful money of the United States of America, at
the principal place of business of the Lender or at such other place as the
Lender may have designated from time to time in writing to the Company.

 

2.Conversion.

 

2.1   Conversion Right. The Lender shall have the right from time to time to
convert all or a part of the outstanding and unpaid principal amount of this
Note and all or part of the outstanding and unpaid accrued interest of this Note
into fully paid and non-assessable shares of Common Stock, as such Common Stock
exists on the Issue Date, or any shares of capital stock or other securities of
the Company into which such Common Stock shall hereafter be changed or
reclassified at the conversion price (the "Conversion Price") determined as
provided herein (a "Conversion").

 

The Lender shall have the right to convert one hundred percent (I 00%) of the
Principal Amount and any accrued interest commencing as of the date which is the
earlier of:

 

(i) One day subsequent to the execution of an agreement to a transaction whose
completion would result in a "Change of Control" of the Company. For purposes of
this Note, a Change of Control shall be defined as any transaction or serie of
transactions, whether by merger, sale of substantially all of the assets, or
sale or transfer of more than fifty percent (50%) of the outstanding stock of
the relevant entity . in which the members of the Board of Directors immediately
preceding the closing of the Change of Control transaction no longer constitute
a majority of the Board of Directors of the surviving entity following the
closing of such transaction.

 

 1 

 

 (ii)  One day subsequent to the execution of an agreement to a transaction
whose completion would result in a "Change of Control" of KCL Therapeutics, Inc.
For purposes of this Note, a Change of Control shall be defined as any
transaction or series of transactions, whether by merger, sale of substantially
all of the assets, or sale or tra11-sfer of more than fifty percent (50%) of the
outstanding stock of the relevant entity in which the members of the Board of
Directors immediately preceding the closing of the Change of Control transaction
no longer constitute a majority of the Board of Directors of the surviving
entity following the closing of such transaction.

 

(iii)         One day subsequent to the commencement, in compliance with
applicable law, of a broad sol citation by a third party to purchase a majority
percentage of the Company's outstanding equity securities for a limited period
of time contingent on shareholders of the Company tendering a fixed number of
their equity securities ("Tender Offer").

 

(iv) One day subsequent to the execution of an agreement that could result in a
Transaction Event:

 

"Transaction Event" shall mean either of:

 

(a)  The sale by the Company or by KCL Therapeutics, Inc. of any or all of the
Company's proprietary NR2F6 intellectual property to an unaffiliated third party

 

(b)   The granting of a license by the Company or by KCL Therapeutics, Inc. to
an unaffiliated third party granting that unaffiliated third party the right to
develop and/or commercialize any or all of the Company's proprietary NR2F6
intellectual property

 

lf e execution of the agreement resulting in a Transaction Event shall result in
a closing of the Transaction Event prior to 30 days subsequent to the execution
of the agreement, the right to convert under this subsection (iv) shall be 30
days prior to the closing to the Transaction Event, and the Company shall
provide the Lender with a Notice of Right to Convert at least 30 days pri6rto
the.closing of the Transaction Event.

 

(v)       That date which is twenty four (24) months subsequent to the date of
execution of this Note.

 

The number of shares of Common Stock to be issued upon each conversion of this
Note shall be determined by dividing the principal amount of this Note to be
converted (the "Conversion Amount") by the applicable Conversion Price as
defined in this Section 2 then in effect on the date specified in the notice of
conversion, in the form attached hereto as Exhibit A (the "Notice of
Conversion"), delivered to the Company by the Lender on such conversion date
(the "Conversion Date").

 

 2 

 

 

2.2 Conversion Price. The "Conversion Price" shall be defined as the lower
$0.0125 per share, or, a75% discount to the closing price of the Common Stock on
the Over-the-Counter Bulletin Board on the trading day immediately prior to the
date that a Notice of Conversion is submitted pursuant to Section 2.3. or, if
the Over-the-Counter Bulletin Board is not the principal trading market for such
security, the closing price of such security on the principal securities
exchange or trading market where such security is listed or traded on the
trading day immediately prior to the date that a Notice of Conversion is
submitted pursuant to Section 2.3. or, if no closing bid price of such security
is available in any of the foregoing manners, the average of the closing bid
prices of any market makers for such security that are listed in the "pink
sheets" by the National Quotation Bureau, Inc. on the trading day immediately
prior to the date that a Notice of Conversion is submitted pursuant to Section
2.3.

 

2.3   Method of Conversion. Subject to Section 2.1, this Note may be converted
by the Lender by submitting to the Company a Notice of Conversion by facsimile,
e-mail or other reasonable me s of communication dispatched on the Conversion
Date prior to 5:00 p.m., New York, New York time. The Lender shall not be
required to physically surrender this Note to the Company unless the entire
unpaid principal amount of this Note is so converted. The Lender and the Company
shall maintain records showing the principal amount so converted and the dates
of sucth conversions so as not to require physical surrender of this Note upon
each such conversion. In the event of any dispute or discrepancy, such records
of the Company shall, prima facie, be controlling and determinative in the
absence of manifest error. Notwithstanding the foregoing, if any portion of this
Note is converted as aforesaid, the Lender may not transfer this Note unless the
lender first physically surrenders this Note to the Company, whereupon the
Company will forttwith issue and deliver upon the order of the Lender a new Note
of like tenor, registered as the i Lender (upon payment by the Lender of any
applicable transfer taxes) may request, representing in the aggregate the
remaining unpaid principal amount of this Note.

 

Upon receipt by the Company from the Lender of a facsimile transmission, e-mail,
or other reasonable means of communication of a Notice of Conversion meeting the
requirements for !conversion, the Company shall issue and deliver or cause to be
issued and delivered to or upon the order. of the Lender certificates for the
Common Stock issuable upon such conversion within ten (10) business days after
such receipt. Upon receipt by the Company of a Notice of Co version, the Lender
shall be deemed to be the Lender of record of the Common Stock issuable upon
such conversion, the outstanding principal amount and the amount of accrued and
unpaid interest on this Note shall be reduced to reflect such conversion. All
rights with respect to the portion of this Note being so converted shall
forthwith terminate except the right to receive the: Common Stock or other
securities as herein provided on such conversion. In lieu of delivering physical
certificates representing the Common Stock issuable upon conversion, provided
the .Company is participating in the Depository Trust Company ("DTC") Fast
Automated Securities Transfer ("FAST") program, upon request of the Lender, the
Company shall use its best efforts to cause its transfer agent to electronically
transmit the Common Stock issuable upon conversion to the Lender by crediting
the account of Lender's Prime Broker with DTC through its Deposit Withdrawal
Agent Commission ("DWAC") system.

 

2.4 Concerning the Shares. The shares of Common Stock issuable upon conversion
of this Note may not be sold or transferred unless (i) such shares are sold
pursuant to an effective registration statement under the Act or (ii) the
Company or its transfer agent shall have been furnished with an opinion of
counsel (which opinion shall be in form, substance and scope customary for
opinions of counsel in comparable transactions) to the effect that the shares to
be sold or transferred may be sold or transferred pursuant to an exemption from
such registration or (iii) such shares are sold or transferred pursuant to Rule
144 under the Act (or a successor rule) ("Rµle 144") or (iv) such shares are
transferred to an "affiliate" (as defined in Rule 144) of the Company who agrees
to sell or otherwise transfer the shares only in accordance with this Section
2.5; and who is an Accredited Investor as the term Accredited Investor is
defined in Rule 501 of Regulation D, promulgated under the Act.

 3 

 

 

Subject to the removal provisions set forth below, until such time as the shares
of Common Stock issuable upon conversion of this Note have been registered under
the Act or otherwise may be sold pursuant to Rule 144 without any restriction as
to the number of securities as of a particular date that can then be immediately
sold, each certificate for shares of issuable upon conversion of this Note that
has not been so included in an effective registration statement or that has not
been sold pursuant to an effective registration statement or an exemption that
permits removal of the legend, shall bear a legend substantially in the
following form, as appropriate:

 

"NEITHER THE ISSUANCE OR SALE OF THE SECURITIES REPRESENTED BY THIS CERTIFICATE
HAS BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE
STATE SECURITIES LAWS. THE SECURITIES MAY NOT BE OFFERED FOR SALE, SOLD,
TRANSFERRED OR ASSIGNED (I) IN THE ABSENCE OF (A) AN EF ECTIVE REGISTRATION
STATEMENT FOR THE SECURITIES UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR
(B) AN OPINION OF COUNSEL (WHICH COUNSEL SHALL BE SELECTED BY THE LENDER), IN A
GENERALLY ACCEPTABLE FORM, THAT REGISTRATIO:N IS NOT REQUIRED UNDER SAID ACT."

 

The legend set forth above shall be removed and the Company shall issue to the
Lender a new certificate therefore free of any transfer legend if (i) the
Company or its transfer agent shall have received an opinion of counsel, in
form, substance and scope customary for opinions of counsel in comparable
transactions, to the effect that a public sale or transfer of such Common Stock
may be made without registration under the Act and the shares are so sold or
transferred, (ii) suci1 Lender provides the Company or its transfer agent with
reasonable assurances that the Common Stock issuable upon conversion of this
Note (to the extent such securities are deemed to have been acquired on the same
date) can be sold pursuant to Rule 144 or (iii) in the case of the Common Stock
issuable upon conversion of this Note, such security is registered for sale by
unc(er an effective registration statement filed under the Act or (iv) otherwise
may be sold pursuant to Rule 144 without any restriction as to the number of
securities as of a particular date that can then be immediately sold.

 

2.5    Reverse Stock Splits. If the number of shares of Common Stock outstanding
at any time while this Not is outstanding is decreased by a combination of the
outstanding shares of Common Stock, then, following the record date of such
combination, the Conversion Price shall be appropriately increased so that the
number of shares of Common Stock issuable on conversion hereof shall be
decreased in proportion to such decrease in outstanding shares.

 2.6 Stock Dividends and Stock Splits. If the Company, at any time while this
Note is outstandings ubdivides outstanding shares of Common Stock into a larger
number of shares then the Conversion price shall be multiplied by a fraction of
which the numerator shall be the number of shares of Common Stock (excluding any
treasury shares of the Company) outstanding immediately before such event and of
which the denominator shall be the number of shares of Common Stock outstanding
immediately after such event

 

 4 

 

 

3. Payment.

 

 

WIRE INSTRUCTIONS:

4.           Prepayment. Notwithstanding anything to the contrary contained
herein, the Company shall have the right, exercisable on not less than ten (10)
Trading Days prior written notice to the Lender, to prepay the outstanding Note
in part or in full, including outstanding principal and accrued interest. Any
notice of prepayment hereunder shall be delivered to the Lender at its
registered addresses and shall state that the Company is exercising its right to
prepay the Note and the date of prepayment, which shall be not more than ten
(10) Trading Days from the date of the prepayment notice. Upon receipt of a
prepayment notice, Lender shall have the :right, but not the obligation, to
accelerate the conversion period specified in Section 2.1 and convert that
portion of the outstanding principal balance which is subject to prepayment to
Common Shares as provided for in Section 2.

 

5. Warrant Coverage. In the event that that the Company exercises its right to
prepay the Note, or if the Lender chooses not to convert the remaining amount of
the note into Common Shares of the company, the Lender shall receive warrants
equal to 10% of the Common shares it would have received had the Lender
converted the remaining amount of the Note into Common shares of the Company.
The warrants shall have a strike price of $0.0125 per share. See Exhibit B
(incorporated into this Note) for instructions on completing the Exercise of
Warrants document.

 

6.    Events of Default.

 

6.1 The following shall constitute events of default (individually an "Event of
Default"):

 

(a) default in the payment, when due or payable, of an obligation to pay
interest or principal under this Note, which default is not cured by payment in
full of the amount due within thirty (30) days om the date that the Lender
receives notice of the occurrence of such default;

 

(b) filing of a petition in bankruptcy or the commencement of any proceedings
under any bankruptcy laws by or against the Company, which filing or proceeding,
is not dismissed within ninety (90) days after the filing or commencement
thereof; or

 

(c)  failure of the Company to comply in any way with the terms, covenants or
conditions contained in this Note.

 5 

 

 

6.2 If an Event of Default shall occur and be continuing, the Lender may, at its
option, declare trus Note to be immediately due and payable without further
notice or demand, wh re upo n this Note shall become immediately due and payable
without presentment, demand or protest, all of which are hereby waived by the
Company.

 

7.    Transfer of Note. This Note may not be transferred or assigned other than
a transfer or assignment to an Affiliate of the Lender. As used herein, the term
" Affiliate" means an entity that directly, or indirectly through one or more
intermediaries, controls, or is controlled by, or is under common control with,
the Lender.

8. Certain Waivers. The Company hereby expressly and irrevocably waives
presentment, demand, protest, notice of protest and any other formalities of any
kind.

 

9. Amendment, Modification or Termination. This Note may only be modified,
amended, or terminated (other than by payment in full) by an agreement in
writing signed by the Company and the Lender. No waiver of any term, covenant or
provision of this Note shall be effective unless given in writing by the Lender.

 

10. Governing Law. This Note and the obligations of the Company hereunder shall
be governed by and interpreted and determined in accordance with the laws of the
State of California (excluding the laws ru1d rules of law applicable to
conflicts or choice of law).

 

IN WITNESS WHEREOF, this Note has been duly executed on behalf of the un
ersigned on the day and in the year first above written.

 

 

REGEN BIOPHARMA, INC           /s/ David R. Koos   9/25/2017 Chairman and CEO  
Date

 

The foregoing Convertible Promissory Note is hereby accepted and agreed to by
the undersigned on and as of the date first above written.

 

_______, an individual

 

 

 6 

 

 

 

EXHIBIT A NOTICE OF CONVERSION

 

The undersigned hereby elects to convert $ __________ principal amount and $
__________ accrued interest of the Note into that number of shares of Common
Stock to be issued pursuant to the conversion of the Note as set forth below of
REGEN BIOPHARMA. INC. according to the conditions of the convertible note of the
Company dated as of Month XX 2020 as of the date written below.

 

Date of Conversion:     Applicable Conversion Price:     (Attach Bloomberg price
documentation)   Number of Shares of Common Stock to be Issued Pursuant to
Conversion of the Note:           Amount of Principal Balance Due Remaining
Under the Note After This Conversion:    

 

Checked box corresponds to applicable instructions:

 

☐  The Borrower shall electronically transmit the Common Stock issuable pursuant
to this Notice of Conversion to the account of the undersigned or its nominee
with OTC through its Deposit Withdrawal Agent Commission system (“Wire
Transfer”)         Name of DTC Prime Broker:       Account Number:           ☐ 
The undersigned hereby requests that the Borrower issue a certificate or
certificates for the number of shares of Common Stock set forth below in the
name(s) specified immediately below or, if additional space is necessary, on an
attachment hereto:         Name:       Address:                       Phone:    

 

      Name   Date Title    

 

 

 7 

 

 

EXHIBIT B

 

COMMON STOCK PURCHASE WARRANT REGEN BIOPHARMA, INC.

 

THIS WARRANT AND THE SHARES ISSUABLE UPON EXERCISE OF THIS WARRANT HAVE NOT BEEN
REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED. THIS WARRANT AND THE
SHARES ISSUABLE UPON EXERCISE OF THIS WARRANT MAY NOT BE SOLD, OFFERED FOR SALE,
PLEDGED OR HYPOTHECATED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT OR
APPLICABLE EXEMPTION OR SAFE HARBOR PROVISION.

 

 

THIS COMMON STOCK PURCHASE WARRANT (the "Warrant") certifies that, for value
received, Lender is entitled, solely upon the terms and subject to the
limitations on exercise and the :conditions hereinafter set forth, to subscribe
for and purchase from the Company, shares of common stock of the Company (the
"Warrant Shares"). The purchase price of one Warrant Share under this Warrant
shall be equal to the $0.0125 per Warrant Share ("Exercise Price").

 

1. In the event that Company shall exercise Company's rights pursuant to Section
4 of the Note ("Prepayment Clause") , Lender shall be entitled , on or prior to
the close of business on the three (3) month anniversary of the date that the
Note shall have been prepaid by the Company ("Prepayment Date'') , to subscribe
for and purchase from the Company up to that number of Warrant Shares at the
Exercise Price per Share equivalent to that one tenth of that number of Common
Shares that Lender would have been entitled to be issued had Lender exercised
Lender's Conversion Right pursuant to Section 2.1 of the Note as of the
Prepayment Date.

 

2. In the event that, as of the Maturity Date, part of the outstanding and
unpaid principal amount of this Note and any Accrued Interest remains
outstanding, Lender shall be entitled, on or prior to the close of business on
the three (3) month anniversary of the Maturity Date, to subscribe for and
purchase from the Company up to that number of Warrant Shares at the Exercise
Price per Share equivalent to that one tenth of that number of Common Shares
that Lender would have been entitled to be issued had Lender exercised Lender's
Conversion Right pursuant to Section 2.1 of the Note as of the Maturity Date.

 

3. If the Company, at any time while this Warrant is outstanding: (i) pays a
stock dividend or otherwise makes a distribution or distributions on shares of
its Common Stock or any other equity or equity equivalent securities payable in
shares of Common Stock (which, for avoidance of doubt, shall not include any
shares of Common Stock issued by the Company upon exercise of this Warrant),
(ii) subdivides outstanding shares of Common Stock into a larger number of
shares, (iii) combines (including by way of reverse stock split) outstanding
shares of Common Stock into a smaller number of shares or (iv) issues by
reclassification of shares of the Common Stock any shares of capital stock of
the Company, then in each case the Exercise Price shall be multiplied by a
fraction of which the numerator shall be the number of shares of Common Stock
(excluding treasury shares, if y) outstanding immediately before such event and
of which the denominator shall be the number of shares of Common Stock
outstanding immediately after such event, and the number of shares issuable upon
exercise of this Warrant shall be proportionately adjusted such that the
aggregate Exercise Price of this Warrant shall remain unchanged. Any adjustment
made pursuant to this Section 3 shall become effective immediately after the
record date for the determination of stockholders entitled to receive such
dividend or distribution and shall become effective immediately after the
effective date in the case of a subdivision, combination or reclassification

 

 8 

 

4. Exercise of the purchase rights represented by this Warrant may be made, in
whole or in part, from and after the initial exercise date, and then at any
time, by delivery to the Comp8!J.y (or such other office or agency of the
Company as it may designate by notice in writing to-Lender at the address of the
Lender appearing on the books of the Company) of a duly executed facsimile or
emailed copy of the Notice of Exercise form annexed hereto and delivery of the
aggregate Exercise Price for the Warrant Shares specified in the applicable
Notice of Exercise by wire transfer.

 

5. Warrant Shares purchased hereunder will be delivered to Holder within 10
business days of Notice of Exercise.

 

6. The Warrant Shares may not.be sold or transferred unless (i) such shares are
sold pursuant to an effective registration statement under the Act or (ii) the
Company or its transfer agent shall have been furnished with an opinion of
counsel (which opinion shall be in form, substance and scope customary for
opinions of counsel in comparable transactions) to the effect that the shares to
be sold or transferred may be sold or transferred pursuant to an exemption from
such registration or (iii) such shares are sold or transferred pursuant to Rule
144 under the Act (or a successor rule) ("Rule 144") or (iv) such shares are
transferred to an "affiliate" (as defined in Rule 144) of the Company who agrees
to sell or otherwise transfer the shares only in accordance with this Section 6
and who is an Accredited Investor as the term Accredited Investor is defined in
Rule 50l of Regulation D, promulgated under the Act. subject to the removal
provisions set forth below, until such time as the Warrant Shares have been
registered wider the Act or otherwise may be sold pursuant to Rule 144 without
any restriction as to the number of securities as of a particular date that can
then be immediately sold, each certificate for Warrant Shares that have not been
so included in an effective registration statement or that have not been sold
pursuant to an effective registration statement or exemption that permits
removal of the legend, shall bear a legend substantially in the following form,
as appropriate:

 

"NEITHER THE ISSUANCE OR SALE OF THE SECURITIES REPRESENTED BY THIS CERTIFICATE
HAS BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE
STATE SECURITIES LAWS. THE SECURITIES MAY NOT BE OFFERED FOR SALE, SOLD,
TRANSFERRED OR ASSIGNED (l) IN THE ABSENCE OF (A) AN EFFECTIVE REGISTRATION
STATEMENT FOR THE SECURITIES UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR
(B) AN OPINION OF COUNSEL (WHICH COUNSEL SHALL BE SELECTED BY THE LENDER), IN A
GENERALLY ACCEPTABLE FORM, THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT."

 9 

 

 

 

The legend set forth above shall be removed and the Company shall issue to the
Lender a new certificate therefore free of any transfer legend if (i) the
Company or its transfer agent Shall have received an opinion of counsel, in
form, substance and scope customary for opinions of counsel in comparable
transactions, to the effect that a public sale or transfer of such securities
may be made without registration under the Act and the shares are so sold or
transferred, (ii) such Lender provides the Company or its transfer agent with
reasonable assurances that the Warrant Shares can be sold pursuant to Rule 144
or (iii) such security is registered for sale by under an effective registration
statement filed under the Act or (iv) otherwise may be sold pursuant to Rule 144
without any restriction as to the number of securities as of a particular date
that can then be immediately sold.

 

7. The Lender shall not be required to physically surrender this Warrant to the
Company. If the Lender has purchased all of the Warrant Shares available
hereunder and the Warrant has been exercised in full, this Warrant shall
automatically be cancelled without the need to surrender the Warrant to the
Company for cancellation.

 

8. This Warrant may not be transferred or assigned other than a transfer or
assignment to an Affiliate of the Lender. As used herein, the term "Affiliate"
means an entity that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the Lender.

 

9. FORM OF WARRANT NOTICE

 

NOTICE OF EXERCISE

 

To: REGEN BIOPHARMA, INC.

 

The undersigned hereby elects to purchase __________ Warrant Shares of the
Company pursuant to the terms of the Warrant issued in connection with that
Convertible Note in the amount of ___ by and between __________ and the Company
dated __________ and maturing _____, 2020 and tenders herewith payment of the
exercise price in full, together with all applicable transfer taxes, if any.

 

Please issue a certificate or certificates representing said Warrant Shares in
the name of the undersigned. The undersigned is an "accredited investor" as
defined in Regulation D promulgated under the Securities Act of 1933, as
amended.

 

[SIGNATURE]

 

Name:   Date:  

 

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