Exhibit 10.3

 

FOURTH AMENDMENT TO AMENDED AND RESTATED

CREDIT AGREEMENT

 

THIS FOURTH AMENDMENT TO AMENDED AND RESTATED CREDIT AGREEMENT (this
“Amendment”), is made and entered into as of December 31, 2004, among CURATIVE
HEALTH SERVICES, INC., a Minnesota corporation formerly known as Curative
Holding Co. (“Holdings”), EBIOCARE.COM, INC., a Delaware corporation
(“eBioCare”), HEMOPHILIA ACCESS, INC., a Tennessee corporation (“Hemophilia
Access”), APEX THERAPEUTIC CARE, INC., a California corporation (“Apex”), CHS
SERVICES, INC., a Delaware corporation (“CHS”), CURATIVE HEALTH SERVICES OF NEW
YORK, INC., a New York corporation (“CHSNY”), OPTIMAL CARE PLUS, INC., a
Delaware corporation (“Optimal Care”),  INFINITY INFUSION, LLC, a Delaware
limited liability company (“Infinity”), INFINITY INFUSION II, LLC, a Delaware
limited liability company (“Infinity II”), INFINITY INFUSION CARE, LTD., a Texas
limited partnership (“Infinity Infusion”), MEDCARE, INC., a Delaware corporation
(“Medcare”), CURATIVE PHARMACY SERVICES, INC., a Delaware corporation (“CPS”),
CURATIVE HEALTH SERVICES CO., a Minnesota corporation formerly known as Curative
Health Services, Inc. (“CHSC”), CRITICAL CARE SYSTEMS, INC., a Delaware
corporation (“CCS”) (Holdings, eBioCare, Hemophilia Access, Apex, CHS, CHSNY,
Optimal Care, Infinity, Infinity II, Infinity Infusion, Medcare, CPS, CHSC and
CCS are sometimes collectively referred to herein as the “Borrowers” and
individually as a “Borrower”), CURATIVE HEALTH SERVICES III CO., a Minnesota
corporation, and GENERAL ELECTRIC CAPITAL CORPORATION, a Delaware corporation
(“GE Capital”), as Agent and Lender.

 

Statement of Facts

 

A.                                    BORROWERS AND GE CAPITAL ARE PARTIES TO
THAT CERTAIN AMENDED AND RESTATED CREDIT AGREEMENT, DATED APRIL 23, 2004, AS
AMENDED BY (I) THAT CERTAIN FIRST AMENDMENT TO AMENDED AND RESTATED CREDIT
AGREEMENT AND COLLATERAL DOCUMENTS DATED AS OF MAY 3, 2004, (II) THAT CERTAIN
SECOND AMENDMENT TO AMENDED AND RESTATED CREDIT AGREEMENT DATED AS OF JUNE 30,
2004 AND (III) THAT CERTAIN THIRD AMENDMENT TO AMENDED AND RESTATED CREDIT
AGREEMENT DATED AS OF OCTOBER 20, 2004 (AS SO AMENDED, THE “CREDIT AGREEMENT”;
CAPITALIZED TERMS USED BUT NOT DEFINED IN THIS AMENDMENT HAVE THE MEANINGS GIVEN
IN THE CREDIT AGREEMENT, AS AMENDED BY THIS AMENDMENT), WHEREBY THE LENDERS HAVE
MADE AVAILABLE A REVOLVING CREDIT FACILITY AND OTHER FINANCIAL ACCOMMODATIONS TO
BORROWERS, SUBJECT TO THE TERMS AND CONDITIONS CONTAINED IN THE CREDIT
AGREEMENT.

 

B.                                    THE PARTIES HERETO DESIRE TO ENTER INTO
THIS AMENDMENT TO AMEND CERTAIN PROVISIONS OF THE CREDIT AGREEMENT AS PROVIDED
FOR HEREIN.

 

Statement of Terms

 

NOW THEREFORE, in consideration of the premises and mutual covenants contained
herein, and other good and valuable consideration, the receipt and sufficiency
of which are hereby acknowledged, the parties hereto agree as follows:

 

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1.                                      Amendments to Credit Agreement.  Subject
to the terms and conditions of this Amendment, including without limitation
Section 3 hereof, the Credit Agreement is hereby amended as follows:

 

(A)                                  SECTION 7.15 OF THE CREDIT AGREEMENT IS
HEREBY AMENDED BY DELETING SUCH SECTION IN ITS ENTIRETY AND SUBSTITUTING IN LIEU
THEREOF THE FOLLOWING NEW SECTION TO READ IN ITS ENTIRETY AS FOLLOWS:

 

Section 7.15. Total Leverage Ratio.  The Borrowers shall not permit the Total
Leverage Ratio as of the last day of any Fiscal Quarter to be greater than the
amount specified in the table below for the corresponding period specified below
for each Fiscal Quarter.

 

Quarterly Period

 

Maximum Total Leverage
Ratio

 

Fiscal Quarter Ended June 30, 2004

 

5.25:1.00

 

Fiscal Quarter Ended September 30, 2004

 

6.50:1.00

 

Fiscal Quarter Ended December 31, 2004

 

9.75:1.00

 

Fiscal Quarter Ended March 31, 2005

 

10.50:1.00

 

Fiscal Quarter Ended June 30, 2005

 

10.75:1.00

 

Fiscal Quarter Ended September 30, 2005

 

10.75:1.00

 

Fiscal Quarter Ended December 31, 2005

 

10.00:1.00

 

Fiscal Quarter Ended March 31, 2006

 

3.75:1.00

 

Fiscal Quarter Ended June 30, 2006

 

3.75:1.00

 

Fiscal Quarter Ended September 30, 2006

 

3.25:1.00

 

Fiscal Quarter Ended December 31, 2006

 

3.25:1.00

 

Fiscal Quarter Ended March 31, 2007

 

3.00:1.00

 

Fiscal Quarter Ended June 30, 2007

 

3.00:1.00

 

Fiscal Quarter Ended September 30, 2007

 

2.75:1.00

 

Fiscal Quarter Ended December 31, 2007

 

2.75:1.00

 

Fiscal Quarter Ended March 31, 2008

 

2.50:1.00

 

Fiscal Quarter Ended June 30, 2008

 

2.50:1.00

 

Fiscal Quarter Ended September 30, 2008 and each Fiscal Quarter thereafter

 

2.25:1.00

 

 

(B)                                 SECTION 7.17 OF THE CREDIT AGREEMENT IS
HEREBY AMENDED BY DELETING SAID SECTION IN ITS ENTIRETY AND SUBSTITUTING IN LIEU
THEREOF THE FOLLOWING NEW SECTION TO READ IN ITS ENTIRETY AS FOLLOWS:

 

Section 7.17.  Fixed Charge Coverage Ratio.  The Borrowers shall not permit the
Fixed Charge Coverage Ratio, determined on a consolidated basis for the
Borrowers and their consolidated Subsidiaries, for the twelve (12) months ending
as of the last day of any Fiscal Quarter, to be less than the amount specified
in the table below for the corresponding period specified below for each Fiscal
Quarter.

 

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Quarterly Period

 

Minimum Fixed Charge
Coverage Ratio

 

Fiscal Quarter Ended June 30, 2004

 

1.50:1.00

 

Fiscal Quarter Ended September 30, 2004

 

1.50:1.00

 

Fiscal Quarter Ended December 31, 2004

 

0.85:1.00

 

Fiscal Quarter Ended March 31, 2005

 

0.75:1.00

 

Fiscal Quarter Ended June 30, 2005

 

0.55:1.00

 

Fiscal Quarter Ended September 30, 2005

 

0.50:1.00

 

Fiscal Quarter Ended December 31, 2005

 

0.50:1.00

 

Fiscal Quarter Ended March 31, 2006

 

2.00:1.00

 

Fiscal Quarter Ended June 30, 2006

 

2.00:1.00

 

Fiscal Quarter Ended September 30, 2006

 

2.25:1.00

 

Fiscal Quarter Ended December 31, 2006

 

2.25:1.00

 

Fiscal Quarter Ended March 31, 2007

 

2.75:1.00

 

Fiscal Quarter Ended June 30, 2007

 

2.75:1.00

 

Fiscal Quarter Ended September 30, 2007

 

2.75:1.00

 

Fiscal Quarter Ended December 31, 2007

 

2.75:1.00

 

Fiscal Quarter Ended March 31, 2008 and each Fiscal Quarter thereafter

 

3.25:1.00

 

 

(C)                                  THE DEFINITION OF “APPLICABLE PERCENTAGE”
IN SECTION 1.1 OF THE CREDIT AGREEMENT IS HEREBY AMENDED BY DELETING SAID
DEFINITION IN ITS ENTIRETY AND SUBSTITUTING IN LIEU THEREOF THE FOLLOWING NEW
DEFINITION TO READ IN ITS ENTIRETY AS FOLLOWS:

 

“APPLICABLE PERCENTAGE” MEANS (A) THREE PERCENT (3%), IN THE CASE OF A
PREPAYMENT OR REDUCTION ON OR PRIOR TO MARCH 1, 2006, (B) TWO PERCENT (2%), IN
THE CASE OF A PREPAYMENT OR REDUCTION AFTER MARCH 1, 2006 BUT ON OR PRIOR TO
MARCH 1, 2007, AND (C) ONE PERCENT (1%), IN THE CASE OF A PREPAYMENT OR
REDUCTION AFTER MARCH 1, 2007, BUT ON OR PRIOR TO MARCH 1, 2008.

 

2.                                      REPRESENTATIONS AND WARRANTIES.  EACH
BORROWER HEREBY JOINTLY AND SEVERALLY REPRESENTS AND WARRANTS TO THE AGENT AND
THE LENDERS THAT (A) THIS AMENDMENT AND THE CONFIRMATION OF GUARANTY ATTACHED
HERETO HAVE EACH BEEN DULY AUTHORIZED, EXECUTED AND DELIVERED BY BORROWERS AND
EACH CREDIT PARTY SIGNATORY THERETO, (B) NO DEFAULT OR EVENT OF DEFAULT HAS
OCCURRED AND IS CONTINUING AS OF THIS DATE AFTER GIVING EFFECT TO THIS
AMENDMENT, AND (C) AFTER GIVING EFFECT TO THIS AMENDMENT, ALL OF THE
REPRESENTATIONS AND WARRANTIES MADE BY BORROWERS OR ANY CREDIT PARTY IN THE
CREDIT AGREEMENT ARE TRUE AND CORRECT IN ALL MATERIAL RESPECTS ON AND AS OF THE
DATE OF THIS AMENDMENT (EXCEPT TO THE EXTENT THAT ANY SUCH REPRESENTATIONS OR
WARRANTIES EXPRESSLY REFERRED TO A SPECIFIC PRIOR DATE OR HAVE CHANGED BASED
UPON EVENTS EXPRESSLY PERMITTED BY THE CREDIT AGREEMENT).

 

3.                                      CONDITIONS TO EFFECTIVENESS.  THIS
AMENDMENT SHALL BE EFFECTIVE AS OF THE DATE OF THIS AMENDMENT FIRST SET FORTH
ABOVE UPON THE SATISFACTION IN FULL OF EACH OF THE FOLLOWING CONDITIONS:

 

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(A)                                  THE AGENT SHALL HAVE RECEIVED COUNTERPARTS
OF THIS AMENDMENT, DULY EXECUTED, COMPLETED AND DELIVERED BY GE CAPITAL AND EACH
OF THE CREDIT PARTIES;

 

(b)                                 the Agent shall have received the
Confirmation of Guaranty duly executed by Curative Health Services III Co.;

 

(C)                                  THE AGENT SHALL HAVE RECEIVED A
FULLY-EARNED AND NON-REFUNDABLE AMENDMENT FEE IN THE AMOUNT OF $200,000.

 

4.                                      RELEASE. 
(A)                              EACH CREDIT PARTY, ON BEHALF OF ITSELF AND ITS
SUCCESSORS, ASSIGNS, AND OTHER LEGAL REPRESENTATIVES, HEREBY ABSOLUTELY,
UNCONDITIONALLY AND IRREVOCABLY RELEASES, REMISES AND FOREVER DISCHARGES GE
CAPITAL, AGENT AND LENDERS, AND THEIR SUCCESSORS AND ASSIGNS, AND THEIR PRESENT
AND FORMER SHAREHOLDERS, AFFILIATES, SUBSIDIARIES, DIVISIONS, PREDECESSORS,
DIRECTORS, OFFICERS, ATTORNEYS, EMPLOYEES, AGENTS AND OTHER REPRESENTATIVES (GE
CAPITAL, AGENT, EACH LENDER AND ALL SUCH OTHER PERSONS BEING HEREINAFTER
REFERRED TO COLLECTIVELY AS THE “RELEASEES” AND INDIVIDUALLY AS A “RELEASEE”),
OF AND FROM ALL DEMANDS, ACTIONS, CAUSES OF ACTION, SUITS, CONTROVERSIES, SUMS
OF MONEY, ACCOUNTS, BILLS, RECKONINGS, DAMAGES AND ANY AND ALL OTHER CLAIMS,
COUNTERCLAIMS, DEFENSES, RIGHTS OF SET OFF, DEMANDS AND LIABILITIES WHATSOEVER
(INDIVIDUALLY, A “CLAIM” AND COLLECTIVELY, “CLAIMS”) OF EVERY NAME AND NATURE,
KNOWN OR UNKNOWN, SUSPECTED OR UNSUSPECTED, BOTH AT LAW AND IN EQUITY, WHICH
SUCH CREDIT PARTY OR ANY OF ITS SUCCESSORS, ASSIGNS, OR OTHER LEGAL
REPRESENTATIVES MAY NOW OR HEREAFTER OWN, HOLD, HAVE OR CLAIM TO HAVE AGAINST
THE RELEASEES OR ANY OF THEM FOR, UPON, OR BY REASON OF ANY CIRCUMSTANCE,
ACTION, CAUSE OR THING WHATSOEVER WHICH ARISES AT ANY TIME ON OR PRIOR TO THE
DATE THAT THIS AMENDMENT IS EXECUTED BY ALL PARTIES, INCLUDING, WITHOUT
LIMITATION, FOR OR ON ACCOUNT OF, OR IN RELATION TO, OR IN ANY WAY IN CONNECTION
WITH THE CREDIT AGREEMENT OR ANY OF THE OTHER LOAN DOCUMENTS OR TRANSACTIONS
THEREUNDER OR RELATED THERETO AND WHICH ARISE AT ANY TIME ON OR PRIOR TO THE
DATE THAT THIS AMENDMENT IS EXECUTED BY ALL PARTIES.

 

(b)                                 Each Credit Party understands, acknowledges
and agrees that its release set forth above may be pleaded as a full and
complete defense and may be used as a basis for an injunction against any
action, suit or other proceeding which may be instituted, prosecuted or
attempted in breach of the provisions of such release.

 

(c)                                  Each Credit Party agrees that no fact,
event, circumstance, evidence or transaction which could now be asserted or
which may hereafter be discovered shall affect in any manner the final, absolute
and unconditional nature of the release set forth above.

 

5.                                      Covenant Not to Sue.  Each Credit Party,
on behalf of itself and its successors, assigns, and other legal
representatives, hereby absolutely, unconditionally and irrevocably, covenants
and agrees with and in favor of each Releasee that it will not sue (at law, in
equity, in any regulatory proceeding or otherwise) any Releasee on the basis of
any Claim released, remised and discharged by such Credit Party pursuant to
Section 4 above.  If any Credit Party or any of their respective successors,
assigns or other legal representations violates the foregoing covenant, each
Credit Party, for themselves and their successors, assigns and legal
representatives, jointly and severally agree to pay, in addition to such other
damages as any

 

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Releasee may sustain as a result of such violation, all attorneys’ fees and
costs incurred by any Releasee as a result of such violation.

 

6.                                      REIMBURSEMENT OF EXPENSES.  EACH
BORROWER HEREBY AGREES THAT IT SHALL REIMBURSE THE AGENT AND THE LENDERS ON
DEMAND FOR ALL COSTS AND EXPENSES (INCLUDING WITHOUT LIMITATION ATTORNEY’S FEES)
INCURRED BY SUCH PARTIES IN CONNECTION WITH THE NEGOTIATION, DOCUMENTATION AND
CONSUMMATION OF THIS AMENDMENT AND THE OTHER DOCUMENTS EXECUTED IN CONNECTION
HEREWITH AND THEREWITH AND THE TRANSACTIONS CONTEMPLATED HEREBY AND THEREBY.

 

7.                                      GOVERNING LAW.  THIS AMENDMENT SHALL BE
GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK
FOR CONTRACTS TO BE PERFORMED ENTIRELY WITHIN SAID STATE.

 

8.                                      SEVERABILITY OF PROVISIONS.  ANY
PROVISION OF THIS AMENDMENT WHICH IS PROHIBITED OR UNENFORCEABLE IN ANY
JURISDICTION SHALL, AS TO SUCH JURISDICTION, BE INEFFECTIVE TO THE EXTENT OF
SUCH PROHIBITION OR UNENFORCEABILITY WITHOUT INVALIDATING THE REMAINING
PROVISIONS HEREOF OR AFFECTING THE VALIDITY OR ENFORCEABILITY OF SUCH PROVISION
IN ANY OTHER JURISDICTION.  TO THE EXTENT PERMITTED BY APPLICABLE LAW, EACH
CREDIT PARTY HEREBY WAIVES ANY PROVISION OF LAW THAT RENDERS ANY PROVISION
HEREOF PROHIBITED OR UNENFORCEABLE IN ANY RESPECT.

 

9.                                      COUNTERPARTS.  THIS AMENDMENT MAY BE
EXECUTED IN ANY NUMBER OF COUNTERPARTS, ALL OF WHICH SHALL BE DEEMED TO
CONSTITUTE BUT ONE ORIGINAL AND SHALL BE BINDING UPON ALL PARTIES, THEIR
SUCCESSORS AND PERMITTED ASSIGNS.  DELIVERY OF AN EXECUTED SIGNATURE PAGE HEREOF
BY FACSIMILE TRANSMISSION SHALL BE EFFECTIVE AS DELIVERY OF A MANUALLY EXECUTED
COUNTERPART HEREOF.

 

10.                               EFFECT OF THIS AMENDMENT.  EXCEPT AS
SPECIFICALLY AMENDED OR MODIFIED PURSUANT TO SECTION 1 OF THIS AMENDMENT, NO
OTHER AMENDMENTS, CHANGES, MODIFICATIONS, CONSENTS OR WAIVERS TO THE LOAN
DOCUMENTS ARE INTENDED OR IMPLIED BY THIS AMENDMENT AND IN ALL OTHER RESPECTS
THE LOAN DOCUMENTS ARE HEREBY SPECIFICALLY RATIFIED, RESTATED AND CONFIRMED BY
ALL PARTIES HERETO AS OF THE EFFECTIVE DATE HEREOF.  TO THE EXTENT OF CONFLICT
BETWEEN THE TERMS OF THIS AMENDMENT AND THE OTHER LOAN DOCUMENTS, THE TERMS OF
THIS AMENDMENT SHALL CONTROL.  THE CREDIT AGREEMENT AND THIS AMENDMENT SHALL BE
READ AND CONSTRUED AS ONE AGREEMENT.

 

11.                               ENTIRE AGREEMENT.  THE CREDIT AGREEMENT AS
AMENDED BY THIS AMENDMENT EMBODIES THE ENTIRE AGREEMENT BETWEEN THE PARTIES
HERETO RELATING TO THE SUBJECT MATTER HEREOF AND SUPERSEDES ALL PRIOR
AGREEMENTS, REPRESENTATIONS AND UNDERSTANDINGS, IF ANY, RELATING TO THE SUBJECT
MATTER HEREOF.

 

[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]

 

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IN WITNESS WHEREOF, the parties have caused this Fourth Amendment to Amended and
Restated Credit Agreement to be duly executed by their respective officers
thereunto duly authorized, as of the date first above written.

 

 

BORROWERS:

 

 

 

CURATIVE HEALTH SERVICES, INC.,

 

a Minnesota corporation formerly known as
Curative Holding Co.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

EBIOCARE.COM, INC.

 

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

HEMOPHILIA ACCESS, INC.

 

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

APEX THERAPEUTIC CARE, INC.

 

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

[Signature page to Fourth Amendment to Amended and Restated Credit Agreement

 

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CHS SERVICES, INC.

 

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

CURATIVE HEALTH SERVICES OF NEW
YORK, INC.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

OPTIMAL CARE PLUS, INC.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

INFINITY INFUSION, LLC

 

 

 

By: Curative Health Services Co., its Sole
Member

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

[Signature page to Fourth Amendment to Amended and Restated Credit Agreement]

 

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INFINITY INFUSION II, LLC

 

 

 

By: Curative Health Services Co., its Sole
Member

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

INFINITY INFUSION CARE, LTD.

 

 

 

By: Infinity Infusion  II, LLC, its Sole General
Partner

 

 

 

By: Curative Health Services Co., the Sole
Member of Infinity Infusion II, LLC

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

MEDCARE, INC.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

CURATIVE PHARMACY SERVICES, INC.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

[Signature page to Fourth Amendment to Amended and Restated Credit Agreement]

 

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CURATIVE HEALTH SERVICES CO.,
a Minnesota corporation formerly known as
Curative Health Services, Inc.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

CRITICAL CARE SYSTEMS, INC.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

GUARANTORS:

 

 

 

CURATIVE HEALTH SERVICES III CO.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

[Signature page to Fourth Amendment to Amended and Restated Credit Agreement]

 

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GENERAL ELECTRIC CAPITAL
CORPORATION, as Lender and Agent

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Its Duly Authorized Signatory

 

Date:

 

 

 

[Signature page to Fourth Amendment to Amended and Restated Credit Agreement]

 

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CONFIRMATION OF GUARANTY

 

The undersigned Guarantor hereby (a) acknowledges, consents and agrees to the
terms of the foregoing Fourth Amendment to Amended and Restated Credit Agreement
(the “Amendment”), including without limitation, the amendments to the Amended
and Restated Credit Agreement set forth therein, and (b) agrees and confirms
that its obligations under the Guaranty Agreement to which it is a party will
continue in full force and effect and extend to all Obligations under and as
defined in the Amended and Restated Credit Agreement as amended and modified by
(i) that certain First Amendment to Amended and Restated Credit Agreement and
Collateral Documents dated as of May 3, 2004, (ii) that certain Second Amendment
to Amended and Restated Credit Agreement dated as of June 30, 2004, (iii) that
certain Third Amendment to Amended and Restated Credit Agreement dated as of
October 20, 2004 and (iv) the Amendment.

 

As of this 28th day of February, 2005.

 

 

 

CURATIVE HEALTH SERVICES III CO.

 

 

 

 

 

By:

 

 

 

Name:

 

 

 

Title:

 

 

 

Date:

 

 

 

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