Exhibit 10.3

 

PLACEMENT AGENT WARRANT

 

INTELLINETICS, INC.

Warrant No. PA4-[00__]

WARRANT TO PURCHASE COMMON STOCK

 

VOID AFTER 5:00 P.M., EASTERN TIME,
ON THE EXPIRATION DATE

 

THIS WARRANT AND ANY SHARES ACQUIRED UPON THE EXERCISE OF THIS WARRANT HAVE NOT
BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE
STATE SECURITIES LAWS, AND MAY NOT BE OFFERED FOR SALE, SOLD, PLEDGED,
HYPOTHECATED, DONATED OR OTHERWISE TRANSFERRED IN THE ABSENCE OF SUCH
REGISTRATION OR AN APPLICABLE EXEMPTION FROM SUCH REGISTRATION.

 

FOR VALUE RECEIVED, Intellinetics, Inc., a Nevada corporation (the “Company”),
hereby agrees to sell upon the terms and on the conditions hereinafter set
forth, at any time commencing on the date hereof but no later than 5:00 p.m.,
Eastern Time, on [September 29, 2023] (the “Expiration Date”), to
________________, or its registered assigns (the “Holder”), under the terms as
hereinafter set forth, [___________ (_______)] fully paid and non-assessable
shares of the Company’s Common Stock, par value $0.001 per share (the “Common
Stock”), at a purchase price per share of Eighteen cents ($0.18) (the “Warrant
Price”), pursuant to the terms and conditions set forth in this warrant (this
“Warrant”). The number of shares of Common Stock issued upon exercise of this
Warrant (“Warrant Shares”) and the Warrant Price are subject to adjustment in
certain events as hereinafter set forth.

 

1.                   Exercise of Warrant.

 

(a)                 The Holder may exercise this Warrant at any time after
issuance according to the terms and conditions set forth herein by delivering to
the Company, at the address of the Company set forth in Section 10 prior to 5:00
p.m., Eastern Time, at any time prior to the Expiration Date (such date of
exercise, the “Exercise Date”) (i) this Warrant, (ii) the Subscription Form
attached hereto as Exhibit A (the “Subscription Form”) (having then been duly
executed by the Holder), (iii) unless the Warrant is being exercised pursuant to
a Cashless Exercise (as defined below), cash, a certified check or a bank draft
in payment of the purchase price, in lawful money of the United States of
America, for the number of Warrant Shares specified in the Subscription Form.

 

(b)                This Warrant may be exercised in whole or in part so long as
any exercise in part hereof would not involve the issuance of fractional Warrant
Shares. If exercised in part, the Company shall deliver to the Holder a new
Warrant, identical in form to this Warrant, in the name of the Holder,
evidencing the right to purchase the number of Warrant Shares as to which this
Warrant has not been exercised, which new Warrant shall be signed by the
President or Chief Executive Officer of the Company. The term Warrant as used
herein shall include any subsequent Warrant issued as provided herein.

 

(c)                 Notwithstanding any provisions herein to the contrary, in
lieu of exercising this Warrant in the manner set forth in Section 1(a), the
Holder may elect to exercise this Warrant, or a portion hereof, and to pay for
the Warrant Shares by way of cashless exercise (a “Cashless Exercise”). If the
Holder wishes to effect a cashless exercise, the Holder shall deliver the
Exercise Notice duly executed by such Holder or by such Holder’s duly authorized
attorney, at the principal office of the Company, or at such other office or
agency as the Company may designate in writing prior to the date of such
exercise, in which event the Company shall issue to the registered Holder the
number of Warrant Shares computed according to the following equation:

 

 1 

 

 

[image_001.jpg]

; where

X = the number of Warrant Shares to be issued to the registered Holder.

 

Y = the Warrant Shares purchasable under this Warrant or, if only a portion of
the Warrant is being exercised, the portion of the Warrant Shares being
exercised.

 

A = the Fair Market Value (defined below) of one share of Common Stock on the
Exercise Date.

 

B = the Exercise Price (as adjusted pursuant to the provisions of this Warrant).

 

For purposes of this Section 1(c), the “Fair Market Value” of one share of
Common Stock on the Exercise Date shall have one of the following meanings:

 

(1)       if the Common Stock is traded on a national securities exchange, the
Fair Market Value shall be deemed to be the Closing Price on the trading day
preceding the Exercise Date. For the purposes of this Warrant, “Closing Price”
means the closing sale price of one share of Common Stock, as reported by
Bloomberg; or

 

(2)       if the Common Stock is traded over-the-counter, the Fair Market Value
shall be deemed to be the Closing Price on the trading day immediately preceding
the Exercise Date; or

 

(3)       if neither (1) nor (2) is applicable, the Fair Market Value shall be
at the commercially reasonable price per share which the Company could obtain on
the Exercise Date from a willing buyer (not a current employee or director) for
shares of Common Stock sold by the Company, from authorized but unissued shares,
as determined in good faith by the Company’s Board of Directors.

 

For illustration purposes only, if this Warrant entitles the Holder the right to
purchase 100,000 Warrant Shares and the Holder were to exercise this Warrant for
50,000 Warrant Shares at a time when the Exercise Price per share was $1.00 and
the Fair Market Value of each share of Common Stock was $2.00 on the Exercise
Date, as applicable, the cashless exercise calculation would be as follows:

 

X = 50,000 ($2.00-$1.00)

2.00

 

X = 25,000

 

Therefore, the number of Warrant Shares to be issued to the Holder after giving
effect to the cashless exercise would be 25,000 Warrant Shares and the Company
would issue the Holder a new Warrant to purchase 50,000 Warrant Shares,
reflecting the portion of this Warrant not exercised by the Holder. For purposes
of Rule 144 promulgated under the Securities Act of 1933, as amended (the
“Securities Act”), it is intended, understood and acknowledged that the Warrant
Shares issued in the cashless exercise transaction described pursuant to Section
1(c) shall be deemed to have been acquired by the Holder, and the holding period
for the shares of Warrant Shares shall be deemed to have commenced, on the date
of the Holder’s acquisition of the Warrant.

 

(d)                No fractional Warrant Shares or scrip representing fractional
Warrant Shares shall be issued upon the exercise of this Warrant. The Company
shall pay cash in lieu of such fractional Warrant Shares. The price of a
fractional Warrant Share shall equal the product of (i) the closing price of the
Common Stock on the exchange or market on which the Common Stock is then traded
(if the Common Stock is not then publicly traded, then upon the fair market
value per share of the Common Stock (as determined by the Company’s Board of
Directors)), and (ii) the applicable fraction.

 

(e)                 In the event of any exercise of the rights represented by
this Warrant, a certificate or certificates for Warrant Shares so purchased,
registered in the name of the Holder on the stock transfer books of the Company,
shall be delivered to the Holder within a reasonable time after such rights
shall have been so exercised. The person or entity in whose name any certificate
for Warrant Shares is issued upon exercise of the rights represented by this
Warrant shall for all purposes be deemed to have become the holder of record of
such Warrant Shares immediately prior to the close of business on the date on
which the Warrant was surrendered and payment of the Warrant Price and any
applicable taxes was made, irrespective of the date of delivery of such
certificate, except that, if the date of such surrender and payment is a date
when the stock transfer books of the Company are closed, such person shall be
deemed to have become the holder of such shares at the opening of business on
the next succeeding date on which the Company’s stock transfer books are open.
Except as provided in Section 4 hereof, the Company shall pay any and all
documentary stamp or similar issue payable in respect of the issue or delivery
of Warrant Shares on exercise of this Warrant.

 

 2 

 

 

(f)                  The Company will not close its stockholder books or records
in any manner which prevents the timely exercise of this Warrant, pursuant to
the terms hereof.

 

2.                   Disposition of Warrant Shares and Warrant.

 

(a)                 The Holder hereby acknowledges that: (i) this Warrant and
any Warrant Shares purchased pursuant hereto are not being registered (A) under
the Securities Act of 1933 (the “Act”) on the ground that the issuance of this
Warrant is exempt from registration under Section 4(a)(2) of the Act as not
involving any public offering, or (B) under any applicable state securities law
because the issuance of this Warrant does not involve any public offering; and
(ii) that the Company’s reliance on the registration exemption under Section
4(a)(2) of the Act and under applicable state securities laws is predicated in
part on the representations hereby made to the Company by the Holder. The Holder
represents and warrants that he, she or it is acquiring this Warrant and will
acquire Warrant Shares for investment for his, her or its own account, with no
present intention of dividing his, her or its participation with others or
reselling or otherwise distributing this Warrant or Warrant Shares.

 

(b)                The Holder hereby agrees that he, she or it will not sell,
transfer, pledge or otherwise dispose of (collectively, “Transfer”) all or any
part of this Warrant and/or Warrant Shares unless and until he, she or it shall
have first have given notice to the Company describing such Transfer and
furnished to the Company (i) a statement from the transferee, whereby the
transferee represents and warrants that he, she, or it is acquiring this Warrant
and will acquire Warrant Shares, as applicable, for investment for his, her or
its own account, with no present intention of dividing his, her or its
participation with others or reselling or otherwise distributing this Warrant or
Warrant Shares, as applicable, and either (ii) an opinion, reasonably
satisfactory to counsel for the Company, of counsel (competent in securities
matters, selected by the Holder and reasonably satisfactory to the Company) to
the effect that the proposed Transfer may be made without registration under the
Act and without registration or qualification under any state law, or (iii) an
interpretative letter from the U.S. Securities and Exchange Commission to the
effect that no enforcement action will be recommended if the proposed sale or
transfer is made without registration under the Act.

 

(c)                 If, at the time of issuance of Warrant Shares, no
registration statement is in effect with respect to such shares under applicable
provisions of the Act, the Company may, at its election, require that (i) the
Holder provide written reconfirmation of the Holder’s investment intent to the
Company, and (ii) any stock certificate evidencing Warrant Shares shall bear
legends reading substantially as follows:

 

“THE SALE, TRANSFER, PLEDGE OR OTHER DISPOSITION OF THE SHARES REPRESENTED BY
THIS CERTIFICATE IS SUBJECT TO CERTAIN RESTRICTIONS SET FORTH IN THE WARRANT
PURSUANT TO WHICH THESE SHARES WERE PURCHASED FROM THE COMPANY. COPIES OF SUCH
RESTRICTIONS ARE ON FILE AT THE PRINCIPAL OFFICES OF THE COMPANY. NO TRANSFER OF
SUCH SHARES OR OF THIS CERTIFICATE (OR OF ANY SHARES OR OTHER SECURITIES (OR
CERTIFICATES THEREFOR) ISSUED IN EXCHANGE FOR OR IN RESPECT OF SUCH SHARES)
SHALL BE EFFECTIVE UNLESS AND UNTIL THE TERMS AND CONDITIONS SET FORTH IN THE
WARRANT HAVE BEEN COMPLIED WITH.”

 

“THE SHARES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE
SECURITIES ACT OF 1933, AND MAY NOT BE SOLD, TRANSFERRED, PLEDGED OR OTHERWISE
DISPOSED OF IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT UNDER THE
SECURITIES ACT OF 1933 (THE “ACT”) OR AN OPINION OF COUNSEL SATISFACTORY TO THE
ISSUER OF THIS CERTIFICATE THAT REGISTRATION IS NOT REQUIRED UNDER THE ACT.”

 

 3 

 

 

In addition, so long as the foregoing legend may remain on any stock certificate
evidencing Warrant Shares, the Company may maintain appropriate “stop transfer”
orders with respect to such certificates and the shares represented thereby on
its books and records and with those to whom it may delegate registrar and
transfer functions.

 

3.                   Reservation of Shares. The Company hereby agrees that at
all times there shall be reserved for issuance upon the exercise of this Warrant
such number of shares of the Common Stock as shall be required for issuance upon
exercise of this Warrant. The Company further agrees that all Warrant Shares
will be duly authorized and will, upon issuance and payment of the exercise
price therefor, be validly issued, fully paid and non-assessable, free from all
taxes, liens, charges and encumbrances with respect to the issuance thereof,
other than taxes, if any, in respect of any transfer occurring contemporaneously
with such issuance and other than transfer restrictions imposed by federal and
state securities laws.

 

Except and to the extent as waived or consented to by the Holder, the Company
shall not by any action, including, without limitation, amending its certificate
or articles of incorporation or through any reorganization, transfer of assets,
consolidation, merger, dissolution, issue or sale of securities or any other
voluntary action, avoid or seek to avoid the observance or performance of any of
the terms of this Warrant, but will at all times in good faith assist in the
carrying out of all such terms and in the taking of all such actions as may be
necessary or appropriate to protect the rights of Holder as set forth in this
Warrant. Without limiting the generality of the foregoing, the Company will (a)
not increase the par value of any Warrant Shares above the amount payable
therefor upon such exercise immediately prior to such increase in par value, (b)
take all such action as may be necessary or appropriate in order that the
Company may validly and legally issue fully paid and nonassessable Warrant
Shares upon the exercise of this Warrant, and (c) use commercially reasonable
efforts to obtain all such authorizations, exemptions or consents from any
public regulatory body having jurisdiction thereof as may be necessary to enable
the Company to perform its obligations under this Warrant.

 

Before taking any action which would result in an adjustment in the number of
Warrant Shares for which this Warrant is exercisable or in the Exercise Price,
the Company shall obtain all such authorizations or exemptions thereof, or
consents thereto, as may be necessary from any public regulatory body or bodies
having jurisdiction thereof.

 

4.                   Exchange, Transfer or Assignment of Warrant. Subject to
Section 2, this Warrant is exchangeable, without expense, at the option of the
Holder, upon presentation and surrender hereof to the Company or at the office
of its stock transfer agent, if any, for other Warrants of the Company
(“Warrants”) of different denominations, entitling the Holder or Holders thereof
to purchase in the aggregate the same number of Warrant Shares purchasable
hereunder. Subject to Section 2, upon surrender of this Warrant to the Company
or at the office of its stock transfer agent, if any, together with (a) the
Assignment Form attached hereto as Exhibit B (the “Assignment Form”) duly
executed, (b) an opinion of counsel to the Holder (if required by the Company),
in a form reasonably acceptable to the Company, that registration under the
Securities Act is not required, and (c) funds sufficient to pay any transfer
tax, the Company shall, without charge, execute and deliver a new Warrant in the
name of the assignee named in the Assignment Form and this Warrant shall
promptly be canceled. Subject to Section 2, this Warrant may be divided or
combined with other Warrants that carry the same rights upon presentation hereof
at the office of the Company or at the office of its stock transfer agent, if
any, together with a written notice specifying the names and denominations in
which new Warrants are to be issued and signed by the Holder hereof.

 

5.                   Capital Adjustments. This Warrant is subject to the
following further provisions:

 

(a)                 Recapitalization, Reclassification and Succession. If any
recapitalization of the Company or reclassification of its Common Stock or any
merger or consolidation of the Company into or with a corporation or other
business entity, or the sale or transfer of all or substantially all of the
Company’s assets or of any successor corporation’s assets to any other
corporation or business entity (any such corporation or other business entity
being included within the meaning of the term “successor corporation”) shall be
effected, at any time while this Warrant remains outstanding and unexpired,
then, as a condition of such recapitalization, reclassification, merger,
consolidation, sale or transfer, lawful and adequate provision shall be made
whereby the Holder of this Warrant thereafter shall have the right to receive
upon the exercise hereof as provided in Section 1 and in lieu of the Warrant
Shares immediately theretofore issuable upon the exercise of this Warrant, such
shares of capital stock, securities or other property as may be issued or
payable with respect to or in exchange for the number of outstanding shares of
Common Stock equal to the number of Warrant Shares immediately theretofore
issuable upon the exercise of this Warrant had such recapitalization,
reclassification, merger, consolidation, sale or transfer not taken place, and
in each such case, the terms of this Warrant shall be applicable to the shares
of stock or other securities or property receivable upon the exercise of this
Warrant after such consummation.

 

 4 

 

 

(b)                Subdivision or Combination of Shares. If the Company at any
time while this Warrant remains outstanding and unexpired shall subdivide or
combine its Common Stock, the number of Warrant Shares purchasable upon exercise
of this Warrant shall be proportionately adjusted.

 

(c)                 Stock Dividends and Distributions. If the Company at any
time while this Warrant is outstanding and unexpired shall issue or pay the
holders of its Common Stock, or take a record of the holders of its Common Stock
for the purpose of entitling them to receive, a dividend payable in, or other
distribution of, Common Stock, then the number of Warrant Shares purchasable
upon exercise of this Warrant shall be adjusted to the number of shares of
Common Stock that Holder would have owned immediately following such action had
this Warrant been exercised immediately prior thereto.

 

(d)                Price Adjustments. Whenever the number of Warrant Shares
purchasable upon exercise of this Warrant is adjusted pursuant to Sections 5(b),
5(c) or 5(d), the then applicable Warrant Price shall be proportionately
adjusted.

 

(e)                 Certain Shares Excluded. The number of shares of Common
Stock outstanding at any given time for purposes of the adjustments set forth in
this Section 5 shall exclude any shares then directly or indirectly held in the
treasury of the Company.

 

(f)                  Deferral and Cumulation of De Minimis Adjustments. The
Company shall not be required to make any adjustment pursuant to this Section 5
if the amount of such adjustment would be less than one percent (1%) of the
Warrant Price in effect immediately before the event that would otherwise have
given rise to such adjustment. In such case, however, any adjustment that would
otherwise have been required to be made shall be made at the time of and
together with the next subsequent adjustment which, together with any adjustment
or adjustments so carried forward, shall amount to not less than one percent
(1%) of the Warrant Price in effect immediately before the event giving rise to
such next subsequent adjustment. All calculations under this Section 5 shall be
made to the nearest cent or to the nearest one-hundredth of a share, as the case
may be, but in no event shall the Company be obligated to issue fractional
Warrant Shares or fractional portions of any securities upon the exercise of the
Warrant.

 

(g)                Duration of Adjustment. Following each computation or
readjustment as provided in this Section 5, the new adjusted Warrant Price and
number of Warrant Shares purchasable upon exercise of this Warrant shall remain
in effect until a further computation or readjustment thereof is required.

 

(h)                Notwithstanding any other provision, the Company shall have
the right to increase the number of authorized shares and outstanding shares
without the Holder receiving any additional Warrant or Warrant Shares as a
result thereof.

 

 5 

 

 

6.                   Notice to Holders.

 

(a)                 Notice of Record Date. In case:

 

(i)                  the Company shall take a record of the holders of its
Common Stock (or other stock or securities at the time receivable upon the
exercise of this Warrant) for the purpose of entitling them to receive any
dividend (other than a cash dividend payable out of earned surplus of the
Company) or other distribution, or any right to subscribe for or purchase any
shares of stock of any class or any other securities, or to receive any other
right;

 

(ii)                of any capital reorganization of the Company, any
reclassification of the capital stock of the Company, any consolidation with or
merger of the Company into another corporation, or any conveyance of all or
substantially all of the assets of the Company to another corporation; or

 

(iii)              of any voluntary dissolution, liquidation or winding-up of
the Company;

 

then, and in each such case, the Company will mail or cause to be mailed to the
Holder hereof at the time outstanding a notice specifying, as the case may be,
(i) the date on which a record is to be taken for the purpose of such dividend,
distribution or right, and stating the amount and character of such dividend,
distribution or right, or (ii) the date on which such reorganization,
reclassification, consolidation, merger, conveyance, dissolution, liquidation or
winding-up is to take place, and the time, if any, is to be fixed, as of which
the holders of record of Common Stock (or such stock or securities at the time
receivable upon the exercise of this Warrant) shall be entitled to exchange
their shares of Common Stock (or such other stock or securities) for securities
or other property deliverable upon such reorganization, reclassification,
consolidation, merger, conveyance, dissolution or winding-up. Such notice shall
be mailed at least ten (10) calendar days prior to the record date therein
specified, or if no record date shall have been specified therein, at least ten
(10) days prior to such specified date.

 

(b)                Certificate of Adjustment. Whenever any adjustment shall be
made pursuant to Section 5 hereof, the Company shall promptly make a certificate
signed by its Chairman, Chief Executive Officer, President, Vice President,
Chief Financial Officer or Treasurer, setting forth in reasonable detail the
event requiring the adjustment, the amount of the adjustment, the method by
which such adjustment was calculated and the Warrant Price and number of Warrant
Shares purchasable upon exercise of this Warrant after giving effect to such
adjustment, and shall promptly cause copies of such certificates to be mailed
(by first class mail, postage prepaid) to the Holder of this Warrant.

 

7.                   Loss, Theft, Destruction or Mutilation. Upon receipt by the
Company of evidence satisfactory to it, in the exercise of its reasonable
discretion, of the ownership and the loss, theft, destruction or mutilation of
this Warrant and, in the case of loss, theft or destruction, of indemnity
reasonably satisfactory to the Company and, in the case of mutilation, upon
surrender and cancellation thereof, the Company will execute and deliver in lieu
thereof, without expense to the Holder, a new Warrant of like tenor dated the
date hereof.

 

8.                   Warrant Holder Not a Stockholder. The Holder of this
Warrant, as such, shall not be entitled by reason of this Warrant to any rights
whatsoever as a stockholder of the Company, including but not limited to voting
rights. No provision hereof, in the absence of any affirmative action by Holder
to exercise this Warrant to purchase Warrant Shares, and no enumeration herein
of the rights or privileges of Holder, shall give rise to any liability of
Holder for the purchase price of any Common Stock or as a stockholder of the
Company, whether such liability is asserted by the Company or by creditors of
the Company.

 

9.                   Registration Rights. The Warrant Shares are entitled to
limited piggyback registration rights pursuant to the Note Purchase Agreement,
dated September [  ], 2018, by and among the Company and the purchaser
signatories thereto.

 

10.                Notices. Any notice provided for in this Warrant must be in
writing and must be either personally delivered, mailed by first class mail
(postage prepaid and return receipt requested), or sent by reputable overnight
courier service (charges prepaid) to the recipient at the address below
indicated:

 

 6 

 

 

If to the Company:

 

Intellinetics, Inc.

2190 Dividend Drive,

Columbus, OH 43228

Attention: James F. DeSocio

President and Chief Executive Officer

 

If to the Holder:

 

To the address of such Holder set forth on the books and records of the Company.

 

or such other address or to the attention of such other person as the recipient
party shall have specified by prior written notice to the sending party. Any
notice under this Warrant will be deemed to have been given (a) if personally
delivered, upon such delivery, (b) if mailed, five days after deposit in the
U.S. mail, or (c) if sent by reputable overnight courier service, one business
day after such services acknowledges receipt of the notice.

 

11.                Choice of Law. THIS WARRANT IS ISSUED UNDER AND SHALL FOR ALL
PURPOSES BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE
OF OHIO, WITHOUT GIVING EFFECT TO ITS CONFLICTS OF LAW RULES.

 

12.                Submission to Jurisdiction. EACH OF THE HOLDER AND THE
COMPANY SUBMITS TO THE JURISDICTION OF ANY STATE OR FEDERAL COURT SITTING IN THE
COUNTY OF FRANKLIN, STATE OF OHIO, IN ANY ACTION OR PROCEEDING ARISING OUT OF OR
RELATING TO THIS WARRANT AND AGREES THAT ALL CLAIMS IN RESPECT OF THE ACTION OR
PROCEEDING MAY BE HEARD AND DETERMINED IN ANY SUCH COURT. EACH OF THE HOLDER AND
THE COMPANY ALSO AGREE NOT TO BRING ANY ACTION OR PROCEEDING ARISING OUT OF OR
RELATING TO THIS WARRANT IN ANY OTHER COURT. EACH OF THE PARTIES WAIVES ANY
DEFENSE OF INCONVENIENT FORUM TO THE MAINTENANCE OF ANY ACTION OR PROCEEDING SO
BROUGHT AND WAIVES ANY BOND, SURETY, OR OTHER SECURITY THAT MIGHT BE REQUIRED OF
ANY OTHER PARTY WITH RESPECT THERETO.

 

13.                Warrant Register. The Company shall register this Warrant,
upon records to be maintained by the Company for that purpose (the “Warrant
Register”), in the name of the record Holder hereof from time to time. The
Company may deem and treat the registered Holder of this Warrant as the absolute
owner hereof for the purpose of any exercise hereof or any distribution to the
Holder, and for all other purposes, absent actual notice to the contrary.

 

14.                Miscellaneous.

 

(a)                 Remedies. Holder, in addition to being entitled to exercise
all rights granted by law, including recovery of damages, will be entitled to
specific performance of its rights under this Warrant. The Company agrees that
monetary damages would not be adequate compensation for any loss incurred by
reason of a breach by it of the provisions of this Warrant and hereby agrees to
waive and not to assert the defense in any action for specific performance that
a remedy at law would be adequate.

 

(b)                Successors and Assigns. Subject to applicable securities
laws, this Warrant and the rights and obligations evidenced hereby shall inure
to the benefit of and be binding upon the successors of the Company and the
successors and permitted assigns of Holder. The provisions of this Warrant are
intended to be for the benefit of all Holders from time to time of this Warrant
and shall be enforceable by any such Holder or holder of Warrant Shares.

 

(c)                 Amendment. This Warrant may be modified or amended or the
provisions hereof waived with the written consent of the Company and the Holder.

 

(d)                Severability. Wherever possible, each provision of this
Warrant shall be interpreted in such manner as to be effective and valid under
applicable law, but if any provision of this Warrant shall be prohibited by or
invalid under applicable law, such provision shall be ineffective to the extent
of such prohibition or invalidity, without invalidating the remainder of such
provisions or the remaining provisions of this Warrant.

 

[signature page follows]

 

 7 

 

 

IN WITNESS WHEREOF, the Company has duly caused this Warrant to be signed on its
behalf, in its corporate name and by a duly authorized officer, as of this
[_____ day of _______________, 2018].

 

  INETLLINETICS, INC.       By:       James F. DeSocio     President and Chief
Executive Officer

 

 8 

 

 

EXHIBIT A

 

SUBSCRIPTION FORM

 

Intellinetics, Inc.

2190 Dividend Drive,

Columbus, OH 43228

Attention: President and Chief Executive Officer

 

1)The undersigned hereby elects to purchase ______________ Warrant Shares of
Intellinetics, Inc., a Nevada corporation, pursuant to the terms of the attached
Warrant to Purchase Common Stock, and tenders herewith payment of the exercise
price in full, together with all applicable transfer taxes, if any.

2)Payment shall take the form of (check applicable box):

 

[  ]       in lawful money of the United States;

 

[  ]       the cancellation of __________ Warrant Shares in order to exercise
this Warrant with respect to ____________ Warrant Shares (using a Fair Market
Value of $______ for this calculation), in accordance with the formula and
procedure set forth in Section 1(c) of the Warrant; or

 

[  ]       the cancellation of such number of Warrant Shares as is necessary, in
accordance with the formula and procedure set forth in Section 1(c) of the
Warrant, to exercise this Warrant with respect to the maximum number of Warrant
Shares purchasable pursuant to a cashless exercise.

 

3)Please issue a certificate or certificates representing said Warrant Shares in
the name of the undersigned or in such other name as is specified below:

 _______________________________________________________________________________________________

 

The Warrant Shares shall be delivered to the following DWAC Account Number, if
permitted, or by physical delivery of a certificate to:

 _______________________________________________________________________________________________

 

 _______________________________________________________________________________________________

 

_______________________________________________________________________________________________

 

4)If such number of Warrant Shares shall not be all the shares receivable upon
exercise of the attached Warrant, the undersigned requests that a new Warrant
for the balance of the shares covered by the attached Warrant be registered in
the name of, and delivered to:

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

 

5)In lieu of receipt of a fractional share of Common Stock, the undersigned will
receive a check representing payment therefor.

 

 A-1 

 

 

Dated:__________________________________________         PRINT WARRANT HOLDER
NAME                 Name:     Title:       Witness:          

 

 A-2 

 

 

EXHIBIT B

 

ASSIGNMENT FORM

 

Intellinetics, Inc.

2190 Dividend Drive,

Columbus, OH 43228

Attention: President and Chief Executive Officer

 

FOR VALUE RECEIVED, _______________________________________________hereby sells,
assigns and transfers unto

 

(Please print assignee’s name, address and Social Security/Tax Identification
Number)

 

________________________________________________

 

________________________________________________

 

________________________________________________

 

the right to purchase shares of common stock, par value $0.001 per share, of
Intellinetics, Inc., a Nevada corporation (the “Company”), represented by this
Warrant to the extent of shares as to which such right is exercisable and does
hereby irrevocably constitute and appoint ____________________________,
Attorney, to transfer the same on the books of the Company with full power of
substitution in the premises.

 

Dated:__________________________________________         PRINT WARRANT HOLDER
NAME               Name:     Title:       Witness:          

 

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