EX-10.1






Exhibit 10.1



FIFTH AMENDMENT TO

AMENDED AND RESTATED LOAN AND SECURITY AGREEMENT




This FIFTH AMENDMENT TO AMENDED AND RESTATED LOAN AND SECURITY AGREEMENT (this “Amendment”) is
entered into as of September 7, 2016, by and among OXFORD FINANCE LLC, a Delaware limited liability
company with an office located at 133 North Fairfax Street, Alexandria, Virginia 22314 (“Oxford”),
as collateral agent (in such capacity, the “Collateral Agent”), the Lenders listed on Schedule
1.1 of the Loan Agreement (as defined below) or otherwise a party thereto from time to time
including Oxford in its capacity as a Lender and SILICON VALLEY BANK, a California corporation with
an office located at 3005 Carrington Mill Boulevard, Suite 530, Morrisville, North Carolina 27560
(each a “Lender” and collectively, the “Lenders”), and TRANSENTERIX, INC., a Delaware corporation
(“Parent”), TRANSENTERIX SURGICAL, INC., a Delaware corporation (“TransEnterix Surgical”),
SAFESTITCH LLC, a Virginia limited liability company (“SafeStitch”), and TRANSENTERIX
INTERNATIONAL, INC., a Delaware corporation (“TransEnterix International”, and together with
Parent, TransEnterix Surgical, and SafeStitch, individually and collectively, jointly and
severally, “Borrower”), each with offices located at 635 Davis Drive, Suite 300, Morrisville, North
Carolina 27560.



Recitals




A. Collateral Agent, Lenders and Borrower have entered into that certain Amended and Restated
Loan and Security Agreement dated as of September 26, 2014 (as amended by that certain First
Amendment to Amended and Restated Loan and Security Agreement dated as of August 14, 2015, that
certain Consent and Second Amendment to Amended and Restated Loan and Security Agreement dated as
of September 18, 2015, that certain Third Amendment to Amended and Restated Loan and Security
Agreement dated as of November 13, 2015, and that certain Consent and Fourth Amendment to Amended
and Restated Loan and Security Agreement dated as of April 19, 2016, the “Loan Agreement”).



B. Lenders have extended credit to Borrower for the purposes permitted in the Loan Agreement.



C. Borrower and Lenders desire to amend the Loan Agreement to (i) amend certain covenants and
(ii) make certain other revisions as more fully set forth below.



D. Collateral Agent and Lenders have agreed to amend certain provisions of the Loan Agreement,
but only to the extent, in accordance with the terms, subject to the conditions and in reliance
upon the representations and warranties set forth below.



Agreement




Now, Therefore, in consideration of the foregoing recitals and other good and
valuable consideration, the receipt and adequacy of which is hereby acknowledged, and intending to
be legally bound, the parties hereto agree as follows:



1. Definitions. Capitalized terms used but not defined in this Amendment shall have the
meanings given to them in the Loan Agreement.



2. Amendments to Loan Agreement.



2.1 Section 6.6 (Operating Accounts). Section 6.6(d) of the Loan Agreement is amended and
restated to read in full as follows:



“(d) Notwithstanding the foregoing provisions of this Section 6.6, any Foreign
Subsidiary may maintain Collateral Accounts with Persons who are not Silicon Valley
Bank (or its Affiliates) and outside of the United States, and no Foreign Subsidiary
shall be required to deliver a Control Agreement or other instrument granting
Collateral Agent a lien in or control over of any Collateral Account maintained by
such Foreign Subsidiary.”



2.2 Section 6.10 (Minimum Cash). Section 6.10 of the Loan Agreement is amended and restated
as follows:



“6.10 Minimum Cash. Borrower shall maintain at all times at least Ten Million
Dollars ($10,000,000.00) in cash and Cash Equivalents in Collateral Accounts at
Bank.”



2.3 Section 6.12 (Creation/Acquisition of Subsidiaries). Section 6.12 of the Loan Agreement
is amended and restated as follows:



“6.12 Creation/Acquisition of Subsidiaries. In the event Borrower, or any of
Borrower’s Subsidiaries, creates or acquires any Subsidiary (a “New Subsidiary”),
Borrower, or such Subsidiary, shall promptly notify Collateral Agent and each Lender
of the creation or acquisition of such New Subsidiary and take all such action as
may be reasonably required by Collateral Agent or any Lender to cause each such New
Subsidiary to become a co-Borrower hereunder or to guarantee the Obligations of
Borrower under the Loan Documents and, in each case, grant a continuing pledge and
security interest in and to the assets of such New Subsidiary (substantially as
described on Exhibit A hereto); and Borrower, or such Subsidiary, as
applicable, shall grant and pledge to Collateral Agent, for the ratable benefit of
the Lenders, and each Lender, a perfected security interest in the stock, units or
other evidence of ownership of each such New Subsidiary; provided, however, that
solely in the circumstance in which Borrower or any Subsidiary creates or acquires a
Foreign Subsidiary in an acquisition permitted by Section 7.7 hereof or otherwise
approved by the Required Lenders, (i) such Foreign Subsidiary shall not be required
to guarantee the Obligations of Borrower under the Loan Documents nor to grant a
continuing pledge and security interest in and to the assets of such Foreign
Subsidiary, (ii) with regard to a First-Tier Foreign Subsidiary, Borrower or the
applicable Subsidiary shall not be required to grant and pledge to Collateral Agent,
for the ratable benefit of Lenders, a perfected security interest in more than
sixty-five percent (65%) of the issued and outstanding capital stock, membership
units or other securities of such First-Tier Foreign Subsidiary, and (iii) with
regard to a Foreign Subsidiary directly owned by another Foreign Subsidiary,
Borrower and its Subsidiaries shall not be required to grant and pledge to
Collateral Agent a security interest in any of the issued and outstanding capital
stock, membership units or other securities of such Foreign Subsidiary



2.4 Section 7.13 (TransEnterix International/TransEnterix Europe/Vulcanos Assets). Section
7.13 of the Loan Agreement is amended and restated as follows:



“7.13 TransEnterix International/TransEnterix Europe/Vulcanos Assets. Permit
the aggregate value of cash maintained by TransEnterix International and any Foreign
Subsidiaries of a Borrower to exceed Two Million Dollars ($2,000,000.00) at any
time.”



2.5 Section 8.2 (Covenant Default). Section 8.2(a) of the Loan Agreement is amended and
restated as follows:



“(a) Borrower fails or neglects to perform any obligation in Sections 6.2
(Financial Statements, Reports, Certificates), 6.4 (Taxes), 6.5 (Insurance), 6.6
(Operating Accounts), 6.7 (Protection of Intellectual Property Rights), 6.9 (Notices
of Litigation and Default), 6.10 (Minimum Cash), 6.11 (Landlord Waivers; Bailee
Waivers), 6.12 (Creation/Acquisition of Subsidiaries), or 6.14 (ISIS
Telecommunications) or Borrower violates any covenant in Section 7; or”



2.6 Section 13.1 (Definitions). The following definitions are hereby added to or amended and
restated in Section 13.1 of the Loan Agreement as follows:



“Domestic Subsidiary” is an entity organized under the laws of the United
States or any state or territory thereof or the District of Columbia.



“First-Tier Foreign Subsidiary” is a Foreign Subsidiary, the capital stock,
membership units or other securities of which are directly owned by Borrower or a
Domestic Subsidiary.



“Foreign Subsidiary” is a Subsidiary that is not a Domestic Subsidiary.



“Shares” is one hundred percent (100%) of the issued and outstanding capital
stock, membership units or other securities owned or held of record by Borrower or
Borrower’s Subsidiary, in any Subsidiary; provided, however, (i) with regard to a
First-Tier Foreign Subsidiary, “Shares” shall mean sixty-five percent (65%) of the
issued and outstanding capital stock, membership units or other securities owned or
held of record by Borrower or a Domestic Subsidiary in such First-Tier Foreign
Subsidiary, and (ii) “Shares” shall not include any of the issued and outstanding
capital stock, membership units or other securities of Vulcanos or any other Foreign
Subsidiary that is not a First-Tier Foreign Subsidiary.



2.7 Section 13.1 (Definitions). A new clause (n) is hereby added to the definition of
“Permitted Indebtedness” in Section 13.1 of the Loan Agreement as follows:



“(n) Borrower’s unsecured guaranties of obligations of a Subsidiary, provided
that such obligations (i) do not constitute Indebtedness, (ii) are incurred in the
ordinary course of such Subsidiary’s business, and (iii) with regard to obligations
of Foreign Subsidiaries, do not exceed an aggregate amount guaranteed of $2,000,000
(or the equivalent thereof) at any one time.”



2.8 Section 13.1 (Definitions). Clause (f) of the definition of “Permitted Investments” in
Section 13.1 of the Loan Agreement is hereby amended and restated as follows:



“(f) Investments by (i) a Borrower in another Borrower, (ii) by a Borrower in a
Subsidiary that is not a Borrower not to exceed Fifty Thousand Dollars ($50,000.00)
in the aggregate in any fiscal year, provided that Borrower may make Investments in
Foreign Subsidiaries (directly or indirectly through TransEnterix International or
another Foreign Subsidiary) not to exceed Seven Million Dollars ($7,000,000) in the
aggregate in any fiscal quarter, (iii) by Subsidiaries not a Borrower in a Borrower,
or (iv) by a Subsidiary that is not a Borrower in another Subsidiary that is not a
Borrower.”



2.9 Exhibit A to the Loan Agreement is replaced with Exhibit A attached
hereto.



2.10 Exhibit C to the Loan Agreement is replaced with Exhibit C attached
hereto.



3. Limitation of Amendments.



3.1 The amendments set forth in Section 2 above are effective for the purposes set forth
herein and shall be limited precisely as written and shall not be deemed to (a) be a consent to any
amendment, waiver or modification of any other term or condition of any Loan Document, or (b)
otherwise prejudice any right or remedy which Collateral Agent or any Lender may now have or may
have in the future under or in connection with any Loan Document.



3.2 This Amendment shall be construed in connection with and as part of the Loan Documents and
all terms, conditions, representations, warranties, covenants and agreements set forth in the Loan
Documents, except as herein amended, are hereby ratified and confirmed and shall remain in full
force and effect.



4. Representations and Warranties. To induce Collateral Agent and Lenders to enter into this
Amendment, Borrower hereby represents and warrants to Collateral Agent and Lenders as follows:



4.1 Immediately after giving effect to this Amendment (a) the representations and warranties
contained in the Loan Documents are true, accurate and complete in all material respects as of the
date hereof (except to the extent such representations and warranties relate to an earlier date, in
which case they are true and correct in all material respects as of such date), and (b) no Event of
Default has occurred and is continuing;



4.2 Borrower has the power and authority to execute and deliver this Amendment and to perform
its obligations under the Loan Agreement, as amended by this Amendment;



4.3 The organizational documents of Borrower delivered to Collateral Agent and Lenders on the
First Amendment Effective Date remain true, accurate and complete and have not been amended,
supplemented or restated and are and continue to be in full force and effect;



4.4 The execution and delivery by Borrower of this Amendment and the performance by Borrower
of its obligations under the Loan Agreement, as amended by this Amendment, have been duly
authorized;



4.5 The execution and delivery by Borrower of this Amendment and the performance by Borrower
of its obligations under the Loan Agreement, as amended by this Amendment, do not and will not
contravene (a) any law or regulation binding on or affecting Borrower, (b) any contractual
restriction with a Person binding on Borrower, (c) any order, judgment or decree of any court or
other governmental or public body or authority, or subdivision thereof, binding on Borrower, or (d)
the organizational documents of Borrower;



4.6 The execution and delivery by Borrower of this Amendment and the performance by Borrower
of its obligations under the Loan Agreement, as amended by this Amendment, do not require any
order, consent, approval, license, authorization or validation of, or filing, recording or
registration with, or exemption by any governmental or public body or authority, or subdivision
thereof, binding on Borrower, except as already has been obtained or made; and



4.7 This Amendment has been duly executed and delivered by Borrower and is the binding
obligation of Borrower, enforceable against Borrower in accordance with its terms, except as such
enforceability may be limited by bankruptcy, insolvency, reorganization, liquidation, moratorium or
other similar laws of general application and equitable principles relating to or affecting
creditors’ rights.



5. Counterparts. This Amendment may be executed in any number of counterparts and all of such
counterparts taken together shall be deemed to constitute one and the same instrument.



6. Effectiveness. This Amendment shall be deemed effective upon the due execution and
delivery to Collateral Agent and Lenders, in form and substance satisfactory to Collateral Agent
and each Lender, such documents, and completion of such other matters, as Collateral Agent and each
Lender may reasonably deem necessary or appropriate, including, without limitation:




	 	(a)	 	this Amendment by each party hereto; and






	 	(b)	 	Borrower’s payment of all Lenders’ Expenses incurred through
the date of this Amendment.





[Balance of Page Intentionally Left Blank]




In Witness Whereof, the parties hereto have caused this Amendment to be duly
executed and delivered as of the date first written above.



	 
	BORROWER:

	TRANSENTERIX, INC.

	By: /s/ Joseph P. Slattery

	 

	Name: Joseph P. Slattery

	 

	Title: Executive Vice President

	 

	TRANSENTERIX SURGICAL, INC.

	By: /s/ Janet Jamiolkowski

	 

	Name: Janet Jamiolkowski

	 

	Title: Vice President, Finance

	 

	SAFESTITCH LLC

	By: TransEnterix, Inc., its sole member

	By: /s/ Joseph P. Slattery

	 

	Name: Joseph P. Slattery

	 

	Title: Executive Vice President

	 

	TRANSENTERIX INTERNATIONAL, INC.

	By: /s/ Joseph P. Slattery

	 

	Name: Joseph P. Slattery

	 

	Title: Executive Vice President

	 







[Signature Page to Fifth Amendment to Amended and Restated Loan and Security
Agreement]In Witness Whereof, the parties hereto have caused this Amendment to be
duly executed and delivered as of the date first written above.



	 
	COLLATERAL AGENT AND LENDER:

	OXFORD FINANCE LLC

	By: /s/ Mark Davis

	 

	Name: Mark Davis

	 

	Title: Vice President – Finance, Secretary & Treasurer

	 

	LENDER:

	SILICON VALLEY BANK

	By: /s/ Scott McCarty

	 

	Name: Scott McCarty

	 

	Title: Director

	 







[Signature Page to Fifth Amendment to Amended and Restated Loan and Security Agreement]

EXHIBIT A




Description of Collateral




The Collateral consists of all of Borrower’s right, title and interest in and to the following
personal property:



All goods, Accounts (including health-care receivables), Equipment, Inventory, contract rights
or rights to payment of money, leases, license agreements, franchise agreements, General
Intangibles (except as set forth below), commercial tort claims, documents, instruments (including
any promissory notes), chattel paper (whether tangible or electronic), cash, deposit accounts, all
certificates of deposit, fixtures, letters of credit rights (whether or not the letter of credit is
evidenced by a writing), securities and all other investment property (except as set forth below),
supporting obligations, and financial assets, whether now owned or hereafter acquired, wherever
located; and



All Borrower’s Books relating to the foregoing, and any and all claims, rights and interests
in any of the above and all substitutions for, additions, attachments, accessories, accessions and
improvements to and replacements, products, proceeds and insurance proceeds of any or all of the
foregoing.



Notwithstanding the foregoing, the Collateral does not include any of the following, whether
now owned or hereafter acquired: (i) any copyright rights, copyright applications, copyright
registrations and like protections in each work of authorship and derivative work, in each case
whether published or unpublished or registered or unregistered; any patents, patent applications
and like protections, including improvements, divisions, continuations, renewals, reissues,
extensions, and continuations-in-part of the same; trademarks, trade names, service marks, mask
works, rights of use of any name, domain names, trade dress, any applications therefor, in each
case whether registered or not; and the goodwill of the business of Borrower connected with and
symbolized thereby; know-how, operating and production manuals, trade secret rights, clinical and
non-clinical data, rights to unpatented inventions, source code, software, processes, techniques,
research, studies, algorithms, formulae, databases, quality control procedures, technical
specifications and data, sales literature, drawings, blueprints and inventions; and any claims for
damage by way of any past, present, or future infringement of any of the foregoing (collectively,
the “Intellectual Property”); provided, however, the Collateral shall include all Accounts, license
and royalty fees and other revenues, proceeds, or income arising out of or relating to any of the
foregoing; provided that if a judicial authority (including a U.S. Bankruptcy Court) would hold
that a security interest in the underlying Intellectual Property is necessary to have a security
interest in such Accounts, license and royalty fees and other revenues, proceeds, or income of
Intellectual Property, then the Collateral shall automatically, and effective as of the Effective
Date, include the Intellectual Property to the extent necessary to permit perfection of Collateral
Agent’s security interest in such Accounts, license and royalty fees and other revenues, proceeds,
or income of the Intellectual Property; (ii) any United States intent-to-use trademark or service
mark application to the extent that, and solely during the period in which, the grant of a security
interest therein would impair the validity or enforceability of such intent-to-use trademark or
service mark application under applicable law, (iii) the Excluded Accounts, (iv) more than sixty
five percent (65%) of the issued and outstanding capital stock, membership units or other
securities owned or held of record by Borrower in a First-Tier Foreign Subsidiary, or (v) any of
the issued and outstanding capital stock, membership units or other securities of Vulcanos or any
other Foreign Subsidiary that is not a First-Tier Foreign Subsidiary.



Pursuant to the terms of a certain negative pledge arrangement with Collateral Agent and
Lenders, Borrower has agreed not to encumber any of its Intellectual Property.



1



EXHIBIT C




COMPLIANCE CERTIFICATE




	 	 	 
	TO:

	 	OXFORD FINANCE LLC, as Collateral Agent and Lender
	SILICON VALLEY BANK, as Lender

	FROM:

	 	TRANSENTERIX, INC.







TRANSENTERIX SURGICAL, INC.


SAFESTITCH LLC


TRANSENTERIX INTERNATIONAL, INC.



The undersigned authorized officer (“Officer”) of TRANSENTERIX, INC., TRANSENTERIX SURGICAL, INC.,
SAFESTITCH LLC, and TRANSENTERIX INTERNATIONAL, INC. (collectively, the “Borrower”), hereby
certifies, solely in his or her capacity as an officer of Borrower and not in any individual
capacity, that in accordance with the terms and conditions of the Amended and Restated Loan and
Security Agreement by and among Borrower, Collateral Agent, and the Lenders (the “Agreement”),



(i) Borrower is in complete compliance for the period ending        with all required
covenants except as noted below;



(ii) There are no Events of Default, except as noted below;



(iii) Except as noted below, all representations and warranties of Borrower stated in the Loan
Documents are true and correct in all material respects on this date except as noted below;
provided, however, that such materiality qualifier shall not be applicable to any representations
and warranties that already are qualified or modified by materiality in the text thereof; and
provided, further that those representations and warranties expressly referring to a specific date
shall be true, accurate and complete in all material respects as of such date.



(iv) Borrower, and each of Borrower’s Subsidiaries, has timely filed all required tax returns and
reports, Borrower, and each of Borrower’s Subsidiaries, has timely paid all foreign, federal,
state, and local taxes, assessments, deposits and contributions owed by Borrower, or Subsidiary,
except as otherwise permitted pursuant to the terms of Section 5.8 of the Agreement;



(v) No Liens have been levied or claims made against Borrower or any of Borrower’s Subsidiaries
relating to unpaid employee payroll or benefits of which Borrower has not previously provided
written notification to Collateral Agent and the Lenders.



Attached are the required documents, if any, supporting our certification(s). The Officer, on
behalf of Borrower, further certifies that the attached financial statements are prepared in
accordance with Generally Accepted Accounting Principles (GAAP) and are consistently applied from
one period to the next except as explained in an accompanying letter or footnotes and except, in
the case of unaudited financial statements, for the absence of footnotes and subject to year-end
audit adjustments as to the interim financial statements. Capitalized terms used but not otherwise
defined herein shall have the meanings given them in the Agreement.



2



Please indicate compliance status since the last Compliance Certificate by circling Yes, No, or N/A
under “Complies” column.



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Reporting Covenant	 	Requirement	 	 	 	Complies
	 	1	)	 	Financial statements

	 	Monthly within 30 days
	 	 	 	Yes
	 	No
	 	N/A
	 	2	)	 	Annual (CPA Audited)

statements

	 	Within 180 days after

Fiscal Year End
	 	

	 	Yes



	 	No



	 	N/A



	 	3	)	 	Annual Financial

Projections/Budget

(prepared on a monthly

basis)

	 	Annually (w/n 10 days

of FYE) and when

revised



	 	





	 	Yes







	 	No







	 	N/A







	 	4	)	 	A/R & A/P agings

	 	If applicable
	 	 	 	Yes
	 	No
	 	N/A
	 	5	)	 	8-K, 10-K and 10-Q Filings

	 	If applicable
	 	 	 	Yes
	 	No
	 	N/A
	 	6	)	 	Compliance Certificate

	 	Monthly within 30 days
	 	 	 	Yes
	 	No
	 	N/A
	 	8	)	 	Copy of rental check (627

Distribution Drive)

	 	Monthly within 30 days



	 	

	 	Yes



	 	No



	 	N/A



	 	 	 	 	IP Report *

	 	Monthly within 30 days
	 	 	 	Yes
	 	No
	 	N/A
	 	9	)	 	Total amount of

Borrower’s cash and cash

equivalents at the last

day of the measurement

period

	 	







	 	







$     
	 	









	 	









	 	









	 	10	)	 	Total amount of

Borrower’s Subsidiaries’

cash and cash equivalents

at the last day of the

measurement period

	 	







	 	







$     
	 	









	 	









	 	















	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Deposit and	 	(Please list all accounts; attach separate sheet if additional space needed)
	 	 	 	 	Securities Accounts	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	Acct Control
	 	 	 	 	Bank	 	Account Number	 	New Account?	 	Agmt in place?
	 	1	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	 	2	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	 	3	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	 	4	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	 	5	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	 	6	)	 	 	 	 	 	Yes

	 	No
	 	Yes
	 	No
	Bank Services
	 	

	 	

	 	


	 	

	 	

	 	

	 	 	 	 	

	 	

	 	


	 	

	 	

	 	

	Amount of cash secured	 	 	 	 	 	 	 	 	 	 
	Bank Services:	 	 	 	 	 	 	 	 	 	 
	$	     	 	 	

	 	

	 	


	 	

	 	

	 	

	Amount of non-cash secured Bank	 	 	 	 	 	 	 	 	 	 
	Services
	 	

	 	

	 	


	 	

	 	

	 	

	$     	 	 	 	 	 	 	 	 	 	 






Minimum Cash Covenant



	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Requirement	 	Actual	 	Compliance
	1)

	 	Minimum Cash
	 	At least $10,000,000
	 	     
	 	Yes
	 	No






	 	 	 	 	 	 	 
	Other Matters	 	 	 	 	 	 
	Have any Key Persons departed or ceased to be employed
	 	Yes	 	No
	since the last Compliance Certificate?

	 	

	 	

	 	

	Have there been any transfers/sales/disposals/retirement of
	 	Yes	 	No
	Collateral or IP prohibited by the Agreement?
	 	 	 	 
	Have there been any new or pending claims or causes of action
	 	Yes	 	No
	against Borrower that involve more than $150,000?
	 	 	 	 
	* The following Intellectual Property was registered (or a
	 	 	 	 
	registration application submitted) after the Effective Date or
	 	 	 	 
	the most recent Compliance Certificate, as applicable (if no
	 	 	 	 
	registrations, state “None”)

	 	

	 	

	 	

	Exceptions

	 	

	 	

	 	

	 

	 	

	 	

	 	

	Please explain any exceptions with

respect to the certification above:

	 	



	 	



	 	



	(If no exceptions exist, state “No

exceptions.” Attach separate sheet

if additional space needed.)

	 	





	 	





	 	











[Balance of Page Intentionally Left Blank]




TRANSENTERIX, INC.



By  


Name:  


Title:  



Date:



TRANSENTERIX SURGICAL, INC.



By  


Name:  


Title:  



Date:



	 
	SAFESTITCH LLC

	By: TransEnterix, Inc., its sole member

	By

	Name:

	Title:







Date:



TRANSENTERIX INTERNATIONAL, INC.



By  


Name:  


Title:  



Date:



	 	 	 
	LENDER USE ONLY
	Received by:

	 	Date:  
	 

	 	 
	Verified by:  

	 	Date:  
	 

	 	 
	Compliance Status: Yes No








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