Document:

Unlimited Guaranty

 Exhibit 4.6 

 

 

 UNLIMITED GUARANTY 
 This Unlimited Guaranty (this “Guaranty”) is entered into effective November 7, 2008, by UROLOGY ASSOCIATES OF NORTH
TEXAS, L.L.P. (“Guarantor”), a Texas registered limited liability partnership, for the benefit of COMPASS BANK (“Lender”), an Alabama state banking association. For
valuable consideration, Guarantor absolutely and unconditionally guarantees and promises to pay to Lender or its order, in legal tender of the United States of America, the Indebtedness (as defined below) of UANT VENTURES, L.L.P.
(“Borrower”), a Texas registered limited liability partnership, to Lender on the terms and conditions set forth in this Guaranty. Under this Guaranty, the liability of Guarantor is unlimited and the obligations of Guarantor are
continuing. 
 1. DEFINITIONS. The following words have the meanings assigned below when used in this Guaranty: 

(a) “Indebtedness” means any and all of Borrower’s liabilities, obligations, debts, and indebtedness to Lender, now
existing or hereinafter incurred or created, together with all other liabilities, costs, and expenses for which Borrower is responsible under the Loan Agreement, under any Loan Documents, including, without limitation, the obligations evidenced by
the Notes, and all other loans, advances, interest, costs, attorneys fees, debts, overdraft indebtedness, credit card indebtedness, lease obligations, other obligations, and liabilities of Borrower, any present or future judgments against Borrower,
and all renewals, extensions, modifications, substitutions, and rearrangements of the foregoing; and whether any such Indebtedness is voluntarily or involuntarily incurred, due or not due, absolute or contingent, direct or indirect, liquidated or
unliquidated, determined or undetermined; whether Borrower may be liable individually or jointly with others, or primarily or secondarily, or as debtor, maker, comaker, drawer, endorser, guarantor, or surety; whether such Indebtedness arises by
note, draft, acceptance, guaranty, endorsement, letter of credit, assignment, overdraft, indemnity agreement, or otherwise; whether recovery on the Indebtedness may be or may become barred or unenforceable against Borrower for any reason whatsoever;
and whether the Indebtedness arises from transactions which may be voidable on account of infancy, insanity, ultra vires, or otherwise. 
 (b) “Loan Agreement” means the Loan Agreement of even date, executed by Borrower and Guarantor, as co-borrowers, and Lender, as amended. 

(c) “Loan Documents” means the Loan Agreement, the Notes, and all Loan Documents (as defined in the Loan Agreement), and
includes, without limitation, all promissory notes, credit agreements, loan agreements, guaranties, security agreements, mortgages, deeds of trust, and all other instruments, agreements, and documents, whether now or hereafter existing, executed in
connection with the Indebtedness. 
 (d) “Notes” has the meaning assigned in the Loan Agreement and includes
all renewals, extensions, or substitutions for any of those notes. 

 2. NATURE OF GUARANTY. This is a guaranty of payment and not of collection. Guarantor’s
liability under this Guaranty shall be open and continuous for so long as this Guaranty remains in force. Guarantor intends to guarantee at all times the performance and prompt payment when due, whether at maturity or earlier by reason of
acceleration or otherwise, of all Indebtedness. Accordingly, no payments made upon the Indebtedness will discharge or diminish the continuing liability of Guarantor in connection with any remaining portions of the Indebtedness or any of the
Indebtedness which subsequently arises or is thereafter incurred or contracted. 
 3. DURATION OF GUARANTY. This Guaranty will
take effect when received by Lender without the necessity of any acceptance by Lender, or any notice to Guarantor or to Borrower, and will continue in full force until all Indebtedness incurred, committed, or contracted before receipt by Lender of
any notice of revocation shall have been fully and finally paid and satisfied and all other obligations of Guarantor under this Guaranty shall have been performed in full. If Guarantor elects to revoke this Guaranty, Guarantor may only do so in
writing. Guarantor’s written notice of revocation must be delivered to Lender at the address of Lender listed below or such other place as Lender may designate in writing. This Guaranty may be revoked only with respect to Indebtedness incurred
or contracted by Borrower, or acquired or committed to by Lender after the date on which written notice of revocation is actually received by Lender. No notice of revocation hereof shall be effective as to any Indebtedness: (a) existing at the
date of receipt of such notice; (b) incurred or contracted by Borrower, or acquired or committed to by Lender, prior to receipt of such notice; (c) now existing or hereafter created pursuant to or evidenced by the Loan Agreement or a
commitment in existence prior to receipt of such notice under which Borrower is or may become obligated to Lender; or (d) renewals, extensions, consolidations, substitutions, and refinancings of the foregoing. Guarantor waives notice of
revocation given by any other guarantor of the Indebtedness. If Guarantor is an individual, this Guaranty shall bind the estate of Guarantor as to Indebtedness created both before and after the death or incapacity of Guarantor, regardless of
Lender’s actual notice of Guarantor’s death or incapacity. Release of any other guarantor of the Indebtedness, or termination or revocation of any other guaranty of the Indebtedness, shall not affect the liability of Guarantor under this
Guaranty. Notwithstanding any provision to the contrary, it shall be an Event of Default under the Loan Agreement if Guarantor revokes or disputes the validity of or liability under this Guaranty or any of the Loan Documents. It is anticipated that
fluctuations may occur in the aggregate amount of Indebtedness covered by this Guaranty, and it is specifically acknowledged and agreed by Guarantor that reductions in the amount of Indebtedness, even to zero dollars shall not constitute a
termination of this Guaranty, unless and until all Indebtedness has been fully and finally paid and satisfied, Lender has no further commitment to loan funds to Borrower, and all other obligations of Guarantor under this Guaranty have been performed
in full. 
 4. AUTHORIZATION TO LENDER. Guarantor authorizes Lender, either before or after any revocation hereof, without
notice or demand and without lessening or otherwise affecting Guarantor’s liability under this Guaranty, from time to time: (a) prior to revocation as set forth above, to make one or more additional secured or unsecured loans to Borrower,
to lease equipment or other goods to Borrower, or otherwise to extend additional credit to Borrower; (b) to alter, compromise, renew, extend, accelerate, or otherwise change one or more times the time for payment or other terms of the
Indebtedness or any part of the Indebtedness, including increases and decreases of the rate of interest on the Indebtedness; extensions may be repeated and may be for longer than the original loan term; (c) to take and hold security for the
payment of this Guaranty or the Indebtedness, and exchange, enforce, waive, fail or decide not to perfect, and release any such security, with or without the substitution of new collateral; (d) to release, substitute, agree not to sue, or deal
with any one or more of Borrower’s sureties, endorsers, or other guarantors on any terms or in any manner Lender may choose; (e) to determine how, when, and what application of payments

  
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and credits shall be made on the Indebtedness; (f) to apply such security and direct the order or manner of sale thereof, including without limitation, any non-judicial sale permitted by the
terms of the controlling security agreement or deed of trust, as Lender in its discretion may determine; (g) to sell, transfer, assign, or grant participations in all or any part of the Indebtedness; and (h) to assign or transfer this
Guaranty in whole or in part. 
 5. REPRESENTATIONS, WARRANTIES, AND COVENANTS. Guarantor represents, warrants, and covenants to
Lender that (a) no representations or agreements of any kind have been made to Guarantor which would limit or qualify in any way the terms of this Guaranty; (b) this Guaranty is executed at Borrower’s request and not at the request of
Lender; (c) Guarantor has not and will not, without the prior written consent of Lender, sell, lease, assign, encumber, hypothecate, transfer, or otherwise dispose of all or substantially all of Guarantor’s assets; (d) Lender has made
no representation to Guarantor as to the creditworthiness of Borrower; (e) Guarantor will provide to Lender financial statements and other financial information regarding Guarantor as Lender may request from time to time, in form and detail
acceptable to Lender, and all such financial information heretofore and hereafter provided to Lender is and shall be true and correct in all material respects and fairly presents the financial condition of Guarantor as of the dates thereof, and no
material adverse change has occurred in the financial condition of Guarantor since the date of the most current financial statements provided to Lender; (f) Guarantor is familiar with the current financial condition of Borrower and has
established adequate means of obtaining from Borrower on a continuing basis information regarding Borrower’s future financial condition and is not relying on Lender to provide such information to Guarantor; (g) as of the date hereof, and
after giving effect to this Guaranty, (i) Guarantor is and will be solvent, (ii) the fair saleable value of Guarantor’s assets exceeds and will continue to exceed Guarantor’s liabilities (both fixed and contingent),
(iii) Guarantor is and will continue to be able to pay Guarantor’s debts as they mature, and (iv) if Guarantor is not an individual, Guarantor has and will continue to have sufficient capital to carry on its business and all
businesses in which it is about to engage; and (h) Guarantor has the power and authority to execute, deliver, and perform this Guaranty and the other Loan Documents executed by Guarantor. Guarantor agrees to keep adequately informed from such
means of any facts, events, or circumstances which might in any way affect Guarantor’s risks under this Guaranty, and Guarantor further agrees that Lender shall have no obligation to disclose to Guarantor any information or documents acquired
by Lender in the course of its relationship with Borrower. 
 6. WAIVERS. (a) General Waivers. Guarantor waives any
right to require Lender (i) to continue lending money or to extend other credit to Borrower; (ii) to make any presentment, protest, demand, or notice of any kind, including notice of any nonpayment of the Indebtedness or of any nonpayment
related to any collateral, or notice of any action or non-action on the part of Borrower, Lender, any surety, endorser, or other guarantor in connection with the Indebtedness or in connection with the creation of new or additional loans or
obligations; (iii) to notify Guarantor of any change in the manner, place, time, or terms of payment of any of the Indebtedness (including, without limitation, any renewal, extension, or other modification of any of the Indebtedness); or
(iv) to notify Guarantor of any change in the interest rate accruing on any of the Indebtedness (including, without limitation, any periodic change in such interest rate that occurs because such Indebtedness accrues interest at a variable rate
which may fluctuate from time to time). Should Lender seek to enforce the obligations of Guarantor hereunder, Guarantor waives any right to require Lender to first (i) resort for payment or to proceed directly or at once against any person,
including Borrower or any other guarantor of the Indebtedness; (ii) to proceed directly against, marshal, enforce, or exhaust any collateral held by Lender from Borrower, Guarantor, any other guarantor, or any other person; or (iii) to
pursue any other remedy within Lender’s power. 

  
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 (b) Waiver of Defenses. Guarantor waives all rights of Guarantor under, or the
requirements imposed by, Chapter 34 of the Texas Business and Commerce Code. Guarantor also waives any and all rights or defenses arising by reason of (i) any election of remedies by Lender which destroys or otherwise adversely affects
Guarantor’s subrogation rights or Guarantor’s rights to proceed against Borrower for reimbursement, including without limitation, any loss of rights Guarantor may suffer by reason of any law limiting, qualifying, or discharging the
Indebtedness; (ii) any disability or other defense of Borrower, of any other guarantor, or of any other person, or by reason of the cessation of Borrower’s liability from any cause whatsoever, other than payment in full in legal tender of
the Indebtedness; (iii) any right to claim discharge of the Indebtedness on the basis of unjustified impairment of any collateral for the Indebtedness; or (iv) any defenses given to guarantors at law or in equity other than actual payment
and performance of the Indebtedness. This Guaranty shall continue to be effective or be reinstated, as the case may be, if at any time any payment of all or any part of the Indebtedness is rescinded or must otherwise be returned by Lender upon the
insolvency, bankruptcy, or reorganization of Borrower, Guarantor, any other guarantor of all or any part of the Indebtedness, or otherwise, all as though such payment had not been made. 

(c) Waiver of Claims. Guarantor further waives and agrees not to assert or claim at any time any deductions to the amount
guaranteed under this Guaranty for any claim of set off, counterclaim, counter demand, recoupment, or similar right, whether such claim, demand, or right may be asserted by Borrower, Guarantor, or both. In addition to any other waivers, agreements,
and covenants of Guarantor set forth herein, Guarantor hereby further waives and releases all claims, causes of action, defenses, and offsets for any act or omission of Lender, its directors, officers, employees, representatives, or agents in
connection with Lender’s administration of the Indebtedness, except for Lender’s willful misconduct and gross negligence. 
 (d) Waiver of Subrogation. Notwithstanding any provision in this Guaranty to the contrary, Guarantor hereby waives and releases (i) any and all rights of subrogation, reimbursement,
indemnification, or contribution which it may have after payment in full or in part of the Indebtedness against others liable on any of the Indebtedness, (ii) any and all rights to be subrogated to the rights of Lender in any collateral or
security for any of the Indebtedness after payment in full or in part of the Indebtedness, and (iii) any and all other rights and claims of Guarantor against Borrower or any third party as a result of Guarantor’s payment of any
Indebtedness. 
 (e) Waivers Binding. Guarantor warrants and agrees that each of the waivers set forth above is made with
Guarantor’s full knowledge of its significance and consequences and that, under the circumstances, the waivers are reasonable and not contrary to public policy or law. If any such waiver is determined to be contrary to any applicable law or
public policy, such waiver shall be effective only to the extent permitted by law or public policy. 
 7. PAYMENT BY GUARANTOR.
In the event of a default in the payment or performance of all or any part of the Indebtedness when such Indebtedness becomes due, whether by its terms, by acceleration, or otherwise, Guarantor shall, without notice or demand, promptly pay the
amount due thereon to Lender, in lawful money of the United States. The exercise by Lender of any right or remedy under this Guaranty or under any other agreement or instrument, at law, in equity or otherwise, shall not preclude concurrent or
subsequent exercise of any other right or remedy. Whenever Guarantor pays any sum which is or may become due under this Guaranty, written notice must be delivered to Lender contemporaneously with such payment. In the absence of such notice to Lender
by Guarantor, any sum received by Lender on account of the Indebtedness shall be conclusively deemed paid by Borrower. 

  
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 8. MISCELLANEOUS PROVISIONS. (a) Amendments. This Guaranty, together with any
Loan Documents, constitutes the entire understanding and agreement of the parties as to the matters set forth in this Guaranty and supersedes all prior written and oral agreements and understandings, if any, regarding same. No alteration of or
amendment to this Guaranty shall be effective unless given in writing and signed by the party or parties sought to be charged or bound by the alteration or amendment. 
 (b) Applicable Law. This Guaranty has been delivered to Lender and is performable in Tarrant County, Texas. Courts within the State of Texas have jurisdiction over any dispute arising under or
pertaining to this Guaranty, and venue for such dispute shall be in Tarrant County, Texas. THIS GUARANTY SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF TEXAS AND APPLICABLE FEDERAL LAWS. 

(c) Costs and Expenses. Guarantor shall also pay on demand by Lender all costs and expenses, including, without limitation, all
reasonable attorneys fees, incurred by Lender in connection with the enforcement or collection of this Guaranty and with the collection or sale of any collateral securing this Guaranty. This covenant shall survive the payment of the Indebtedness.

 (d) Notice. All notices required to be given by either party to the other under this Guaranty shall be in writing and,
except for revocation notices by Guarantor, shall be effective when actually delivered or when deposited with a nationally recognized overnight courier, or when deposited in the United States mail, first class postage prepaid, addressed to the party
to whom the notice is to be given at the address shown below or to such other addresses as either party may designate to the other in writing. All revocation notices by Guarantor shall be in writing and shall be effective only upon delivery to
Lender as provided above in the section titled “DURATION OF GUARANTY.” For notice purposes, Guarantor agrees to keep Lender informed at all times of Guarantor’s current address. In the event that Guarantor is entitled to receive any
notice under the Uniform Commercial Code, as it exists in the state governing any such notice, of the sale or other disposition of any collateral securing all or any part of the Indebtedness or this Guaranty, reasonable notice shall be deemed given
when such notice is given pursuant to the terms of this Subsection ten (10) days prior to the date any public sale, or after which any private sale, of any such collateral is to be held. 

(e) Interpretation. In all cases where there is more than one Borrower, then all words used in this Guaranty in the
singular shall be deemed to have been used in the plural where the context and construction so require; and where there is more than one Borrower named in this Guaranty, the word “Borrower” shall mean all and any one or more of them. This
Guaranty is for the benefit of Lender, its successors and assigns. This Guaranty is binding upon Guarantor and Guarantors’s heirs, executors, administrators, personal representatives, and successors. Caption headings in this Guaranty are for
convenience purposes only and are not to be used to interpret or define the provisions of this Guaranty. If a court of competent jurisdiction finds any provision of this Guaranty to be invalid or unenforceable as to any person or circumstance, such
finding shall not render that provision invalid or unenforceable as to any other persons or circumstances, and all provisions of this Guaranty in all other respects shall remain valid and enforceable. If any one or more of Borrower or Guarantor are
corporations, limited liability companies, or partnerships, it is not necessary for Lender to inquire into the powers of Borrower or Guarantor or of the officers, directors, managers, members, partners, or agents acting or purporting to act on their
behalf, and any Indebtedness made or created in reliance upon the professed exercise of such powers shall be guaranteed under this Guaranty. 

  
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 (f) Waiver. Lender shall not be deemed to have waived any rights under this Guaranty
unless such waiver is given in writing and signed by Lender, and then only in the specific instance and for the purpose given. No delay or omission on the part of Lender in exercising any right shall operate as a waiver of such right or any other
right. A waiver by Lender of a provision of this Guaranty shall not prejudice or constitute a waiver of Lender’s right to thereafter demand strict compliance with that provision or any other provision of this Guaranty. No prior waiver by
Lender, nor any course of dealing between Lender and Guarantor, shall constitute a waiver of any of Lender’s rights or of any of Guarantor’s obligations as to any future transactions. Whenever the consent of Lender is required under this
Guaranty, the granting of such consent by Lender in any instance shall not constitute continuing consent to subsequent instances where such consent is required, and in all cases such consent may be granted or withheld in the sole discretion of
Lender. 
 9. NOTICE OF FINAL AGREEMENT. (a) In connection with the Indebtedness, Borrower, Guarantor, and Lender have
executed and delivered the Loan Agreement and the Loan Documents (collectively the “Written Loan Agreement”). 

(b) It is the intention of Borrower, Guarantor, and Lender that this paragraph be incorporated by reference into each of the Loan
Documents. Guarantor and Lender each warrant and represent that their entire agreement with respect to the Indebtedness is contained within the Written Loan Agreement, and that no agreements or promises have been made by, or exist by or among,
Borrower, Guarantor, and Lender that are not reflected in the Written Loan Agreement. 
 (c) THE WRITTEN LOAN AGREEMENT
REPRESENTS THE FINAL AGREEMENT BETWEEN THE PARTIES AND MAY NOT BE CONTRADICTED BY EVIDENCE OF PRIOR, CONTEMPORANEOUS, OR SUBSEQUENT ORAL AGREEMENTS OF THE PARTIES. THERE ARE NO UNWRITTEN AGREEMENTS BETWEEN THE PARTIES. 

  
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 GUARANTOR ACKNOWLEDGES HAVING READ ALL THE PROVISIONS OF THIS GUARANTY AND AGREES TO ITS TERMS. IN ADDITION,
GUARANTOR UNDERSTANDS THAT THIS GUARANTY IS EFFECTIVE UPON GUARANTOR’S EXECUTION AND DELIVERY OF THIS GUARANTY TO LENDER AND THAT THE GUARANTY WILL CONTINUE UNTIL TERMINATED IN THE MANNER SET FORTH IN THE SECTION TITLED “DURATION OF
GUARANTY”. NO FORMAL ACCEPTANCE BY LENDER IS NECESSARY TO MAKE THIS GUARANTY EFFECTIVE. 
 Signed effective the date stated
above. 
  

									
		 		 	GUARANTOR:
			
	Guarantor’s address:	 		 	UROLOGY ASSOCIATES OF NORTH TEXAS, L.L.P.
	612 East Lamar Blvd., Suite 700	 		 		 		 	
	Arlington, Texas 76011	 		 		 		 	
					
		 		 	By:	 	  
	 	
		 		 		 	 John M. House, M.D.,
	 	
		 		 		 	 Authorized Partner
	 	

 Lender’s address: 
 COMPASS BANK 
 Attn: Josh Burleson 

701 Highlander Blvd., Suite 520 
 Arlington,
Texas 76015 

  
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Guaranty - Page 7 of 7Form of Subordinated Promissory Note

 Exhibit 4.7 
 SUBORDINATED PROMISSORY NOTE 
  

			
	$30,000,000.00	 	[                    ], 2011

FOR VALUE RECEIVED, on or before
[                    ], 2021 (the “Maturity Date”), USMD Holdings, Inc. (the “Maker”) promises to pay to the
order of UANT Ventures, LLP (the “Payee”), at such address as Payee may specify in a written notice given to Maker, in immediately available funds and in lawful money of the United States of America, the principal amount of [Thirty
Million] and No/100 Dollars ($30,000,000.00) under the terms of that certain Contribution and Purchase Agreement, as amended to date, to which Maker and Payee are parties, together with interest on the unpaid principal balance of this Note from the
date hereof until the Maturity Date at a rate per annum of 12.5%. 
 Payment of Principal and Interest 

This Note shall be payable in 120 equal installments of $[439,128.51], commencing on
[                    ], 2011 and on the last day of each subsequent month until the Maturity Date. 

Notwithstanding anything herein to the contrary, upon the occurrence and during the continuance of an Event of Default (as hereinafter
defined) or after the Maturity Date, whether by acceleration or otherwise, all principal of this Note shall, at the option of Payee, bear interest at the Ceiling Rate (as hereinafter defined) until paid. The term “Ceiling Rate,” as
used herein, shall mean, at the particular time in question, the maximum rate of interest, which, under applicable law, may then be charged on this Note. If such maximum rate of interest changes after the date hereof, the Ceiling Rate shall be
automatically increased or decreased, as the case may be, without notice to Maker from time to time as of the effective date of each change in such maximum rate. If applicable law ceases to provide for such a maximum rate of interest, the Ceiling
Rate shall be equal to fourteen percent (14%) per annum. 
 Maker may from time to time prepay all or any portion of the
principal amount of this Note without premium or penalty. All payments of the indebtedness evidenced by this Note, other than regularly scheduled payments, shall be applied to such indebtedness in the order of their maturities. Any portion of the
principal amount of this Note that is repaid or prepaid may not be reborrowed. If any payment of principal or interest on this Note shall become due and payable on a day which is not a Business Day (as hereinafter defined), such payment shall be
made on the next succeeding Business Day and any such extension of time shall be included in computing interest in connection with such payment. As used herein, the term “Business Day” shall mean any day except a Saturday, Sunday or
other date on which national banks in Dallas, Texas are authorized by law to close. 

 Assignment 
 Maker may not assign this Note or any of its rights, interests and obligations hereunder to any other person without the prior written consent of the Payee. Payee may assign this Note so long as such
assignee expressly assumes all of the obligations of the assignor under the “Subordination” provisions of this Note. Subject to the foregoing, this Note will be binding upon, inure to the benefit of and be enforceable by the parties and
their respective successors and permitted assigns. 
 Subordination 

Payee, by acceptance of this Note, and each subsequent holder of this Note, by acceptance hereof, covenants and agrees that the
indebtedness evidenced by, and payment of the principal of, and interest on, this Note shall be subordinate, junior, and subject in right of payment security or otherwise to all indebtedness of the Maker for borrowed money (“Senior
Debt”) owed to financial institutions (“Senior Lenders”) to the extent set forth below: 
 (a) The
Payee and Maker shall not amend or modify this Note in any manner whatsoever without the prior written consent of Senior Lenders. 
 (b) So long as no default in the payment of Senior Debt (“Senior Default”) has occurred and if no Senior Default would result from the making of any such payments, Maker may pay, and the
Payee may accept, regularly scheduled payments of principal and interest under this Note. Upon the occurrence of a Senior Default, until such Senior Default has been cured to the Senior Lenders’ satisfaction or waiver by the Senior Lenders, or
until the Senior Debt shall have been indefeasibly paid and satisfied in full, Maker shall not pay, and the Payee shall not accept, any payments of any kind associated with this Note. To the extent any amounts owing on this Note are not paid as a
result of the provisions of this paragraph (b) (the “Deferred Amount”), at such time as Maker are permitted to resume payments on this Note, the Deferred Amount shall be amortized and paid to the Payee in equal installments
over the remaining term of this Note in connection with regularly scheduled payments thereunder. 
 (c) At any time after a
Senior Lender provides written notice to the Payee that a Senior Default has occurred, any payments (whether in cash, securities or other property) on this Note received by the Payee (including, without limitation, prepayments on this Note), other
than as expressly permitted in paragraph (b) above, shall be held in trust for the Senior Lenders, and the Payee will forthwith turn over any such payments in the form received, properly endorsed or assigned, to the Senior Lenders to be applied
to the Senior Debt until such time as the Senior Default has been cured to the Senior Lenders’ satisfaction or waived by the Senior Lenders or the Senior Debt shall have been indefeasibly paid and satisfied in full. 

(d) The Payee will not commence any action or proceeding at law or equity against Maker to recover all or any part of this Note not paid
when due (or against any collateral pledged to secure the payment of this Note) and shall at no time join with any creditor, in bringing any proceeding against Maker, under any liquidation, conservatorship, bankruptcy, reorganization, rearrangement,
or other insolvency law now or hereafter existing, unless and until the Senior Debt shall be indefeasibly paid and satisfied in full in cash. Subject to the foregoing, the Payee 

  
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may accelerate this Note upon the occurrence of (i) the acceleration of the Senior Debt; and (ii) the filing of a petition under federal bankruptcy laws by Maker; provided that the
Payee shall reverse such acceleration in the event that the acceleration of the Senior Debt, or any portion thereof, is reversed or such petition is withdrawn. 
 (e) Senior Lenders may at any time and from time to time, without the consent of or notice to the Payee, without incurring responsibility to the Payee and without impairing or releasing any of such
person’s rights, or any of the obligations of the Payee hereunder: 
 (i) Change the amount, manner, place
or terms of payment or change or extend the time of payment of or renew or alter the Senior Debt, or any part thereof, or amend, supplement or replace the agreements pursuant to which Senior Debt has been issued and/or any notes executed in
connection therewith in any manner or enter into or amend, supplement or replace in any manner any other agreement relating to the Senior Debt; 
 (ii) Sell, exchange, release or otherwise deal with all or any part of any property at any time pledged or mortgaged by any party to secure or securing the Senior Debt or any part thereof; 

(iii) Release anyone liable in any manner for the payment or collection of the Senior Debt (including, without limitation,
Maker); 
 (iv) Exercise or refrain from exercising any rights against Maker or others; and 

(v) Apply sums paid by any party to the Senior Debt in any order or manner as determined by Senior Lenders. 

Default; Remedies 
 Each
of the following shall constitute an “Event of Default” under this Note: 
 (a) The failure, refusal or neglect
of Maker to pay when due any part of the principal of, or interest on, this Note and the continuation of such failure, refusal or neglect for ten (10) days after such payment has become due and payable; or 

(b) Maker (i) becomes insolvent, or makes a transfer in fraud of creditors, or makes an assignment for the benefit of creditors, or
admits in writing its inability to pay its debts as they become due; (ii) generally is not paying its debts as such debts become due; (iii) has a receiver or custodian appointed for, or take possession of, all or substantially all of the
assets of such party, either in a proceeding brought by such party or in a proceeding brought against such party and such appointment is not discharged or such possession is not terminated within thirty (30) days after the effective date
thereof or such party consents or acquiesces in such appointment or possession; (iv) files a petition for relief under the United States Bankruptcy Code or any other present or future federal or state insolvency, bankruptcy or similar laws (all
of the foregoing hereinafter collectively called “Applicable Bankruptcy Law”) or an involuntary petition for relief is filed against such party under any Applicable Bankruptcy Law and such involuntary petition is

  
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not dismissed within ninety (90) days after the filing thereof, or an order for relief naming such party is entered under any Applicable Bankruptcy Law, or any composition, rearrangement,
extension, reorganization or other relief of debtors now or hereafter existing is requested or consented to by such party, (v) fails to have discharged within a period of thirty (30) days any attachment, sequestration or similar writ
levied upon any property of such party; or (vi) fails to pay within thirty (30) days any final money judgment against such party. 
 Maker agrees that upon the occurrence and continuance of any Event of Default, the holder of this Note may, at its option, by notice in writing to Maker and subject to any restrictions applicable to this
Note arising out of the Senior Indebtedness, (i) declare the outstanding principal balance of and accrued but unpaid interest on this Note at once due and payable, (ii) pursue any and all other rights, remedies and recourses available to
the holder hereof at law or in equity, or (iii) pursue any combination of the foregoing. 
 The failure to exercise the
option to accelerate the maturity of this Note or any other right, remedy or recourse available to the holder hereof upon the occurrence and continuance of an Event of Default hereunder shall not constitute a waiver of the right of the holder of
this Note to exercise the same at that time or at any subsequent time with respect to such uncured Event of Default or any other Event of Default. The rights, remedies and recourses of the holder hereof, as provided in this Note, shall be cumulative
and concurrent and may be pursued separately, successively or together as often as occasion therefore shall arise, at the sole discretion of the holder hereof. The acceptance by the holder hereof of any payment under this Note which is less than the
payment in full of all amounts due and payable at the time of such payment shall not (i) constitute a waiver of or impair, reduce, release or extinguish any right, remedy or recourse of the holder hereof, or nullify any prior exercise of any
such right, remedy or recourse, or (ii) impair, reduce, release or extinguish the obligations of any party liable under this Note as originally provided herein or therein. 

If any provision hereof or the application thereof to any person or circumstance shall, for any reason and to any extent, be invalid or
unenforceable, neither the application of such provision to any other person or circumstance nor the remainder of the instrument in which such provision is contained shall be affected thereby and shall be enforced to the greatest extent permitted by
law. No provision of this Note or the Purchase Agreement shall require the payment or the collection of interest in excess of the maximum amount permitted by applicable law. If any excess of interest in such respect is hereby provided for, or shall
be adjudicated to be so provided, in this Note or otherwise in connection with this loan transaction, the provisions of this section shall govern and prevail and neither the Maker nor the sureties, guarantors, successors, or assigns of the Maker
shall be obligated to pay the excess amount of such interest or any other excess sum paid for the use, forbearance, or detention of sums loaned pursuant hereto. In the event Payee or any subsequent holder of this Note ever receives, collects, or
applies as interest any such sum, such amount which would be in excess of the maximum amount permitted by applicable law shall be applied as a payment and reduction of the principal of the indebtedness evidenced by this Note; and, if the principal
of this Note has been paid in full, any remaining excess shall forthwith be paid to the Maker. In determining whether or not the interest paid or payable exceeds the maximum rate permitted by applicable law, the Maker and the Payee shall, to the
extent permitted by applicable law, (a) characterize any non-principal payment as an expense, fee, or premium rather than as interest, (b) exclude voluntary 

  
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prepayments and the effects thereof, and (c) amortize, prorate, allocate, and spread in equal or unequal parts the total amount of interest throughout the entire contemplated term of the
indebtedness evidenced by this Note so that interest for the entire term does not exceed the maximum rate permitted by applicable law. 
 If this Note is placed in the hands of an attorney for collection, or is collected in whole or in part by suit or through probate, bankruptcy or other legal proceedings of any kind, Maker agrees to pay,
in addition to all other sums payable hereunder, all costs and expenses of collection, including but not limited to reasonable attorneys’ fees. 
 Maker and any and all endorsers and guarantors of this Note severally waive presentment for payment, notice of nonpayment, protest, demand, notice of protest and dishonor, diligence in enforcement and
indulgences of every kind and without further notice hereby agree to renewals, extensions, exchanges or releases of collateral, taking of additional collateral, indulgences or partial payments, either before or after maturity. 

Governing Law 
 THIS NOTE
HAS BEEN EXECUTED UNDER, AND SHALL BE CONSTRUED AND ENFORCED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF TEXAS. 
  

			
	USMD Holdings, Inc.
		
	By:	 	  

	Name:	 	  

	Title:	 	  

  
 -5-

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