Document:

RVNC 3.31.2015 10Q EX10.2

7555 Gateway Boulevard
Newark, CA 94560

P 510.742.3400
 f 510-742-3401

www.revance.com
March 2, 2015
Philip J. Vickers, Ph.D.
28 Woodcliffe Road
Lexington, MA 02421
Re:    Service on Board of Directors of Revance Therapeutics, Inc.
Dear Phil,
On behalf of Revance Therapeutics, lnc. (the "Company"), I am pleased you have agreed to join the Company's Board of Directors ("Board") under the terms and conditions set forth herein.
The Company has agreed to appoint you (per Board approval), and you agree to serve, as Director effective as of February 26, 2015 (the "Effective Date"). You will serve as a Director from the Effective Date until you voluntarily resign or are removed from the Board (the "Term"). As a Director, you will be expected to participate in regularly scheduled meetings, which are expected to occur approximately four times per year, as well as special meetings of the Board. You will devote your best efforts and apply your professional expertise to the interests and welfare of the Company, and will be expected to comply with all of your legal obligations to the Company as a Director (e.g., fiduciary duties).
During the Term, you will receive quarterly payments of $9,875 as compensation for your services as a Director, payable on the terms set forth in the Company's Non-Employee Director Compensation Policy (the "Policy").
Pursuant to the Policy, you will also receive a non-qualified stock option to purchase 18,000 shares of the Company's common stock (the "Option") under the Company's 2014 Equity Incentive Plan (the "2014 Plan"). The Option will vest on the one year anniversary of the date of the grant subject to your Continuous Service (as defined in the 2014 Plan) and shall be governed in all respects by the 2014 Plan documents and applicable Option agreement. Subject to your Continuous Service as a non-employee member of the Board, you will be eligible for additional grants, as set forth in the Policy.

    

The Company will reimburse you for reasonable travel and other incidental expenses approved by the Company, so long as you provide the Company with appropriate receipts or other relevant documentation. You are not an employee of the Company and have no authority to obligate the Company by contract or otherwise. You will not be eligible for any employee benefits, nor will the Company make deductions from any amounts payable to you for taxes. Any taxes shall be solely your responsibility.
You shall receive indemnification subject to the terms of the Company's form of indemnification agreement, which shall be provided to you under separate cover.
You represent and warrant that your services as a Director of the Company will not conflict with, and will not be constrained by, any prior or current agreement or relationship between you and any third party.
This letter agreement, together with your indemnification agreement and any applicable Option agreements, constitutes the entire agreement between you and the Company with respect to your service as a Director and supersedes any prior agreement, promise, or representation (whether written or oral) between you and the Company with regard to this subject matter. This letter agreement is entered into without reliance on any promise, representation, statement or agreement other than those expressly contained herein, and it cannot be modified or amended except in a writing signed by the party or parties affected by such modification or amendment. All questions concerning the construction, validity and interpretation of this letter agreement will be governed by the law of the State of California as applied to contracts made and to be performed entirely within California.
This letter agreement is being presented to you following the Board's formal appointment of you to the Board and adoption of the other terms of this letter agreement.
We are all delighted to be able to extend you this offer and look forward to working with you. To indicate your acceptance of the Company's offer, please sign and date this letter agreement and return it to Patty Perla, the Director of Human Resources at the Company. You may send an electronic copy to pperla@revance.com.
Sincerely,
REVANCE THERAPEUTICS, INC.
/s/  L. Daniel Browne      
L. Daniel Browne 
Chief Executive officer
AGREED:
/s/ Philip J. Vickers    
Philip J. Vickers, Ph.D.
Date: March 5, 2015    

    

Appendix A
Compensation for Outside Directors
Equity Compensation
1.Initial Option Grant: On the date of initial election to the Board, the Director will be granted a stock option for 18,000 shares. The shares will vest on the 1 year anniversary of the date of grant so long as the Director continued to serve on the Board through such date.
2.    Annual Option Grant: On the date of each annual stockholder meeting, each Director who continues to serve on the Board will be granted a stock option for 8,000 shares. The shares will vest on the 1 year anniversary of the date of grant, so long as the Director continued to serve on the Board through such date.
Cash Compensation
1.    Annual Board Service Retainer:
		
	a.
	$39,500 for Board Members ($64,000 for Chairman of the Board)

2.    Annual Committee Member Service Retainer:
		
	a.
	Member of the Audit Committee: $7,500 ($20,000 for Committee Chair)

		
	b.
	Member of the Compensation Committee: $5,000 ($12,250 for Committee Chair)

		
	c.
	Member of the Nominating & Governance Committee: $4,500 ($8,000 for Committee Chair)RVNC 3.31.2015 10Q EX10.4

[*] = Certain confidential information contained in this document, marked by brackets, has been omitted and filed separately with the Securities and Exchange Commission pursuant to Rule 406 of the Securities Act of 1933, as amended.

Exhibit 10.4
FIRST AMENDMENT TO
DEVELOPMENT, MANUFACTURING AND
SUPPLY AGREEMENT 
___________________________________

This First Amendment to the Development, Manufacturing and Supply Agreement (the “First Amendment”) is entered into as of the 13th day of May, 2015 (the “First Amendment Effective Date”) by and between DUOJECT MEDICAL SYSTEMS INC. (“DUOJECT”) and REVANCE THERAPEUTICS, INC. (“REVANCE”).

R E C I T A L S

		
	A.
	DUOJECT and REVANCE are parties to that certain Development, Manufacturing and Supply Agreement entered into as of April 30, 2010 (the “Agreement”). All capitalized terms not otherwise defined in this First Amendment shall have the meaning ascribed thereto in the Agreement.

		
	B.
	The parties desire to amend the Agreement as set forth herein.

In consideration of the mutual covenants herein contained, and other good and valuable consideration, the receipt of which are hereby acknowledged, DUOJECT and REVANCE agree as follows:

		
	1.
	Modification to the Agreement:  Section 3.1.1 of the Agreement is hereby deleted and replaced with the following:

		
	3.1.1
	Should the RAA not be commercially available by [*] and should REVANCE elect to continue the Agreement, then REVANCE shall accompany the notice to that effect with a payment of [*] Dollars ($[*]) USD.  Should the RAA not be commercially available by [*] and should REVANCE elect to continue the Agreement, then REVANCE shall accompany the notice to that effect with a payment of [*] Dollars ($[*]) USD.  Should the RAA not be commercially available by [*] and should REVANCE elect to continue the Agreement, then REVANCE shall accompany the notice to that effect with a payment of [*] Dollars ($[*]) USD.  Should the RAA not be commercially available by [*] and should REVANCE elect to continue the Agreement, then REVANCE shall accompany the notice to that effect with a payment of [*] Dollars ($[*]) USD.  For each subsequent year thereafter, if the RAA is not yet commercially available, the same election process shall apply but during each such year, REVANCE will instead be required to purchase the minimum RAA units set forth in Section 6.7 to maintain this Agreement in effect for the corresponding year (e.g., as of [*], the quantity of [*] ([*]) RAA units for the Fifth Year will 

1 | Page

[*] = Certain confidential information contained in this document, marked by brackets, has been omitted and filed separately with the Securities and Exchange Commission pursuant to Rule 406 of the Securities Act of 1933, as amended.

apply and each subsequent year will follow in order of the schedule stipulated in Section 6.7).

		
	 2.
	Miscellaneous:  Except to the extent expressly modified by this First Amendment, the Agreement is ratified and remains in full force and effect.  To the extent of any inconsistency between this First Amendment and the Agreement, the terms and conditions of this First Amendment shall control.  This First Amendment may be executed in multiple counterparts, all of which, taken together, shall constitute one document.  This First Amendment shall be deemed effective against a party upon receipt by the other party (or its counsel) of a counterpart executed by facsimile or pdf sent via electronic mail.

IN WITNESS WHEREOF, the Parties have executed this First Amendment as of the First Amendment Effective Date.

	
		
	DUOJECT MEDICAL SYSTEMS INC.
	REVANCE THERAPEUTICS, INC.

	 
	 

	 
	 

	/s/ David L. Reynolds                       
	/s/ L. Daniel Browne                           

	Per:    David L. Reynolds, President
	Per:    L. Daniel Browne, President &         Chief Executive Officer

	 
	 

	Date:  May 8, 2015
	Date:    May 12, 2015

	 
	 

	 
	 

	 
	 

2 | PageEX-4.6

 Exhibit 4.6 

THIS WARRANT AND THE SHARES OF CAPITAL STOCK ISSUED UPON ANY EXERCISE HEREOF HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE
“SECURITIES ACT”), OR ANY APPLICABLE STATE SECURITIES LAWS AND MAY NOT BE SOLD OR OTHERWISE TRANSFERRED BY ANY PERSON, INCLUDING A PLEDGEE, UNLESS (1) EITHER (A) A REGISTRATION WITH RESPECT THERETO SHALL BE EFFECTIVE UNDER THE
SECURITIES ACT, OR (B) THE COMPANY SHALL HAVE RECEIVED AN OPINION OF COUNSEL SATISFACTORY TO THE COMPANY THAT AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT IS AVAILABLE, AND (2) THERE SHALL HAVE BEEN COMPLIANCE WITH ALL
APPLICABLE STATE SECURITIES OR “BLUE SKY” LAWS. 
  

			
			Right to Purchase 7,398 Shares of Common
			Stock of Histogenics Corporation

 COMMON STOCK PURCHASE WARRANT 

Histogenics Corporation, a Delaware corporation (the “Company”), hereby certifies that for value received Danforth Advisors, LLC, a
Massachusetts limited liability corporation (the “Holder”), or assigns, is entitled to purchase, subject to the terms and conditions hereinafter set forth, up to 7,398 shares of Common Stock (the “Warrant Shares”) (subject to
adjustment as hereinafter provided) at the Stated Purchase Price, payable as hereinafter provided. This Warrant is being issued pursuant to the terms of that certain Consulting Agreement, dated March 12, 2105, by and between the Company and
Holder (the “Consulting Agreement”). 
 1. Definitions. As used herein, the following terms shall have the following
meanings, unless the context otherwise requires: 
 (a) “Change of Control” shall mean the occurrence of any of the
following events: (i) any “Person” (as such term is used in Sections 13(d) and 14(d) of the Securities Exchange Act of 1934, as amended (the “Exchange Act”)), other than Pyxis Innovations, Inc. or an affiliate thereof,
becomes the “Beneficial Owner” (as defined in Rule 13d-3 under the Exchange Act), directly or indirectly, of securities of the Company representing fifty percent (50%) or more of the total voting power represented by the
Company’s then outstanding voting securities pursuant to a transaction or a series of related transactions which the Board of Directors of the Company (the “Board”) does not approve; or (ii) (A) a merger or consolidation of
the Company whether or not approved by the Board, other than a merger or consolidation which would result in the voting securities of the Company outstanding immediately prior thereto continuing to represent (either by remaining outstanding or by
being converted into voting securities of the surviving entity or the parent of such corporation) at least fifty percent (50%) of the total voting power represented by the voting securities of the Company or such surviving entity or parent of
such corporation, as the case may be, outstanding immediately after such merger or consolidation; (B) or the Company’s stockholders approve an agreement for the sale or disposition by the Company of all or substantially all of the
Company’s assets. 

 (b) “Common Stock” shall mean the Company’s common stock, $0.01 par value
per share. 
 (b) “Stated Purchase Price” shall mean the purchase price to be paid upon exercise of this Warrant in
accordance with the terms hereof, which price initially shall be $9.75 per Warrant Share. The Stated Purchase Price shall be subject to adjustment from time to time pursuant to the provisions of Sections 5 and 6 hereof. 

(c) “Warrant Expiration Date” shall mean 5:00 p.m., Eastern Time, on March 11, 2025. 

2. Exercise.  
 (a)
Vesting of Warrant Shares. The Warrant Shares subject to this Warrant shall vest and become exercisable in cumulative installments of 1/24th of the Warrant Shares on the last day of each
successive month beginning March 31, 2015 during the term of the Consulting Agreement. Notwithstanding the foregoing, 50% of the Warrant Shares shall become fully vested and exercisable if the Company terminates the Consulting Agreement for any
reason other than “for cause” (as defined in the Consulting Agreement) before March 12, 2016 and the remaining 50% of the warrants shall become fully vested and exercisable if the Company terminates the Consulting Agreement for any
reason other than “for cause” after March 12, 2016 upon the extension of the agreement. In addition, the Warrant granted hereby shall vest and become exercisable as to all of the Warrant Shares upon a Change of Control during the term
of the Consulting Agreement. 
 (b) Manner of Exercise. This Warrant may be exercised at any time or from time to time, on any day
which is not a Saturday, Sunday or holiday under the laws of the Commonwealth of Massachusetts prior to the Warrant Expiration Date, for all or any part of the Warrant Shares that have vested pursuant to Section 2(a) above. In order to exercise
this Warrant, in whole or in part, the Holder shall deliver to the Company at its principal executive offices, or at such other office as the Company may designate by notice in writing, (i) this originally executed Warrant and (ii) a duly
executed written notice of Holder’s election to exercise its Warrant in whole or in part substantially in the form of Exhibit A attached hereto, and shall pay to the Company by check made payable to the order of the Company or wire
transfer of funds to a bank account designated by the Company an amount equal to the aggregate purchase price for all Warrant Shares as to which this Warrant is being exercised. 

(c) Cashless Exercise. In addition to and without limiting the rights of the Holder hereof under the terms of this Warrant, the Holder
may elect to receive, without the payment by the Holder of the Stated Purchase Price, shares of 

  
 -2- 

 
Common Stock equal to the value of the vested Warrant Shares or any portion thereof by the surrender of this Warrant (or such portion of this Warrant being so exercised) together with the Net
Issue Election Notice annexed hereto as Exhibit B duly executed and completed, at its principal executive offices, or at such other office as the Company may designate by notice in writing. Thereupon, the Company shall issue to the Holder
such number of fully paid, validly issued and nonassessable shares of Common Stock, as is computed using the following formula: 
 X=
Y(A-B) 
 A 
 where 

X = the number of shares of Common Stock to be issued to the Holder (or such other person or persons as directed by the Holder) upon such
exercise of the rights under this Section 2(c) 
 Y = the total number of vested Warrant Shares which the Holder has surrendered for
cashless exercise 
 A = the “Fair Market Value” of one share of Common Stock on the date that the Holder delivers the Net Issue
Election Notice to the Company as provided herein 
 B = the Stated Purchase Price in effect under this Warrant on the date that the Holder
delivers the Net Issue Election Notice to the Company as provided herein 
 The “Fair Market Value” of a share of Common Stock as
of a particular date (the “Valuation Date”) shall mean the following: (y) if the Common Stock is then listed on a stock exchange or quoted on a quotation system, the closing sale price of one share of Common Stock on such exchange or
system on the last trading day prior to the Valuation Date; or (z) if the Common Stock is not then listed on a stock exchange or quoted on a quotation system, the Fair Market Value of one share of Common Stock as of the Valuation Date shall be
determined in good faith by the Board of Directors of the Company (the “Board”). The Board shall respond promptly in writing to an inquiry by the Holder prior to the exercise hereunder as to the Fair Market Value of a share of Common
Stock. 
 (d) Issuance of Common Stock. Upon receipt of the documents and payments described in Section 2(b) or
Section 2(c), as the case may be, the Company shall, as promptly as practicable, execute or cause to be executed, and deliver to the Holder a certificate or certificates representing the aggregate number of full Warrant Shares (or such other
stock or securities that may be issuable upon exercise of the Warrant) issuable upon such exercise. The stock certificate or certificates so delivered shall be in the denomination specified in said notice and shall be registered in the name of the
Holder. This Warrant shall be deemed to 

  
 -3- 

 
have been exercised and a certificate or certificates for shares of Common Stock shall be deemed to have been issued, and the Holder or any other person so designated to be named therein shall be
deemed to have become a holder of record of such shares for all purposes as of the date said notice, together with this Warrant and the documents and payments described in Section 2(b) or 2(c), as the case may be, are received by the Company as
aforesaid. If this Warrant shall have been exercised in part, the Company shall, at the time of delivery of said certificate or certificates, deliver to the Holder a new Warrant evidencing the rights of Holder to purchase the unpurchased shares of
Common Stock called for by this Warrant, which new Warrant shall in all other respects be identical with this Warrant. 
 (e) Transfer
Restriction Legend. Each certificate for Common Stock issued upon exercise of this Warrant, unless at the time of exercise the offer and sale of the Warrant Shares are registered under the Securities Act, shall bear the following legend (and any
additional legend required by applicable law or rule) on the face thereof: 
 “THE SECURITIES REPRESENTED BY THIS CERTIFICATE HAVE NOT
BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY,
MAY NOT BE OFFERED, SOLD OR OTHERWISE TRANSFERRED EXCEPT (A) PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR (B) PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS AS EVIDENCED BY A LEGAL OPINION OF COUNSEL TO THE TRANSFEROR TO SUCH EFFECT, THE SUBSTANCE OF WHICH SHALL BE REASONABLY ACCEPTABLE TO THE COMPANY.” 

3. Reservation of Shares. The Company covenants that it will at all times until the Warrant Expiration Date reserve and keep available
out of its authorized and unissued Common Stock, solely for the purpose of issue upon exercise of this Warrant, such number of Warrant Shares as shall then be issuable upon the exercise of this Warrant. 

4. Loss, Theft, Destruction or Mutilation. Upon receipt of evidence satisfactory to the Company of the loss, theft, destruction or
mutilation of this Warrant (including a reasonably detailed affidavit with respect to the circumstances of any loss, theft or destruction of such Warrant and a customary and reasonable indemnity and surety bond, if requested by the Company), and, in
the case of any such mutilation, upon surrender and cancellation of this Warrant, the Company at its expense will execute and deliver, in lieu hereof, a new Warrant of like tenor. 

  
 -4- 

 5. Subdivision or Combination of Common Stock. If the Company at any time subdivides (by
any stock split, stock dividend, recapitalization or otherwise) its outstanding shares of Common Stock into a greater number of shares, the Stated Purchase Price in effect immediately prior to such subdivision will be proportionately reduced and the
number of Warrant Shares issuable upon exercise of this Warrant will be proportionately increased, and if the Company at any time combines (by reverse stock split, recapitalization or otherwise) its outstanding shares of Common Stock into a smaller
number of shares, the Stated Purchase Price in effect immediately prior to such combination will be proportionately increased and the number of Warrant Shares issuable upon exercise of this Warrant will be proportionately decreased. 

6. Consolidation, Merger, etc. If there shall be a merger or consolidation of the Company with or into another corporation (other than
a merger or reorganization involving only a change in the state of incorporation of the Company), then as a part of such transaction, provision shall be made so that the Holder hereof shall thereafter be entitled to receive the number of shares of
stock or other securities or property of the Company, or of the successor corporation resulting from the merger or consolidation, to which the Holder would have been entitled if the Holder had exercised this Warrant immediately prior thereto. 

7. Notice of Adjustment of Stated Purchase Price. Upon any adjustment or other change relating to the Stated Purchase Price or the
securities purchasable upon the exercise of this Warrant, then, and in each such case, the Company shall promptly prepare and deliver to Holder notice, setting forth, in reasonable detail, the event requiring the adjustment and the method by which
such adjustment was calculated. 
 8. Fractional Shares. The Company shall not issue fractions of shares, upon exercise of this
Warrant or otherwise, or distribute certificates that evidence fractional shares. With respect to any fraction of a share called for upon any exercise hereof, such fraction shall neither be issued nor extinguished until the final exercise of this
Warrant, in which event if a fraction is issuable, the Company shall pay to the Holder an amount in cash equal to such fraction multiplied by the Stated Purchase Price, as adjusted to date pursuant to Section 5 or 6. 

9. Holder Not Deemed Stockholder. The Holder shall not be entitled to vote or to receive dividends or be deemed the holder of Common
Stock that may at any time be issuable upon exercise of this Warrant for any purpose whatsoever, nor shall anything contained herein be construed to confer upon the Holder any of the rights of a stockholder of the Company or any right to vote for
the election of directors or upon any matter submitted to stockholders at any meeting thereof, or to receive dividends or subscription rights, until Holder shall have exercised this Warrant in accordance with the provisions hereof. 

10. Successors and Assigns. This Warrant, and the obligations and rights of the Company hereunder, shall be binding upon and inure to
the benefit of the Company, the Holder, and their respective successors and permitted assigns. 
 11. Waiver and Amendment. Any
provision of this Warrant may be amended, waived or modified only upon the written consent of the Company and the Holder. 

  
 -5- 

 12. Notices. Any notice, request or other communication required or permitted hereunder
shall be in writing and shall be delivered in accordance with the terms of Section 15 of the Consulting Agreement. 
 13. Governing
Law. All questions concerning the construction, validity, enforcement and interpretation of this Warrant shall be governed by the internal laws of the State of Delaware, United States of America, without giving effect to any choice of law or
conflict of law provision or rule (whether of the State of Delaware or any other jurisdictions) that would cause the application of the laws of any jurisdictions other than the State of Delaware. 

14. Headings; References. All headings used herein are used for convenience only and will not be used to construe or interpret this
Warrant. Except where otherwise indicated, all references herein to Sections refer to Sections hereof. 
 15. Acceptance. Receipt of
this Warrant by the Holder shall constitute acceptance of and agreement to all of the terms and conditions contained herein. 
 [Remainder of
page intentionally left blank.] 

  
 -6- 

 IN WITNESS WHEREOF, the Company has caused this Warrant to be duly executed as of March 12,
2015. 
  

			
	HISTOGENICS CORPORATION
		
	By:		 /s/ Adam Gridley

	Name:		Adam Gridley
	Title:		President and CEO

  
 -7- 

 EXHIBIT A 

EXERCISE FORM 
 (To be signed only
on exercise of Warrant) 
 Histogenics Corporation 
 830 Winter
Street, 3rd Floor 
 Waltham, MA 02451 

The undersigned hereby irrevocably elects to exercise the right to purchase represented by the within Warrant for, and to purchase thereunder,
                 shares of common stock, $0.01 par value per share, of Histogenics Corporation (the “Common Stock”) at a price of
$         per share of Common Stock, and herewith makes payment of $         (such payment being by check made payable to the order of Histogenics Corporation, or wire
transfer of funds to a bank account designated by Histogenics Corporation, or any combination thereof), surrenders the Warrant and all right, title and interest therein to Histogenics Corporation and requests that certificates for such shares be
issued in the name of: 
  

			
	  
		
	(Please print name, address, and social security number)		
		
	  
		

 and, if said number of shares shall not be all the shares purchasable thereunder, that a new Warrant for the balance remaining
of the shares purchasable under the within Warrant be registered in the name of the undersigned holder of the within Warrant or his Assignee as below indicated and delivered to the address stated below. 

 

							
	NAME OF HOLDER OR ASSIGNEE:		  
		
			(Please print)		

							
			
	ADDRESS OF HOLDER OR ASSIGNEE:		  
		
			

							
			
	SIGNATURE OF HOLDER:		  
		

					
		
	DATED:		  

  
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 EXHIBIT B 

NET ISSUE ELECTION NOTICE 
 (To be
signed only on exercise of Warrant) 
 Histogenics Corporation 

830 Winter Street, 3rd Floor 

Waltham, MA 02451 
 The undersigned hereby elects under
Section 2(c) of this Warrant to surrender the right to purchase [                ] shares of common stock, $0.01 par value per share, of Histogenics Corporation(the
“Common Stock”) pursuant to the within Warrant and hereby requests the issuance of [                ] shares of Common Stock. The undersigned requests that
certificates for such shares be issued in the name of: 
  

			
	  
		
	(Please print name, address, and social security number)		
		
	  
		

 and, if said number of shares shall not be all the shares purchasable thereunder, that a new Warrant for the balance remaining
of the shares purchasable under the within Warrant be registered in the name of the undersigned holder of the within Warrant or his Assignee as below indicated and delivered to the address stated below. 

 

					
	NAME OF HOLDER OR ASSIGNEE:		  
		
			(Please print)		

					
			
	ADDRESS OF HOLDER OR ASSIGNEE:		  
		
				

					
			
	SIGNATURE OF HOLDER:		  
		

			
		
	DATED:		  

  
 -9-

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