Document:

EMPLOYMENT
COMPENSATION FORFEITURE

AND EXCHANGE AGREEMENT

 

This EMPLOYMENT COMPENSATION
FORFEITURE AND EXCHANGE AGREEMENT (this “Agreement”) is entered into as of December ___, 2013 by and among CNS
Response, Inc., a Delaware corporation (the “Company”) and the undersigned employee of the Company (the “Employee”).

 

WHEREAS, the Company
owes the Employee an aggregate of $____________ of salary and wages accrued from ____________ to ____________ (the "Accrued
Wages"), and the Company desires to pay the Employee the Accrued Wages in accordance with the terms set forth herein;

 

WHEREAS, the Company
has experienced continuing losses, extreme cash flow shortfalls, has been unable to satisfy its financial obligations as they have
become due and has failed to raise sufficient additional capital through the sale of equity securities and debt and therefore certain
members of management of the Company, including the Employee, desire to waive the right to receive and forfeit future salary in
consideration for the issuance of options ("Options") to purchase common stock, par value $0.001 per share of
the Company (the “Common Stock”), in accordance with the terms set forth herein;

 

NOW, THEREFORE, the
Company and the Employee, in consideration for the mutual promises and covenants herein, agree as follows:

 

1.Payment of
Accrued Wages. Subject to the terms and conditions of this Agreement, the Company agrees to pay the Employee the Accrued Wages
in accordance with the payment schedule set forth on Exhibit A hereto.

 

2.Forfeiture of Future Wages.

 

Forfeiture. Subject
to the terms and conditions of this Agreement, the Employee agrees to waive receipt of and release the Company from the payment
of future salary and wages that will be accrued from ____________ to ____________ (the "2014 Period"), in the
aggregate amount of $___________, in consideration for which the Company has issued _______ Options to purchase Common Stock on
October 8, 2013. Waiver. Each Employee hereby irrevocably waives the right to receive any wages, salary or compensation
for the period of time prior from ____________ to ____________, and waives all rights and remedies related thereto under all applicable
laws rules and regulations.

 

3.Representations
and Warranties of Employee. The Employee hereby represents and warrants to the Company as follows:

 

(a)Authority.
The Employee has, as appropriate, full power and legal capacity and all right, power, legal capacity and authority to enter into
this Agreement.

 

(b)Authorization.
The execution, delivery and performance of this Agreement has been duly and validly approved and authorized by the Employee.

 

    	 

    	 

    

 

4.Miscellaneous.

 

(a)Governing Law.
THIS AGREEMENT SHALL BE CONSTRUED AND ENFORCED IN ACCORDANCE WITH, AND ALL QUESTIONS CONCERNING THE CONSTRUCTION, VALIDITY, INTERPRETATION
AND PERFORMANCE OF THIS AGREEMENT SHALL BE GOVERNED BY, THE INTERNAL LAWS OF THE STATE OF CALIFORNIA, WITHOUT GIVING EFFECT TO
ANY CHOICE OF LAW OR CONFLICT OF LAW PROVISION OR RULE (WHETHER OF THE STATE OF CALIFORNIA OR ANY OTHER JURISDICTIONS) THAT WOULD
CAUSE THE APPLICATION OF THE LAWS OF ANY JURISDICTIONS OTHER THAN THE STATE OF CALIFORNIA.

 

(b)Amendment.
This Agreement may only be amended by written agreement of the Company and the Employee.

 

(c)Assignment.
The Employee may only assign this Agreement with the written consent of the Company. The Company may freely assign this Agreement
without the consent of the Employee. Any assignment of this Agreement in violation of this Section is null and void. This Agreement
shall be binding and inure to the benefit of the parties hereto and their respective successors and permitted assigns.

 

(d)Waiver of Rights.
No failure on the part of any party hereto to exercise, and no delay in exercising, any right, power or remedy hereunder shall
operate as a waiver thereof, nor shall any single or partial exercise of any such right, power or remedy by such party preclude
any other or further exercise thereof or the exercise of any other right, power or remedy. All rights, powers and remedies under
this Agreement are cumulative and are not exclusive of any other rights, powers and remedies provided by law.

 

(e)No Other Agreements.
This Agreement (including the Exhibits attached hereto) contains a final and complete integration of all prior expressions by the
parties hereto with respect to the subject matter thereof and shall constitute the entire agreement between the parties hereto
with respect to the subject matter thereof, superseding all prior oral or written understandings. There are no unwritten agreements
between the parties hereto.

 

(f)Counterparts.
This Agreement may be executed in two or more counterparts (including via facsimile or other electronic means), each of which shall
be deemed an original, but all of which together shall constitute one and the same instrument. This Agreement will be binding upon
the Company and the Employee and their respective successors, assigns, heirs and personal representatives.

 

(g)Further Assurances.
The Employee shall from time to time and at all times hereafter make, do, execute, or cause or procure to be made, done and executed
such further acts, deeds, conveyances, consents and assurances without further consideration, which may be reasonably required
to effect the transactions contemplated by this Agreement.

 

(h)Severability.
If any term or other provision of this Agreement is determined to be invalid, illegal or incapable of being enforced by any rule
or law, or public policy, all other conditions and provisions of this Agreement shall nevertheless remain in full force and effect
so long as the economic or legal substance of the transactions contemplated hereby is not affected in any manner materially adverse
to any party. Upon such determination that any term or other provision is invalid, illegal or incapable of being enforced, the
parties hereto shall negotiate in good faith to modify this Agreement so as to effect the original intent of the parties as closely
as possible in an acceptable manner to the end that transactions contemplated hereby are fulfilled to the extent possible.

 

[Signature page follows]

 

    	- 2 -

    	 

    

 

IN WITNESS WHEREOF, the parties have executed
this Agreement as of the date first written above.

 

 

 

	 	CNS RESPONSE, INC.	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	By:	 	 
	 	 	Name:  George Carpenter	 
	 	 	Title:     CEO	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	EMPLOYEE	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 

  

    	- 3 -

    	 

    

 

Exhibit A

 

Payment Schedule for Accrued WagesSUBSCRIPTION AGREEMENT

 

This
SUBSCRIPTION Agreement (this “Agreement”) is made as of January 8, 2014 by and between CNS Response,
Inc., a Delaware corporation (the “Company”), and the investor listed on Schedule A hereto (each, an
“Investor” and together, the “Investors”).

 

Agreement

 

In consideration for
the mutual promises and covenants herein, the parties agree as follows:

 

WHEREAS, the Company
is offering in a private placement up to $1.0 million of its common stock, par value $0.001 per share (“Shares”
or “Common Stock”) for $0.25 per share in a private placement to accredited investors pursuant to a Confidential
Offering Memorandum dated January 8, 2014; and

 

WHEREAS, the undersigned
desires to subscribe for and purchase the number of Shares set forth on Schedule A hereto.

 

Section
1 – Purchase and Sale of SHARES

 

1.1Purchase
and Sale of Shares. The Company has authorized the issuance and sale, in accordance with the terms hereof, of shares of Common
Stock, in the aggregate amount of up to $1,000,000 (the “Shares Cap Amount”).
On the terms and subject to the conditions set forth in this Agreement, at the Closings (as defined below), the Company agrees
to issue to each Investor, and the Investor agrees to purchase from the Company, in the amount set forth on Schedule A.
The Company will sell Shares to more than one Investor, each of whom will enter into Subscription Agreement substantially identical
to this one. The financing pursuant to which the Company is issuing the Shares is hereinafter referred to as the “Financing”.

 

1.2Closings.

 

(a)Initial
Closing. The initial purchase and sale of the Shares shall take place at a closing (the “Initial Closing”)
which shall take place remotely via exchange of documents and signatures at 10:00 a.m. Eastern Time on the business day immediately
following execution and delivery of this Agreement, or at such other place and time as may be agreed to among the Company and the
Investors. At the Initial Closing, the Company shall deliver to each of the Investors purchasing Securities for cash at such closing
a certificate or certification representing such number of Shares as is set forth opposite such Investor’s name on Schedule
A under the column entitled “Purchase Price (Initial Closing)” against receipt of a check subject to collection
or a wire transfer in immediately available funds of the purchase price, to an account designated by the Company. 

 

    	 

    	 

    

 

(b)Additional
Closings. The Company shall have the right, on one or more occasions, to hold additional closings (each, an “Additional
Closing”, and collectively with the Initial Closing, the “Closings”,
and individually, a “Closing”), pursuant to which it shall have the right
to issue and sell additional Shares to additional Investors or existing Investors (provided that no Additional Closings shall take
place later than February14, 2014 or upon the withdrawal of this offering by the Board of Directors, whichever occurs sooner).
At each Additional Closing, the Company shall deliver to each Investor purchasing Shares at such closing a certificate or certification
representing such number of Shares as is set forth opposite such Investor’s name on Schedule A under the column entitled
“Purchase Price” against receipt of a check subject to collection or a wire
transfer in immediately available funds of the purchase price, to an account designated by the Company. By receiving Shares at
an Additional Closing, each Investor so receiving Shares thereby represents that its representations and warranties contained in
Section 3 are true and correct as of the date of such Additional Closing. The aggregate principal amount of Shares that may be
issued at Closings hereunder shall, in no event exceed the Share Cap Amount.

 

The obligation of each
Investor to purchase and pay cash for the Shares to be delivered at a Closing is, unless waived by such Investor, subject to the
condition that the Company’s representations and warranties contained in Section 2 are true, complete and correct on and
as of such Closing date. The obligation of the Company to sell and issue Shares to be delivered at a Closing is, unless waived
by the Company, subject to the condition that the relevant Investor’s representations and warranties contained in Section
3 are true, complete and correct on and as of the Closing Date.

 

 

Section
2 - Representations and Warranties

of
the Company

 

The Company represents
and warrants to each Investor as follows:

 

2.1Existence
of Company. The Company is a duly organized Delaware corporation. The Company is validly existing in all jurisdictions where
it conducts its business.

 

2.2Authority to Execute.
The execution, delivery and performance by the Company of this Agreement and the issuance of the Shares are within the Company’s
corporate powers, have been duly authorized by all necessary corporate action, do not and will not conflict with any provision
of law or organizational document of the Company (including its Certificate of Incorporation or Bylaws) or of any agreement or
contractual restrictions binding upon or affecting the Company or any of its property and need no further stockholder or creditor
consent.

 

2.3No Stockholder
Approval Required. No approval of the Company’s stockholders is required for (i) the entry by the Company into this Agreement,
or (ii) the issuance of the Shares contemplated by this Agreement.

 

2.4Valid Issuance.
The Shares will be, validly issued, fully paid and nonassessable and free of restrictions on transfer other than restrictions on
transfer under, applicable state and federal securities laws and liens or encumbrances created by or imposed by the Investor. Assuming
the accuracy of the representations of the Investor in Section 3 of this Agreement, and the Shares will be issued in compliance
with all applicable federal and state securities laws.

 

    	2

    	 

    

 

2.5Binding
Obligation. This Agreement is, a valid and binding obligation of the Company enforceable against the Company in accordance
with its terms, subject, as to enforcement of remedies, to applicable bankruptcy, insolvency, moratorium, reorganization and similar
laws affecting creditors’ rights generally and to general equitable principles.

 

2.6Litigation.
Other than the litigation disclosed in the Company’s most recent SEC Reports (as defined below), no litigation or governmental
proceeding is pending or threatened against the Company which may have a materially adverse effect on the financial condition,
operations or prospects of the Company, and to the knowledge of the Company, no basis therefore exists.

 

2.7Intellectual
Property. To the best of the Company’s knowledge, the Company owns or possesses sufficient legal rights to all patents,
trademarks, service marks, trade names, copyrights, trade secrets, licenses, information and other proprietary rights and processes
necessary for its business as now conducted and as presently proposed to be conducted, without any known infringement of the rights
of others. There are no outstanding options, licenses or agreements of any kind relating to the foregoing proprietary rights, nor
is the Company bound by or a party to any options, licenses or agreements of any kind with respect to the patents, trademarks,
service marks, trade names, copyrights, trade secrets, licenses, information and other proprietary rights and processes of any
other person or entity other than such licenses or agreements arising from the purchase of “off the shelf” or standard
products.

 

2.8SEC Reports.The
Company has filed all forms, reports, schedules, proxy statements, registration statements and other documents (including all exhibits
thereto) required to be filed by it with the Securities and Exchange Commission (the “SEC”) pursuant to the
federal securities laws and the SEC rules and regulations thereunder, together with all certifications required pursuant to the
Sarbanes-Oxley Act of 2002 (the “Sarbanes-Oxley Act”) (as they have been amended since the time of their filing,
including all exhibits thereto, the “SEC Reports”). Each of the SEC Reports complied in all material respects
with the applicable requirements of the Securities Act of 1933, as amended (the “Securities Act”) and the Securities
Exchange Act of 1934, as amended (the “Exchange Act”), the Sarbanes-Oxley Act and the rules and regulations
of the SEC under all of the foregoing. None of the SEC Reports contained any untrue statement of a material fact or omitted to
state a material fact required to be stated therein or necessary in order to make the statements therein, in light of the circumstances
under which they were made, not misleading.

 

Section
3 - Representations and Warranties

of
the Investors

 

Each Investor represents
and warrants to the Company as follows:

 

3.1Authorization;
Binding Obligations. The Investor has full power and authority to enter into this Agreement and this Agreement constitutes
a valid and legally binding obligation of the Investor, enforceable against the Investor in accordance with its terms, subject,
as to enforcement of remedies, to applicable bankruptcy, insolvency, moratorium, reorganization and similar laws affecting creditors’
rights generally and to general equitable principles.

 

    	3

    	 

    

 

3.2Accredited
Investor. The Investor is an “accredited investor” within the meaning of SEC Rule 501 of Regulation D promulgated
under the Securities Act.

 

3.3Investment
for Own Account. The Shares are being acquired for his, her or its own account, for investment and not with a view to, or for
resale in connection with, any distribution or public offering thereof within the meaning of the Securities Act.

 

3.4Knowledge
and Experience. The Investor has such knowledge and experience in financial and business matters that (s)he is capable of evaluating
the merits and risks of an investment in the Shares and of making an informed investment decision with respect thereto, has the
ability and capacity to protect his/her interests and can bear the economic risk of the acceptance of the Shares, including a total
loss of his/her investment.

 

3.5 Opportunity
to Ask Questions. The Investor has had the opportunity to ask questions and receive answers from the Company or any authorized
person acting on its behalf concerning the Company and its business and to obtain any additional information, to the extent possessed
by the Company (or to the extent it could have been acquired by the Company without unreasonable effort or expense) necessary to
verify the accuracy of the information received by the Investor. In connection therewith, the Investor acknowledges that (s)he
has had the opportunity to discuss the Company’s business, management and financial affairs with the Company’s management
or any authorized person acting on its behalf.

 

3.6.Receipt
of Information. The Investor has received and reviewed all the information concerning the Company, the Securities and the Shares,
both written and oral, that the Investor desires. Without limiting the generality of the foregoing, the Investor has been furnished
with or has had the opportunity to acquire, and to review: all information, both written and oral, that the Investor desires with
respect to the Company’s business, management, financial affairs and prospects. In determining whether to make this investment,
the Investor has relied solely on his/her own knowledge and understanding of the Company and its business and prospects based upon
the Investor’s own due diligence investigations and the Company’s filings with the SEC.

 

Section
4 - Miscellaneous

 

4.1No Waiver;
Cumulative Remedies. No failure or delay on the part of any party to this Agreement in exercising any right or remedy under,
or pursuant to, this Agreement shall operate as a waiver thereof, nor shall any single or partial exercise of any such right, remedy
or power preclude other or further exercise thereof, or the exercise of any other right, remedy or power. The remedies in this
Agreement are cumulative and are not exclusive of any remedies provided by law.

 

4.2Amendments
and Waivers. Except as otherwise expressly set forth in this Agreement, any term of this Agreement may be amended (either retroactively
or prospectively) with the written consent of the Company and the Investor. Any amendment effected in accordance with this Section
4.2 shall be binding upon each Investor, each future holder of Securities and the Company.

 

    	4

    	 

    

 

4.3Notices,
Etc. All notices, requests, consents and other communications hereunder to any party shall be deemed to be sufficient if contained
in a written instrument delivered in person; sent by facsimile transmission; sent by electronic mail; duly sent by first class
registered or certified mail, return receipt requested, postage prepaid; or duly sent by overnight delivery service (e.g.,
Federal Express) addressed to such party (i) if to the Company, at the address, fax number or electronic mail address, as applicable,
set forth on the signature page hereof or (ii) if to an Investor, at the address, fax number or electronic mail address, as applicable,
set forth on Schedule A hereto, or at such other address, fax number or electronic mail address as may hereafter be designated
in writing by the addressee to the sender. All such notices, advises and communications shall be deemed to have been received:
(a) in the case of personal delivery, on the date of such delivery; (b) in the case of facsimile or electronic mail transmission,
on the date of transmission; and (c) in the case of mailing or delivery by service, on the date of delivery as shown on the return
receipt or delivery service statement.

 

4.4Governing
Law. This Agreement shall be governed by and construed in accordance with the laws of the State of California, without regard
to the conflicts of law provisions of the State of California or of any other state. The Company and each Investor consent to personal
jurisdiction in Orange County, California.

 

4.5Severability.
If any term in this Agreement is held to be illegal or unenforceable, the remaining portions of this Agreement shall not be affected,
and this Agreement shall be construed and enforced as if this Agreement did not contain the term held to be illegal or unenforceable.

 

4.6Binding Effect.
This Agreement shall be binding upon and inure to the benefit of the Company and each Investor and their respective successors
and assigns.

 

4.7Transfer
of Shares. Notwithstanding the legend required to be placed on the Shares by applicable law, no registration statement or opinion
of counsel shall be necessary: (a) for a transfer of Shares to the respective estate of each Investor or for a transfer of Shares
by gift, will or intestate succession of each Investor to his or her spouse or to the siblings, lineal descendants or ancestors
each Investor or his or her spouse, if the transferee agrees in writing to be subject to the terms hereof to the same extent as
if he or she were the original Investor hereunder; or (b) for a transfer of Shares pursuant to SEC Rule 144 or any successor rule,
or for a transfer of Shares pursuant to a registration statement declared effective by the SEC under the Securities Act relating
to the Securities.

 

4.8Survival
of Representations, Warranties and Covenants. The representations and warranties of the parties contained in or made pursuant
to this Agreement shall survive the execution and delivery of this Agreement indefinitely, and shall in no way be affected by any
investigation of the subject matter thereof made by or on behalf of the other parties. The covenants of the parties contained in
or made pursuant to this Agreement shall survive the execution and delivery of this Agreement until such time as the Notes have
been paid in full.

 

    	5

    	 

    

 

4.9California
Commissioner of Corporations. THE SALE OF THE SECURITIES WHICH ARE THE SUBJECT OF THIS AGREEMENT HAS NOT BEEN QUALIFIED WITH
THE COMMISSIONER OF CORPORATIONS OF THE STATE OF CALIFORNIA AND THE ISSUANCE OF THE SECURITIES OR PAYMENT OR RECEIPT OF ANY PART
OF THE CONSIDERATION FOR SUCH SECURITIES PRIOR TO THE QUALIFICATION IS UNLAWFUL, UNLESS THE SALE OF SECURITIES IS EXEMPT FROM QUALIFICATIONS
BY SECTION 25100, 25102 OR 25105 OF THE CALIFORNIA CORPORATIONS CODE. THE RIGHTS OF ALL PARTIES TO THIS AGREEMENT ARE EXPRESSLY
CONDITIONED UPON SUCH QUALIFICATION BEING OBTAINED, UNLESS THE SALE IS SO EXEMPT.

 

 

 

 

[Remainder of Page Intentionally Left
Blank]

 

    	6

    	 

    

 

IN WITNESS WHEREOF,
the parties hereto have caused this Agreement to be duly executed and delivered by their proper and duly authorized officers as
of the date first written above.

 

 

	 	CNS RESPONSE, INC.
	 	 	 
	 	 	 
	 	By:	 
	 	 	Name: Paul Buck
	 	 	Title:   Chief Financial Officer

 

Address/Fax Number/E-mail Address for Notice:

 

85 Enterprise, Suite 410

Aliso Viejo, CA 92656

Fax: (866) 867 4446

pbuck@cnsresponse.com

 

 

	 	INVESTOR:
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	By:	 
	 	 	Name:
	 	 	 
	 	 	 
	 	 	Title:

 

 

 

 

 

[SIGNATURE PAGE TO SUBSCRIPTION AGREEMENT]

 

    	 

    	 

    

 

SCHEDULE A

 

	Name, Address, Fax Number, E-Mail Address and Tax ID Number of Investor 	
        Aggregate Purchase Price 

         

	
         

         

        Name:_________________________________

         

        Address:_______________________________

         

        ______________________________________

         

        Fax:__________________________________

         

        Email:_________________________________

         

        Tax ID:________________________________

         
	
         

         

         

        $______________________

	TOTAL:

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00226-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00226-of-00352.parquet"}]]