Document:

Indenture

 Exhibit 4.1 

 
  
  

 
 AMERICAN RENAL HOLDINGS
COMPANY, INC., 
 as Issuer 
 9.75%/10.50% Senior PIK Toggle Notes due 2016 
 INDENTURE 

Dated as of March 4, 2011 
 WILMINGTON TRUST FSB, 
 as Trustee 

 
  

 CROSS-REFERENCE TABLE 

 

					
	 TIA Section
	 	Indenture
Section
	 303
	  		 	1.4
	 310
	  	 (a)(1)
 (a)(2)

(a)(3)
 (a)(4)

(a)(5)
 (b)

(c)
	 	7.9
 7.9
 N.A.
 N.A.
 7.9
 7.9
 N.A.

	 311
	  	 (a)
 (b)

(c)
	 	7.11
 7.11
 N.A.

	 312
	  	 (a)
 (b)

(c)
	 	2.5
 12.18
 12.18

	 313
	  	 (a)
 (b)

(b)(1)
 (b)(2)

(c)
 (d)
	 	7.12
 7.12
 7.12
 7.6; 7.12
 7.12; 12.1
 7.12

	 314
	  	 (a)
 (a)(1)

(a)(4)
 (b)

(c)(1)
 (c)(2)

(c)(3)
 (d)

(e)
 (f)
	 	5.4; 12.3
 6.2

3.12; 12.3
 N.A.

12.2
 12.2

N.A.
 N.A.

12.2; 12.3
 N.A.

	 315
	  	 (a)
 (b)

(c)
 (d)

(e)
	 	7.1(b); 7.2
 7.5; 12.1

7.1(a)
 7.1(c)

6.11

	 316
	  	 (a) (last sentence)

(a)(1)(A)
 (a)(1)(B)

(a)(2)
 (b)

(c)
	 	2.16
 6.5
 6.4
 N.A.
 6.7
 2.14

	 317
	  	 (a)(1)
 (a)(2)

(b)
	 	6.8
 6.9
 2.4

	 318
	  	 (a)
 (c)
	 	12.17
 12.17

 N.A. means Not Applicable. 
 Note: This Cross-Reference Table shall not, for any purposes, be deemed to be part hereof. 

  
 i 

 TABLE OF CONTENTS 

 

							
	 	  	 	  	Page	 
	ARTICLE I DEFINITIONS AND INCORPORATION BY REFERENCE	  			
			
	 SECTION 1.1.
	  	Definitions	  	 	1	  
	 SECTION 1.2.
	  	Other Definitions	  	 	34	  
	 SECTION 1.3.
	  	Rules of Construction. Unless the context otherwise requires	  	 	35	  
	 SECTION 1.4.
	  	Incorporation by Reference of Trust Indenture Act	  	 	35	  
		
	ARTICLE II THE NOTES	  			
			
	SECTION 2.1.	  	Form and Dating	  	 	36	  
	 SECTION 2.2.
	  	Form of Execution and Authentication	  	 	39	  
	 SECTION 2.3.
	  	Registrar and Paying Agent	  	 	40	  
	 SECTION 2.4.
	  	Paying Agent to Hold Money in Trust	  	 	41	  
	 SECTION 2.5.
	  	Lists of Holders of the Notes	  	 	41	  
	 SECTION 2.6.
	  	Transfer and Exchange	  	 	41	  
	 SECTION 2.7.
	  	Replacement Note	  	 	53	  
	 SECTION 2.8.
	  	Outstanding Notes	  	 	53	  
	 SECTION 2.9.
	  	Treasury Notes	  	 	53	  
	 SECTION 2.10.
	  	Temporary Notes	  	 	54	  
	 SECTION 2.11.
	  	Cancellation	  	 	54	  
	 SECTION 2.12.
	  	Payment of Interest; Defaulted Interest	  	 	54	  
	 SECTION 2.13.
	  	CUSIP Numbers	  	 	55	  
	 SECTION 2.14.
	  	Record Date	  	 	55	  
	 SECTION 2.15.
	  	Tax Treatment	  	 	55	  
		
	ARTICLE III COVENANTS	  			
			
	 SECTION 3.1.
	  	Payment of Notes	  	 	56	  
	 SECTION 3.2.
	  	Reports	  	 	56	  
	 SECTION 3.3.
	  	Limitation on Indebtedness and Issuance of Disqualified Stock and Preferred Stock	  	 	59	  
	 SECTION 3.4.
	  	Limitation on Restricted Payments	  	 	64	  
	 SECTION 3.5.
	  	Limitation on Liens	  	 	70	  
	 SECTION 3.6.
	  	Limitation on Restrictions on Distributions from Restricted Subsidiaries	  	 	70	  
	 SECTION 3.7.
	  	Limitation on Sales of Assets	  	 	72	  
	 SECTION 3.8.
	  	Limitation on Affiliate Transactions	  	 	75	  
	 SECTION 3.9.
	  	Change of Control	  	 	77	  
	 SECTION 3.10.
	  	[Reserved]	  	 	79	  
	 SECTION 3.11.
	  	Future Guarantors	  	 	79	  
	 SECTION 3.12.
	  	Limitation on Line of Business	  	 	80	  
	 SECTION 3.13.
	  	Compliance Certificate	  	 	80	  
	 SECTION 3.14.
	  	Statement by Officers as to Default	  	 	80	  
	 SECTION 3.15.
	  	[Reserved]	  	 	80	  
	 SECTION 3.16.
	  	No Layering of Debt	  	 	80	  
	 SECTION 3.17.
	  	[Reserved]	  	 	80	  
	 SECTION 3.18.
	  	Designation of Restricted and Unrestricted Subsidiaries	  	 	80	  

  
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	 SECTION 3.19.
	  	Payments for Consent	  	 	81	  
	 SECTION 3.20.
	  	Intercompany Loan Refinancing	  	 	81	  
	 SECTION 3.21.
	  	Stay, Extension and Usury Laws	  	 	82	  
		
	ARTICLE IV MERGER; CONSOLIDATION OR SALE OF ASSETS	  			
			
	 SECTION 4.1.
	  	When the Issuer May Merge or Otherwise Dispose of Assets	  	 	82	  
		
	ARTICLE V REDEMPTION OF NOTES	  			
			
	 SECTION 5.1.
	  	Optional Redemption	  	 	84	  
	 SECTION 5.2.
	  	Mandatory Redemption Upon Certain Equity Issuances	  	 	84	  
	 SECTION 5.3.
	  	Election to Redeem; Notice to Trustee of Optional and Mandatory Redemptions	  	 	85	  
	 SECTION 5.4.
	  	Selection by Trustee of Notes to Be Redeemed	  	 	85	  
	 SECTION 5.5.
	  	Notice of Redemption	  	 	86	  
	 SECTION 5.6.
	  	Deposit of Redemption Price	  	 	87	  
	 SECTION 5.7.
	  	Notes Payable on Redemption Date	  	 	87	  
	 SECTION 5.8.
	  	Notes Redeemed in Part	  	 	87	  
	 SECTION 5.9.
	  	Offer to Repurchase	  	 	87	  
		
	ARTICLE VI DEFAULTS AND REMEDIES	  			
			
	 SECTION 6.1.
	  	Events of Default	  	 	89	  
	 SECTION 6.2.
	  	Acceleration	  	 	91	  
	 SECTION 6.3.
	  	Other Remedies	  	 	91	  
	 SECTION 6.4.
	  	Waiver of Past Defaults	  	 	91	  
	 SECTION 6.5.
	  	Control by Majority	  	 	92	  
	 SECTION 6.6.
	  	Limitation on Suits	  	 	92	  
	 SECTION 6.7.
	  	Rights of Holders to Receive Payment	  	 	92	  
	 SECTION 6.8.
	  	Collection Suit by Trustee	  	 	93	  
	 SECTION 6.9.
	  	Trustee May File Proofs of Claim	  	 	93	  
	 SECTION 6.10.
	  	Priorities	  	 	93	  
	 SECTION 6.11.
	  	Undertaking for Costs	  	 	93	  
		
	ARTICLE VII TRUSTEE	  			
			
	 SECTION 7.1.
	  	Duties of Trustee	  	 	94	  
	 SECTION 7.2.
	  	Rights of Trustee	  	 	95	  
	 SECTION 7.3.
	  	Individual Rights of Trustee	  	 	97	  
	 SECTION 7.4.
	  	Disclaimer	  	 	97	  
	 SECTION 7.5.
	  	Notice of Defaults	  	 	97	  
	 SECTION 7.6.
	  	Compensation and Indemnity	  	 	97	  
	 SECTION 7.7.
	  	Replacement of Trustee	  	 	98	  
	 SECTION 7.8.
	  	Successor Trustee by Merger	  	 	99	  
	 SECTION 7.9.
	  	Eligibility; Disqualification	  	 	99	  
	 SECTION 7.10.
	  	Limitation on Duty of Trustee	  	 	99	  
	 SECTION 7.11.
	  	Preferential Collection of Claims Against the Issuer	  	 	99	  
	 SECTION 7.12.
	  	Reports by Trustee to Holders of the Notes	  	 	100	  

  
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	ARTICLE VIII DISCHARGE OF INDENTURE; DEFEASANCE	  			
			
	 SECTION 8.1.
	  	Discharge of Liability on Notes; Defeasance	  	 	100	  
	 SECTION 8.2.
	  	Conditions to Defeasance	  	 	101	  
	 SECTION 8.3.
	  	Application of Trust Money	  	 	102	  
	 SECTION 8.4.
	  	Repayment to Issuer	  	 	103	  
	 SECTION 8.5.
	  	Indemnity for U.S	  	 	103	  
	 SECTION 8.6.
	  	Reinstatement	  	 	103	  
		
	ARTICLE IX AMENDMENTS	  			
			
	 SECTION 9.1.
	  	Without Consent of Holders	  	 	103	  
	 SECTION 9.2.
	  	With Consent of Holders	  	 	104	  
	 SECTION 9.3.
	  	Effect of Consents and Waivers	  	 	105	  
	 SECTION 9.4.
	  	Notation on or Exchange of Notes	  	 	105	  
	 SECTION 9.5.
	  	Trustee To Sign Amendments	  	 	106	  
	 SECTION 9.6.
	  	Compliance with Trust Indenture Act	  	 	106	  
		
	ARTICLE X GUARANTEES	  			
			
	 SECTION 10.1.
	  	Guarantees	  	 	106	  
	 SECTION 10.2.
	  	Limitation on Liability; Termination, Release and Discharge	  	 	108	  
	 SECTION 10.3.
	  	Right of Contribution	  	 	109	  
	 SECTION 10.4.
	  	No Subrogation	  	 	109	  
	 SECTION 10.5.
	  	Limitations on Merger	  	 	109	  
		
	ARTICLE XI [RESERVED]	  			
		
	ARTICLE XII MISCELLANEOUS	  			
			
	 SECTION 12.1.
	  	Notices	  	 	110	  
	 SECTION 12.2.
	  	Certificate and Opinion as to Conditions Precedent	  	 	111	  
	 SECTION 12.3.
	  	Statements Required in Certificate or Opinion	  	 	111	  
	 SECTION 12.4.
	  	When Notes Disregarded	  	 	112	  
	 SECTION 12.5.
	  	Rules by Trustee, Paying Agent and Registrar	  	 	112	  
	 SECTION 12.6.
	  	Days Other than Business Days	  	 	112	  
	 SECTION 12.7.
	  	Governing Law	  	 	112	  
	 SECTION 12.8.
	  	Waiver of Jury Trial	  	 	112	  
	 SECTION 12.9.
	  	No Recourse Against Others	  	 	112	  
	 SECTION 12.10.
	  	Successors	  	 	113	  
	 SECTION 12.11.
	  	Multiple Originals	  	 	113	  
	 SECTION 12.12.
	  	Variable Provisions	  	 	113	  
	 SECTION 12.13.
	  	Table of Contents; Headings	  	 	113	  
	 SECTION 12.14.
	  	[Reserved].Force Majeure	  	 	113	  
	 SECTION 12.15.
	  	USA Patriot Act	  	 	113	  
	 SECTION 12.16.
	  	Trust Indenture Act Controls	  	 	113	  
	 SECTION 12.17.
	  	Communication by Holders of Notes with Other Holders of Notes	  	 	113	  

  
 iv 

 INDENTURE, dated as of March 4, 2011 (this “Indenture”), between AMERICAN
RENAL HOLDINGS COMPANY, INC., a corporation duly organized and existing under the laws of the State of Delaware (the “Issuer”) and Wilmington Trust FSB, a federal savings bank, as trustee (the “Trustee”). 

Recitals of the Issuer 
 Each party agrees as follows for the benefit of the other parties and for the equal and ratable benefit of the Holders of the Notes: 

ARTICLE I 

DEFINITIONS AND INCORPORATION BY REFERENCE 
 SECTION 1.1. Definitions. 
 “144A Global Note” means a
global note substantially in the form of Exhibit A hereto bearing the Global Note Legend and the Private Placement Legend and deposited with or on behalf of, and registered in the name of, the Depositary or its nominee that shall be issued in a
denomination equal to the outstanding principal amount of the Notes sold in reliance on Rule 144A. 
 “Acquired Debt”
means, with respect to any specified Person: 
 (1) Indebtedness of any other Person existing at the time such other Person is
merged with or into or became a Restricted Subsidiary of such specified Person, whether or not such Indebtedness is incurred in connection with, or in contemplation of, such other Person merging with or into, or becoming a Restricted Subsidiary of,
such specified Person; and 
 (2) Indebtedness secured by a Lien encumbering any asset acquired by such specified Person.

 “Additional Interest” means all additional interest then owing pursuant to the Registration Rights Agreement.

 “Affiliate” of any specified Person means any other Person directly or indirectly controlling or controlled by or
under direct or indirect common control with such specified Person. For purposes of this definition, “control,” as used with respect to any Person, means the possession, directly or indirectly, of the power to direct or cause the direction
of the management or policies of such Person, whether through the ownership of voting securities, by agreement or otherwise. For purposes of this definition, the terms “controlling,” “controlled by” and “under common control
with” have correlative meanings. No Person in whom a Receivables Subsidiary makes an Investment in connection with a Qualified Receivables Transaction will be deemed to be an Affiliate of the Issuer or any of its Subsidiaries solely by reason
of such Investment. 
 “Agent” means any Registrar, Paying Agent or co-registrar. 

  
 1 

 “Applicable Premium” means, with respect to any Note on any Make-Whole Redemption
Date, the greater of: 
 (i) 1.0% of the principal amount of such Note; and 

(ii) the excess of (A) the present value at such Make-Whole Redemption Date of (1) the redemption price of such Note at
March 1, 2013 as set forth in Section 5.1(c) (exclusive of accrued interest), plus (2) all scheduled interest payments due on such Note from the Make- Whole Redemption Date through March 1, 2013, computed using a discount rate
equal to the Treasury Rate at such Make-Whole Redemption Date, plus 50 basis points over (B) the principal amount of such Note. 
 “Applicable Procedures” means, with respect to any transfer or exchange of or for beneficial interests in any Global Note, the rules and procedures of the Depositary that apply to such transfer
or exchange. 
 “ARH” means American Renal Holdings, Inc. 

“Asset Sale” means: 
 (1) the sale, lease (other than operating leases), conveyance or other disposition of any assets or rights outside of the ordinary course of business; provided that the sale, lease, conveyance or
other disposition of all or substantially all of the assets of the Issuer and its Restricted Subsidiaries taken as a whole will be governed by Sections 3.9 and 4.1 and not Section 3.7; and 

(2) the issuance of Equity Interests in any of the Issuer’s Restricted Subsidiaries or the sale of Equity Interests in any of its
Restricted Subsidiaries (other than directors’ qualifying Equity Interests or Equity Interests required by applicable law to be held by a Person other than the Issuer or a Restricted Subsidiary). 

Notwithstanding the preceding, none of the following items will be deemed to be an As- set Sale: 

(1) any single transaction or series of related transactions that involves assets having a Fair Market Value of less than $5.0 million;

 (2) a transfer of assets between or among the Issuer and its Restricted Subsidiaries; 

(3) an issuance or sale of Equity Interests of a Restricted Subsidiary of the Issuer to the Issuer or to a Restricted Subsidiary of the
Issuer or of a Qualified Restricted Subsidiary to Strategic Investors in connection with the start-up of such Qualified Restricted Subsidiary; 

  
 2 

 (4) the sale or lease of products, services or accounts receivable (including at a
discount) in the ordinary course of business and any sale or other disposition of damaged, worn-out, negligible, surplus or obsolete assets in the ordinary course of business; 

(5) the sale or other disposition of Cash Equivalents; 
 (6) a Restricted Payment that does not violate Section 3.4 or a Permitted Investment; 
 (7) the sale or disposition of any assets or property received as a result of a foreclosure by the Issuer or any of its Restricted Subsidiaries on any secured Investment or any other transfer of title
with respect to any secured Investment in default; 
 (8) the licensing of intellectual property in the ordinary course of
business or in accordance with industry practice; 
 (9) surrender or waiver of contract rights or the settlement, release or
surrender of contract, tort or other claims of any kind; 
 (10) leases or subleases to third persons in the ordinary course of
business that do not interfere in any material respect with the business of the Issuer or any of its Restricted Subsidiaries; 

(11) transfers of accounts receivable and related assets of the type specified in the definition of Qualified Receivables Transaction
(or a fractional undivided interest therein) by a Receivables Subsidiary in a Qualified Receivables Transaction; 
 (12) any
sale or disposition deemed to occur in connection with creating or granting any Permitted Liens (but not the sale or other disposition of the property subject to such Permitted Lien); 

(13) any disposition of an account receivable in connection with the collection or compromise thereof; and 

(14) any Intercompany Loan Refinancing if and to the extent the proceeds thereof are utilized as described in Section 3.20.

 “Beneficial Owner” has the meaning assigned to such term in Rule 13d-3 and Rule 13d-5 under the Exchange Act,
except that in calculating the beneficial ownership of any particular “person” (as that term is used in Section 13(d)(3) of the Exchange Act), such “person” will be deemed to have beneficial ownership of all securities that
such “person” has the right to acquire by conversion or exercise of other securities, whether such right is currently exercisable or is exercisable only after the passage of time. 

“Board of Directors” means: 
 (1) with respect to a corporation, the board of directors of the corporation or any committee thereof duly authorized to act on behalf of such board; 

  
 3 

 (2) with respect to a partnership, the board of directors or board of managers of the
general partner of the partnership; 
 (3) with respect to a limited liability company, the managing member or members or any
controlling committee of managing members thereof; and 
 (4) with respect to any other Person, the board or committee of such
Person serving a similar function. 
 “Broker-Dealer” means any broker or dealer registered under the Exchange Act.

 “Business Day” means each day which is not a Legal Holiday. 

“Capital Lease Obligation” means, at the time any determination is to be made, the amount of the liability in respect of a
capital lease that would at that time be required to be capitalized on a balance sheet prepared in accordance with GAAP, and the Stated Maturity thereof shall be the date of the last payment of rent or any other amount due under such lease prior to
the first date upon which such lease may be prepaid by the lessee without payment of a penalty. 
 “Capital Stock”
means: 
 (1) in the case of a corporation, corporate stock; 

(2) in the case of an association or business entity, any and all shares, interests, participations, rights or other equivalents
(however designated) of corporate stock; 
 (3) in the case of a partnership or limited liability company, partnership
interests (whether general or limited) or membership interests; and 
 (4) any other interest or participation that confers on
a Person the right to receive a share of the profits and losses of, or distributions of assets of, the issuing Person, but excluding from all of the foregoing any debt securities convertible into Capital Stock, whether or not such debt securities
include any right of participation with Capital Stock. 
 “Cash Equivalents” means: 

(1) United States dollars or, in the case of any Restricted Subsidiary which is not a Domestic Subsidiary, any other currencies held
from time to time in the ordinary course of business; 
 (2) securities issued or directly and fully guaranteed or insured by
the United States government or any agency or instrumentality of the United States government (provided that the full faith and credit of the United States is pledged in support of those securities) having maturities of not more than 12
months from the date of acquisition; 

  
 4 

 (3) direct obligations issued by any state of the United States of America or any political
subdivision of any such state, or any public instrumentality thereof, in each case having maturities of not more than 12 months from the date of acquisition; 
 (4) certificates of deposit and eurodollar time deposits with maturities of 12 months or less from the date of acquisition, bankers’ acceptances with maturities not exceeding 12 months and overnight
bank deposits, in each case, with any lender party to the Credit Agreement or with any domestic commercial bank that has capital and surplus of not less than $500.0 million; 
 (5) repurchase obligations with a term of not more than one year for underlying securities of the types described in clauses (2) and (4) above entered into with any financial institution meeting
the qualifications specified in clause (4) above; 
 (6) commercial paper having one of the two highest ratings obtainable
from Moody’s Investors Service, Inc. or Standard & Poor’s Rating Services and, in each case, maturing within 12 months after the date of acquisition; and 
 (7) money market funds at least 95% of the assets of which constitute Cash Equivalents of the kinds described in clauses (1) through (6) of this definition or money market funds that comply with
the criteria set forth in SEC Rule 2a-7 under the Investment Company Act of 1940, as amended. 
 “Change of Control”
means the occurrence of any of the following: 
 (1) the direct or indirect sale, lease, transfer, conveyance or other
disposition (other than by way of merger or consolidation), in one or a series of related transactions, of all or substantially all of the properties or assets of the Issuer and its Subsidiaries taken as a whole to any “person” (as that
term is used in Section 13(d) of the Exchange Act) other than Permitted Holders; 
 (2) the consummation of any
transaction (including, without limitation, any merger or consolidation), the result of which is that any “person” (as defined above), other than Permitted Holders, becomes the Beneficial Owner, directly or indirectly, of 50% or more of
the Voting Stock of the Issuer, measured by voting power rather than number of shares; provided, however, for purposes of this clause (2), each Person will be deemed to beneficially own any Voting Stock of another Person held by one or
more of its Subsidiaries; or 
 (3) the Issuer ceases to beneficially own (within the meaning of Rule 13d-3 under the Exchange
Act, or any successor provision) directly or indirectly 100% of the issued and outstanding Capital Stock of ARH other than in a transaction which complies with the provisions of Section 4.1. 

“Clearstream” means Clearstream Banking, Société Anonyme. 

“Code” means the Internal Revenue Code of 1986, as amended. 

  
 5 

 “Company Order” means a written request or order signed in the name of the Issuer
by any Officer. 
 “Consolidated EBITDA” means, with respect to any specified Person for any period, Consolidated Net
Income for such Person for such period plus 
 (a) without duplication and to the extent deducted in determining such
Consolidated Net Income for such period, the sum of: 
 (i) consolidated interest expense (and solely for purposes of
calculating the Fixed Charge Coverage Ratio, other Fixed Charges) of the Issuer and its Restricted Subsidiaries for such period and, to the extent not reflected in such total interest expense, increased by payments made in respect of Hedging
Obligations or other derivative instruments entered into for the purpose of hedging interest rate risk, minus any payments received in respect of such Hedging Obligations or other derivative instruments, 

(ii) consolidated tax expense of the Issuer and its Restricted Subsidiaries based on income, profits or capital, including state,
franchise, capital and similar taxes and withholding taxes paid or accrued during such period, 
 (iii) all amounts attributable
to depreciation and amortization expense of the Issuer and its Restricted Subsidiaries for such period, 
 (iv) any Non-Cash
Charges for such period, 
 (v) costs associated with the Transactions (to the extent applicable to such Person and its
Subsidiaries) made or incurred by such Person and its Restricted Subsidiaries in connection with the Transactions for such period that are paid, accrued or reserved for within 365 days of the consummation of the Transactions, 

(vi) any restructuring charges (including restructuring costs related to acquisitions after the Issue Date and to closure or
consolidation of facilities) for such period and any “Specified Payments” as defined in Schedule 11 .2(a)(vi) to the Merger Agreement made during such period, 
 (vii) any unusual or nonrecurring fees, cash charges and other cash expenses for such period (A) made or incurred by the Issuer and its Restricted Subsidiaries in connection with any acquisition or
investment not prohibited by this Indenture, including severance, relocation and facilities closing costs, including any earnout payments, whether or not accounted for as such, that are paid, accrued or reserved for within 365 days of such
transaction, or (B) incurred in connection with the issuance of Equity Interests or Indebtedness, 
 (viii) cash expenses
incurred during such period in connection with an acquisition not prohibited by this Indenture to the extent that such expenses are reimbursed in cash during such period pursuant to indemnification provisions of any agreement relating to such
transaction, 
 (ix) periodic management fees that are permitted by Section 3.8(b)(xiii)(ii), 

  
 6 

 (x) cash expenses incurred during such period in connection with extraordinary casualty
events to the extent such expenses are reimbursed in cash by insurance during such period, and 
 (xi) the amount of any
minority interest expense consisting of Restricted Subsidiary income attributable to minority equity interests of third parties in any non- Wholly Owned Restricted Subsidiary to the extent the Indebtedness owed by such Restricted Subsidiary is
included in the Indebtedness of the Issuer; minus 
 (b) without duplication and, in the case of clause (ii) below,
to the extent included in determining such Consolidated Net Income, 
 (i) any cash payments made during such period in respect
of Non-Cash Charges described in clause (a)(iv) taken in a prior period or taken in such period, 
 (ii) any non-cash items of
income for such period (other than the accrual of revenue or recording of receivables in the ordinary course of business); 
 provided
that (I) in no event shall any charge, expense or loss relating to write-downs, write-offs or reserves with respect to current assets be added back and (II) the aggregate amount added back pursuant to clauses (vi) and (vii) shall not
exceed 10% of Consolidated EBITDA (calculated before giving effect to such clauses) for any period. 
 “Consolidated
Leverage Ratio” means, as of any date of determination, the ratio of (1) Consolidated Net Debt as of such date after giving effect to all incurrences and repayments of Indebtedness to occur on such date to (2) the Issuer’s
Consolidated EBITDA for the Measurement Period calculated on a Pro Forma Basis. 
 “Consolidated Net Debt” means, as
of any date, (a) the aggregate principal amount of Indebtedness of the type specified in clauses (a), (b) and (g) of the definition thereof of the Issuer and its Restricted Subsidiaries outstanding as of such date determined on a
consolidated basis or is owing by Restricted Subsidiaries, minus (b) the amount of unrestricted cash and Cash Equivalents held, on such date, by the Issuer, minus (c) the amount of unrestricted cash and Cash Equivalents held, on such date,
by any Restricted Subsidiary, up to, the greater of (x) the aggregate principal amount of Indebtedness of such Restricted Subsidiary included in clause (a) of this definition and (y) the amount of such unrestricted cash and Cash
Equivalents of such Restricted Subsidiary times the percentage of such Restricted Subsidiary owned directly or indirectly by the Issuer. 
 “Consolidated Net Income” means, with respect to any specified Person for any period, the aggregate of the Net Income attributable to such specified Person and its Restricted Subsidiaries for
such period, on a consolidated basis, determined in accordance with GAAP; provided that: 
 (1) the Net Income (and net
loss) of any other Person (other than a Restricted Subsidiary of such Person) in which such Person or any of its Restricted Subsidiaries has an ownership interest will be excluded, except to the extent that any such Net Income is actually received
in cash by such Person or a Restricted Subsidiary of such Person in the form of dividends or similar distributions in respect of such period; 

  
 7 

 (2) the cumulative effect of a change in accounting principles will be excluded;

 (3) the amortization of any premiums, fees or expenses incurred in connection with the Transactions or any amounts required
or permitted by Accounting Principles Board Opinions No. 16 (including non-cash write-ups and non-cash charges relating to inventory and fixed assets, in each case arising in connection with the Transactions) and No. 17 (including non-cash
charges relating to intangibles and goodwill), in each case in connection with the Transactions, will be excluded; 
 (4) any
gain or loss, together with any related provision for taxes on such gain or loss, realized in connection with: (a) any sales of assets out of the ordinary course of business (it being understood that a sale of assets comprising discontinued
operations shall be deemed a sale of assets out of the ordinary course of business); or (b) the disposition of any securities by such Person or any of its Restricted Subsidiaries or the extinguishment of any Indebtedness of such Person or any
of its Restricted Subsidiaries will be excluded; 
 (5) any extraordinary gain or loss, together with any related provision for
taxes on such extraordinary gain or loss, will be excluded; 
 (6) income or losses attributable to discontinued operations
(including without limitation, operations disposed during such period whether or not such operations were classified as discontinued) will be excluded; 
 (7) any non-cash charges (i) attributable to applying the purchase method of accounting in accordance with GAAP, (ii) resulting from the application of FAS 142 or FAS 144, and
(iii) relating to the amortization of intangibles resulting from the application of FAS 141, will be excluded; 
 (8) all
non-cash charges relating to employee benefit or other management or stock compensation plans of such Person or a Restricted Subsidiary of such Person (excluding any such non-cash charge to the extent that it represents an accrual of or reserve for
cash expenses in any future period or amortization of a prepaid cash expense incurred in a prior period) will be excluded to the extent that such non-cash charges are deducted in computing such Consolidated Net Income; provided,
further, that if such Person or any Restricted Subsidiary of such Person makes a cash payment in respect of such non-cash charge in any period, such cash payment will (without duplication) be deducted from the Consolidated Net Income of such
Person for such period; 
 (9) all unrealized gains and losses relating to hedging transactions and mark-tomarket of
Indebtedness denominated in foreign currencies resulting from the application of FAS 52 shall be excluded; 
 (10) solely for
the purpose of Section 3.4(a)(3)(a), the Net Income for such period of any Restricted Subsidiary of such Person (other than ARH, any Guarantor or any 

  
 8 

 
guarantor under the Secured Notes) shall be excluded to the extent that the declaration or payment of dividends or similar distributions by that Restricted Subsidiary of its Net Income is not at
the date of determination permitted without any prior governmental approval (which has not been obtained) or, directly or indirectly, by the operation of the terms of its charter or any agreement, instrument, judgment, decree, order, statute, rule,
or governmental regulation applicable to that Restricted Subsidiary or its stockholders, except to the extent such restriction with respect to the payment of dividends or similar distributions has been legally waived; and 

(11) Consolidated Net Income of ARH or the Issuer shall be reduced by the amount of any payments made by ARH or the Issuer,
respectively, described in clause (2) of the definition of “Permitted Payments to Parent.” 
 “Contribution
Indebtedness” means Indebtedness of the Issuer or any Restricted Subsidiary in an aggregate principal amount not to exceed the aggregate net cash proceeds received by the Issuer after the date hereof from the sale of its Equity Interests (other
than Disqualified Stock) or as a contribution to its common equity capital (in each case, other than to or from a Subsidiary of the Issuer); provided that such Indebtedness (a) is incurred within 180 days after the sale of such Equity
Interests or the making of such capital contribution and (b) is designated as “Contribution Indebtedness” pursuant to an Officers’ Certificate delivered to the Trustee within one business day of the date of its incurrence. Any
sale of Equity Interests or capital contribution that forms the basis for an incurrence of Contribution Indebtedness will not be considered to be a sale of Capital Stock and will be disregarded for purposes of Section 3.4. 

“Corporate Trust Office” shall be at the address of the Trustee specified in Section 12.1 or such other address as to
which the Trustee may give notice to the Issuer or Holders pursuant to the procedures set forth in Section 12.1. 

“Credit Agreement” means that certain Credit Agreement, dated as of May 7, 2010, by and among ARH, as borrower, the
guarantors party thereto, Bank of America, N.A., as administrative agent and collateral agent, and various lenders from time to time party thereto, including any related notes, guarantees, collateral documents, instruments and agreements executed in
connection therewith, and, in each case, as amended, restated, modified, renewed, refunded, replaced (whether upon or after termination or otherwise) or refinanced from time to time. 

“Credit Facilities” means one or more debt facilities (including, without limitation, the Credit Agreement) or commercial paper
facilities or indentures, in each case, with banks or other institutional lenders providing for revolving credit loans, notes, term loans, receivables financing (including through the sale of receivables to such lenders or to special purpose
entities formed to borrow from such lenders against such receivables) or letters of credit or any other Indebtedness, in each case, as amended, restated, modified, renewed, refunded, replaced (whether upon or after termination or otherwise) or
refinanced (including by means of sales of debt securities and including any amendment, restatement, modification, renewal, refunding, replacement or refinancing that increases the amount borrowed thereunder or extends the maturity thereof) in whole
or in part from time to time. 

  
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 “Default” means any event that is, or with the passage of time or the giving of
notice or both would be, an Event of Default. 
 “Definitive Note” means a certificated Note registered in the name of
the Holder thereof and issued in accordance with Section 2.6 hereof, substantially in the form of Exhibit A hereto except that such Note shall not bear the Global Note Legend and shall not have the “Schedule of Exchanges of Interests in
the Global Note” attached thereto. 
 “Depositary” means The Depository Trust Company, its nominees and their
respective successors and assigns, or such other depository institution hereinafter appointed by the Issuer. 
 “Designated
Noncash Consideration” means any non-cash consideration received by the Issuer or a Restricted Subsidiary in connection with an Asset Sale that is designated as Designated Non- cash Consideration pursuant to an Officers’ Certificate.

 “Disqualified Stock” means any Capital Stock that, by its terms (or by the terms of any security into which it is
convertible, or for which it is exchangeable, in each case, at the option of the holder of the Capital Stock), or upon the happening of any event, matures or is mandatorily redeemable, pursuant to a sinking fund obligation or otherwise, or is
redeemable at the option of the holder of the Capital Stock, in whole or in part, on or prior to the date that is 91 days after the date on which the Notes mature. Notwithstanding the preceding sentence, (x) any Capital Stock that would
constitute Disqualified Stock solely because the holders of the Capital Stock have the right to require the Issuer or the Subsidiary that issued such Capital Stock to repurchase such Capital Stock upon the occurrence of a change of control or an
asset sale will not constitute Disqualified Stock if the terms of such Capital Stock provide that the Issuer may not repurchase such Capital Stock unless the Issuer would be permitted to do so in compliance with Section 3.4, (y) any
Capital Stock that would constitute Disqualified Stock solely as a result of any redemption feature that is conditioned upon, and subject to, compliance with Section 3.4 will not constitute Disqualified Stock and (z) any Capital Stock
issued to any plan for the benefit of employees will not constitute Disqualified Stock solely because it may be required to be repurchased by the Issuer or the Subsidiary that issued such Capital Stock in order to satisfy applicable statutory or
regulatory obligations. The amount of Disqualified Stock deemed to be outstanding at any time for purposes of this Indenture will be the maximum amount that the Issuer and its Restricted Subsidiaries may become obligated to pay upon the maturity of,
or pursuant to any mandatory redemption provisions of, such Disqualified Stock, exclusive of accrued dividends. 

“Domestic Subsidiary” means any Restricted Subsidiary of the Issuer that was formed under the laws of the United States or any
state of the United States. 
 “Equity Interests” means Capital Stock and all warrants, options or other rights to
acquire Capital Stock (but excluding any debt security that is convertible into, or exchangeable for, Capital Stock). 

“Euroclear” means Euroclear S.A./N.V., as operator of the Euroclear system. 

“Exchange Act” means the Securities Exchange Act of 1934, as amended and the rules and regulations of the SEC promulgated
thereunder. 

  
 10 

 “Exchange Notes” means the notes issued in the Exchange Offer pursuant to the
Registration Rights Agreement. 
 “Exchange Offer” has the meaning set forth for such term in the Registration Rights
Agreement. 
 “Exchange Offer Registration Statement” has the meaning set forth in the Registration Rights Agreement.

 “Excluded Contributions” means net cash proceeds, marketable securities or Qualified Proceeds received by the
Issuer from (i) contributions to its equity capital (other than Disqualified Stock) or (ii) the sale (other than to a Subsidiary of the Issuer or to any management equity plan or stock option plan or any other management or employee
benefit plan or agreement of the Issuer) of Equity Interests (other than Disqualified Stock) of the Issuer, in each case designated as Excluded Contributions pursuant to an Officers’ Certificate on the date such capital contributions are made
or the date such Equity Interests are sold, as the case may be, that are excluded from any calculation set forth in Section 3.4(a)(3). 
 “Existing Indebtedness” means Indebtedness (other than the Indebtedness under the Credit Agreement and Indebtedness owed to the Issuer or any of its Subsidiaries), existing on the Issue Date.

 “Fair Market Value” means the value that would be paid by a willing buyer to an unaffiliated willing seller in a
transaction not involving distress or necessity of either party, determined in good faith by the Board of Directors, chief executive officer or chief financial officer of the Issuer (unless otherwise provided in this Indenture). 

“Financing Transactions” means (i) this offering of Notes and (ii) the payment of a dividend by the Issuer in an
aggregate amount up to (x) the net proceeds of the offering of Notes on the Issue Date plus (y) the cash and cash equivalents held by the Issuer on the Issue Date. 
 “Fixed Charge Coverage Ratio” means, with respect to any specified Person at any date of determination, the ratio of the Consolidated EBITDA of such Person for the Measurement Period to the
Fixed Charges of such Person for the Measurement Period, in each case, calculated on a Pro Forma Basis. In the event that the specified Person or any of its Restricted Subsidiaries incurs, assumes, guarantees, repays, repurchases, redeems, defeases
or otherwise discharges any Indebtedness (other than ordinary working capital borrowings) or issues, repurchases or redeems preferred stock or Disqualified Stock subsequent to the commencement of the Measurement Period, then the Fixed Charge
Coverage Ratio will be calculated giving pro forma effect to such incurrence, assumption, Guarantee, repayment, repurchase, redemption, defeasance or other discharge of Indebtedness, or such issuance, repurchase or redemption of preferred stock or
Disqualified Stock, and the use of the proceeds therefrom, as if the same had occurred at the beginning of the Measurement Period. 
 “Fixed Charges” means, with respect to any specified Person for any period, the sum, without duplication, of: 

  
 11 

 (1) the consolidated interest expense of such Person and its Restricted Subsidiaries for
such period, net of interest income, whether paid or accrued, including, without limitation, original issue discount, non-cash interest payments, the interest component of all payments associated with Capital Lease Obligations, commissions,
discounts and other fees and charges incurred in respect of letter of credit or bankers’ acceptance financings, and net of the effect of all cash payments made or received pursuant to Hedging Obligations in respect of interest rates, and
excluding (v) amortization of deferred financing costs, (w) accretion or accrual of discounted liabilities not constituting Indebtedness, (x) any expense resulting from the discounting of any Indebtedness in connection with the
application of purchase accounting in connection with any acquisition, (y) any expensing of bridge, commitment and other financing fees and (z) to the extent included in Fixed Charges, the portion of consolidated interest expense of such
Person and its Restricted Subsidiaries attributable to Fixed Charges incurred in connection with the acquisition of discontinued operations; plus 
 (2) any interest on Indebtedness of another Person that is Guaranteed by such Person or one of its Restricted Subsidiaries or secured by a Lien on assets of such Person or one of its Restricted
Subsidiaries, but only to the extent such Guarantee or Lien is called upon; plus 
 (3) the product of (A) all cash
dividends paid on any series of preferred stock of such Person or any of its Restricted Subsidiaries (other than to the Issuer or any Restricted Subsidiary), in each case, determined on a consolidated basis in accordance with GAAP, multiplied
by (B) a fraction, the numerator of which is one and the denominator of which is one minus the then current combined federal, state and local statutory tax rate of the Issuer and its Restricted Subsidiaries expressed as a decimal.

 “GAAP” means generally accepted accounting principles set forth in the opinions and pronouncements of the
Accounting Principles Board of the American Institute of Certified Public Accountants and statements and pronouncements of the Financial Accounting Standards Board or in such other statements by such other entity as have been approved by a
significant segment of the accounting profession, which are in effect on the Issue Date. For the purposes of this Indenture, the term “consolidated” with respect to any Person shall mean such Person consolidated with its Restricted
Subsidiaries, and shall not include any Unrestricted Subsidiary, but the interest of such Person in an Unrestricted Subsidiary will be accounted for as an Investment. 
 “Global Note Legend” means the legend set forth in Section 2.1(b) hereof, which is required to be placed on all Global Notes issued under this Indenture. 

“Global Notes” means, individually and collectively, each of the Restricted Global Notes and the Unrestricted Global Notes,
substantially in the form of Exhibit A hereto issued in accordance with Section 2.1 or 2.6 hereof. 
 “Government
Securities” means direct obligations of, or obligations guaranteed by, the United States of America (including any agency or instrumentality thereof) and the payment for which the United States pledges its full faith and credit. 

  
 12 

 “guarantee” of or by any Person (the “guarantor”) means any obligation,
contingent or otherwise, of the guarantor guaranteeing or having the economic effect of guaranteeing any Indebtedness or other obligation of any other Person (the “primary obligor”) in any manner, whether directly or indirectly, and
including any obligation of the guarantor, direct or indirect, (a) to purchase or pay (or advance or supply funds for the purchase or payment of) such Indebtedness or other obligation or to purchase (or to advance or supply funds for the
purchase of) any security for the payment thereof, (b) to purchase or lease property, securities or services for the purpose of assuring the owner of such Indebtedness or other obligation of the payment thereof, (c) to maintain working
capital, equity capital or any other financial statement condition or liquidity of the primary obligor so as to enable the primary obligor to pay such Indebtedness or other obligation or (d) as an account party or applicant in respect of any
letter of credit or letter of guaranty issued to support such Indebtedness or obligation, provided that the term “guarantee” shall not include endorsements for collection or deposit in the ordinary course of business. The amount of
any guarantee of any guarantor shall be deemed to be the lower of (a) an amount equal to the stated or determinable amount of the primary obligation in respect of which the guarantee is made and (b) the maximum amount for which such
guarantor may be liable pursuant to the terms of the instrument embodying such guarantee. 
 “Guarantee” means the
guarantee by each Guarantor of the Issuer’s obligations under this Indenture and the Notes. 
 “Guarantee
Agreement” means a supplemental indenture or a notation of guarantee, in a form satisfactory to the Trustee, pursuant to which a Guarantor guarantees the Issuer’s obligations with respect to the Notes on the terms provided for in this
Indenture. 
 “Guarantors” means the Subsidiary Guarantors, if any. 

“Hedging Obligations” means, with respect to any specified Person, the obligations of such Person under: 

(1) interest rate swap agreements (whether from fixed to floating or from floating to fixed), interest rate cap agreements and interest
rate collar agreements; 
 (2) other agreements or arrangements designed to manage interest rates or interest rate risk; and

 (3) other agreements or arrangements designed to protect such Person against fluctuations in currency exchange rates or
commodity prices. 
 “Holder” means any registered holder, from time to time, of the Notes. 

“Indebtedness” of any Person means, without duplication, (a) all obligations of such Person for borrowed money,
(b) all obligations of such Person evidenced by bonds, debentures, notes or similar instruments, (c) all obligations of such Person under conditional sale or other title retention agreements relating to property acquired by such Person,
(d) all obligations of such Person in respect of the deferred purchase price of property or services (excluding trade accounts payable and accrued obligations incurred in the ordinary course of business), (e) all obligations of others
secured by any Lien on property owned or acquired by such Person, whether or not the 

  
 13 

 
obligations secured thereby have been assumed, but limited, in the event such secured obligations are nonrecourse to such Person, to the fair value of such property, (f) all Guarantees by
such Person of the Indebtedness of any other Person, (g) all Capital Lease Obligations of such Person, (h) all reimbursement obligations of such Person as an account party or applicant in respect of letters of credit and letters of
guaranty, (i) all obligations, contingent or otherwise, of such Person in respect of bankers’ acceptances and (j) all obligations of such Person in respect of Disqualified Stock. The Indebtedness of any Person shall include the
Indebtedness of any other entity (including any partnership in which such Person is a general partner) to the extent such Person is liable therefor as a result of such Person’s ownership interest in or other relationship with such entity,
except to the extent the terms of such Indebtedness provide that such Person is not liable therefor. For the avoidance of doubt, any right of Strategic Investors in a Qualified Restricted Subsidiary to require the Issuer or any Qualified Restricted
Subsidiary to repurchase the Equity Interests in such Qualified Restricted Subsidiary held by such Strategic Investors does not constitute Indebtedness. 
 “Indenture” has the meaning set forth in the preamble hereto. 

“Indirect Participant” means a Person who holds a beneficial interest in a Global Note through a Participant. 

“Initial Notes” means the $135,000,000 in aggregate principal amount of 9.75%/10.50% Senior PIK Toggle Notes due 2016 of the
Issuer issued under this Indenture on the Issue Date. 
 “Initial Purchasers” means, with respect to the Initial
Notes, Merrill Lynch, Pierce, Fenner & Smith Incorporated and Barclays Capital Inc. 
 “Interest Payment
Date” means March 1 and September 1 of each year, commencing, in the case of the Initial Notes, on September 1, 2011 and ending at the Stated Maturity of the Notes. 

“Investments” means, with respect to any Person, all direct or indirect investments by such Person in other Persons (including
Affiliates) in the forms of loans (including guarantees or other obligations), advances or capital contributions (excluding accounts receivable, trade credit, advances to customers and commission, travel, relocation and similar advances to officers
and employees made in the ordinary course of business), purchases or other acquisitions for consideration of Indebtedness, Equity Interests or other securities, together with all items that are or would be classified as investments on a balance
sheet (excluding the footnotes) prepared in accordance with GAAP. If the Issuer or any Restricted Subsidiary of the Issuer sells or otherwise disposes of any Equity Interests of any direct or indirect Restricted Subsidiary of the Issuer such that,
after giving effect to any such sale or disposition, such Person is no longer a Subsidiary of the Issuer, the Issuer will be deemed to have made an Investment on the date of any such sale or disposition equal to the Fair Market Value of the
Issuer’s Investments in such Subsidiary that were not sold or disposed of in an amount determined as provided in Section 3.4(c). The acquisition by the Issuer or any Restricted Subsidiary of the Issuer of a Person that holds an Investment
in a third Person will not be deemed to be an Investment by the Issuer or such Restricted Subsidiary in such third Person, unless such third Person’s Investment was made in contemplation of the acquisition by the Issuer or a Restricted
Subsidiary, in which case it shall be 

  
 14 

 
an Investment in an amount equal to the Fair Market Value of the Investments held by the acquired Person in such third Person in an amount determined as provided in Section 3.4(c). The
outstanding amount of any Investment shall be the original cost thereof, reduced by all returns on such Investment (including dividends, interest, distributions, returns of principal and profits on sale). 

“Issue Date” means the date the Notes are first issued under this Indenture. 

“Issuer” means American Renal Holdings Company, Inc., a Delaware corporation. 

“Legal Holiday” means a Saturday, a Sunday or a day on which banking institutions are not required to be open in the State of
New York. 
 “Letter of Transmittal” means the letter of transmittal to be prepared by the Issuer and sent to all
Holders of the Notes for use by such Holders in connection with the Exchange Offer. 
 “Lien” means, with respect to
any asset, (a) any mortgage, deed of trust, lien, pledge, hypothecation, encumbrance, charge or security interest in, on or of such asset and (b) the interest of a vendor or a lessor under any conditional sale agreement, capital lease or
title retention agreement (or any financing lease having substantially the same economic effect as any of the foregoing) relating to such asset. 
 “Management Agreements” means the management, service or similar agreements pursuant to which the Issuer or any of its Qualified Restricted Subsidiaries manages the assets and businesses of any
of its Restricted Subsidiaries. 
 “Measurement Period” means, at any date of determination, the period of four full
fiscal quarters for which internal financial statements are available immediately preceding such date. 
 “Merger
Agreement” means the Agreement and Plan of Merger by and among, inter alia, American Renal Holdings Intermediate Company, LLC (formerly known as C.P. Atlas Intermediate Holdings, LLC), the Issuer (fomerly known as C.P. Atlas Holdings Company,
Inc.), Pamlico Capital I, L.P. (formerly known as Wachovia Capital Partners GP I, LLC) and the selling shareholders named therein, dated as of March 22, 2010, as amended or modified from time to time prior to May 7, 2010. 

“Merger Transaction” means the transactions contemplated by the Merger Agreement and the other related transactions described
in ARH’s filing with the SEC on Form S-4 (registration 333- 170376). 
 “Net Income” means, with respect to any
specified Person, the net income (loss) attributable to such Person (which shall exclude, for the avoidance of doubt, the income (loss) attributable to minority interests), determined in accordance with GAAP and before any reduction in respect of
preferred stock dividends. 
 “Net Proceeds” means the aggregate cash proceeds received by the Issuer or any of its
Restricted Subsidiaries in respect of any Asset Sale (including, without limitation, any cash received upon the sale or other disposition of any non-cash consideration received in any Asset 

  
 15 

 
Sale), net of the direct costs relating to such Asset Sale, including, without limitation, legal, accounting and investment banking fees, payments made in order to obtain a necessary consent or
required by applicable law, and sales commissions, and any relocation expenses incurred as a result of the Asset Sale, taxes paid or payable as a result of the Asset Sale, including taxes resulting from the transfer of the proceeds of such Asset
Sale to the Issuer, in each case, after taking into account: 
 (1) any available tax credits or deductions and any tax sharing
arrangements; 
 (2) any reserve for adjustment in respect of the sale price of such asset or assets established in accordance
with GAAP; 
 (3) any reserve for adjustment in respect of any liabilities associated with the asset disposed of in such
transaction and retained by the Issuer or any Restricted Subsidiary after such sale or other disposition thereof; 
 (4) any
distributions and other payments required to be made to minority interest holders in Subsidiaries or joint ventures as a result of such Asset Sale; and 
 (5) in the event that a Restricted Subsidiary consummates an Asset Sale and makes a pro rata payment of dividends to all of its stockholders from any cash proceeds of such Asset Sale, the amount of
dividends paid to any stockholder other than the Issuer or any other Restricted Subsidiary, provided that any net proceeds of an Asset Sale by a Restricted Subsidiary that are subject to legal or contractual restrictions on repatriation to
the Issuer will not be considered Net Proceeds for so long as such proceeds are subject to such restrictions, provided, however, that any such contractual restrictions on repatriation were not entered into in contemplation of such
Asset Sale. 
 “Non-Cash Charges” means (a) losses on asset sales, disposals or abandonments, (b) any
impairment charge or asset write-off or write-down related to intangible assets, goodwill, long-lived assets, and investments in debt and equity securities pursuant to GAAP, (c) all losses from investments recorded using the equity method,
(d) stock-based awards compensation expense, and (e) other non-cash charges (provided that if any non-cash charges, expenses and write-downs referred to in this clause (e) represent an accrual or reserve for potential cash
items in any future period, the cash payment in respect thereof in such future period shall be subtracted from Consolidated EBITDA to such extent, and excluding amortization of a prepaid cash item that was paid in a prior period). 

“Non-Recourse Debt” means Indebtedness: 
 (1) as to which neither the Issuer nor any of its Restricted Subsidiaries (a) provides credit support of any kind (including any undertaking, agreement or instrument that would constitute
Indebtedness), (b) is directly or indirectly liable as a guarantor or (c) otherwise constitutes the lender; 
 (2) no
default with respect to which (including any rights that the holders of the Indebtedness may have to take enforcement action against an Unrestricted 

  
 16 

 
Subsidiary) would permit upon notice, lapse of time or both any holder of any other Indebtedness of the Issuer or any of its Restricted Subsidiaries to declare a default on such other
Indebtedness or cause the payment of such other Indebtedness to be accelerated or payable prior to its Stated Maturity; and 

(3) as to which the lenders have been notified in writing or have agreed in writing (in the agreement relating thereto or otherwise)
that they will not have any recourse to the stock or assets of the Issuer or any of its Restricted Subsidiaries. 

“Non-U.S. Person” means a Person who is not a U.S. Person. 

“Notes” means the Initial Notes, the Exchange Notes and any Additional Notes, treated as a single class of securities.

 “Notes Custodian” means the custodian with respect to the Global Note (as appointed by the Depositary), or any
successor Person thereto and shall initially be the Trustee. 
 “Obligations” means any principal, interest,
penalties, fees, indemnifications, reimbursements, damages and other liabilities payable under the documentation governing any Indebtedness. 
 “Offering Memorandum” means the confidential Offering Memorandum dated March 1, 2011, used in connection with the offering of the Initial Notes. 

“Officer” means any of the following of the Issuer: the Chairman of the Board of Directors, the Chief Executive Officer, the
Chief Financial Officer, the President, any Vice President, the Treasurer or the Secretary. 
 “Officers’
Certificate” means a certificate signed by two Officers. 
 “Opinion of Counsel” means a written opinion from
legal counsel who is acceptable to the Trustee. The counsel may be an employee of or counsel to the Issuer. 
 “Original
Issue Discount Legend” means the legend set forth in Section 2.1(d) to be placed on any Note issued under this Indenture. 
 “Participant” means, with respect to the Depositary, a Person who has an account with the Depositary. 
 “Permanent Regulation S Global Note” means a permanent Global Note in the form of Exhibit A hereto bearing the Global Note Legend and the Private Placement Legend and deposited with or on behalf
of and registered in the name of the Depositary or its nominee, issued in a denomination equal to the outstanding principal amount of the Temporary Regulation S Global Note upon expiration of the Restricted Period. 

“Permitted Business” means (i) any business engaged in by the Issuer or any of its Restricted Subsidiaries on the Issue
Date, and (ii) any business or other activities that are reasonably similar, ancillary, complementary or related to, or a reasonable extension, development or expansion of, the businesses in which the Issuer and its Restricted Subsidiaries are
engaged on the Issue Date. 

  
 17 

 “Permitted Holder” means the Sponsor and its Affiliates (other than portfolio
companies or holding companies of other portfolio companies). 
 “Permitted Investments” means: 

(1) any Investment in the Issuer or any Restricted Subsidiary of the Issuer; 

(2) any Investment in Cash Equivalents; 
 (3) any Investment by the Issuer or any Restricted Subsidiary of the Issuer in a Person (other than the Issuer or a Restricted Subsidiary of the Issuer) that is engaged as its primary business in a
Permitted Business, if as a result of such Investment: 
 (a) such Person becomes a Restricted Subsidiary of the Issuer; or

 (b) such Person, in one transaction or a series of transactions, is merged, consolidated or amalgamated with or into, or
transfers or conveys substantially all of its assets to, or is liquidated into, the Issuer, or a Restricted Subsidiary of the Issuer; 
 (4) any Investment received in connection with a disposition of assets not constituting an Asset Sale; 
 (5) any Investment solely in exchange for the issuance of Equity Interests (other than Disqualified Stock) of the Issuer or any parent of the Issuer; 

(6) any Investments received in compromise, settlement or resolution of (A) obligations of trade debtors or customers that were
incurred in the ordinary course of business of the Issuer or any of its Restricted Subsidiaries, including pursuant to any plan of reorganization or similar arrangement upon the bankruptcy or insolvency of any trade debtor or customer,
(B) litigation, arbitration or other disputes with Persons who are not Affiliates or (C) as a result of a foreclosure by the Issuer or any Restricted Subsidiary with respect to any secured Investment or other transfer of title with respect
to any secured Investment in default; 
 (7) Investments represented by Hedging Obligations entered into to protect against
fluctuations in interest rates, exchange rates and commodity prices; 
 (8) any Investment in payroll, travel and similar
advances to cover business-related travel expenses, moving expenses or other similar expenses, in each case incurred in the ordinary course of business; 
 (9) Investments in receivables owing to the Issuer or any Restricted Subsidiary if created or acquired in the ordinary course of business and payable or dischargeable in accordance with customary trade
terms; provided, however, that such trade terms may include such concessionary trade terms as the Issuer or any such Restricted Subsidiary deems reasonable under the circumstances; 

  
 18 

 (10) Investments in prepaid expenses, negotiable instruments held for collection and lease,
utility and workers compensation, performance and similar deposits entered into as a result of the operations of the business in the ordinary course of business; 
 (11) obligations of one or more officers or other employees of the Issuer or any of its Restricted Subsidiaries in connection with such officer’s or employee’s acquisition of shares of Capital
Stock of the Issuer or Capital Stock of any direct or indirect parent company of the Issuer so long as no cash or other assets are paid by the Issuer or any of its Restricted Subsidiaries to such officers or employees in connection with the
acquisition of any such obligations; 
 (12) loans or advances to and guarantees provided for the benefit of employees made in
the ordinary course of business of the Issuer or the Restricted Subsidiary of the Issuer in an aggregate principal amount not to exceed $2.0 million at any one time outstanding; 

(13) Investments existing as of the Issue Date or an Investment consisting of any extension, modification or renewal of any Investment
existing as of the Issue Date (excluding any such extension, modification or renewal involving additional advances, contributions or other investments of cash or property or other increases thereof unless it is a result of the accrual or accretion
of interest or original issue discount or payment-in-kind pursuant to the terms, as of the Issue Date, of the original Investment so extended, modified or renewed) and pursuant to any binding commitment outstanding as of the Issue Date; 

(14) repurchases of the Notes; 
 (15) the acquisition by a Receivables Subsidiary in connection with a Qualified Receivables Transaction of Equity Interests of a trust or other Person established by such Receivables Subsidiary to effect
such Qualified Receivables Transaction; and any other Investment by the Issuer or a Subsidiary of the Issuer in a Receivables Subsidiary or any Investment by a Receivables Subsidiary in any other Person in connection with a Qualified Receivables
Transaction customary for such transactions; 
 (16) Investments not otherwise permitted by the foregoing clauses in an amount,
taken together with all other Investments made pursuant to this clause, not to exceed, in the aggregate at any time outstanding, the greater of (i) $20.0 million and (ii) 3.75% of Total Assets at the time of any Investment pursuant to this
clause; 
 (17) Investments consisting of amounts potentially due from a seller of property in an acquisition that
(i) relate to customary post-closing adjustments with respect to accounts receivable, accounts payable and similar items typically subject to post-closing adjustments in similar transactions and (ii) are outstanding for a period of one
hundred twenty (120) days or less following the closing of such acquisition; 

  
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 (18) good faith deposits in connection with any acquisition, joint venture or acquisition
of assets and escrowed money in connection with Asset Sales, acquisitions or joint ventures; 
 (19) Investments of a
Restricted Subsidiary of the Issuer acquired after the Issue Date or of a Person merged into, amalgamated with or consolidated with a Restricted Subsidiary of the Issuer in a transaction that is not prohibited by Article IV after the Issue Date to
the extent that such Investments were not made in contemplation of such acquisition, merger, amalgamation or consolidation and were in existence on the date of such merger, acquisition, amalgamation or consolidation; 

(20) any investment in a Receivables Subsidiary or any Investment by a Receivables Subsidiary in any other Person in connection with a
Qualified Receivables Transaction, including, without limitation, Investments of funds held in accounts permitted or required by the arrangements governing such Qualified Receivables Transaction or any related indebtedness; and 

(21) guarantees of obligations (other than Indebtedness) incurred by Qualified Restricted Subsidiaries in the ordinary course of
business and not otherwise prohibited by this Indenture. 
 “Permitted Liens” means: 

(1) Liens in favor of the Issuer or any Subsidiary Guarantor; 
 (2) Liens on property or assets of a Person, existing at the time such Person is merged with or into, consolidated with or acquired by the Issuer or any Restricted Subsidiary of the Issuer;
provided that such Liens were in existence prior to, and were not incurred in contemplation of, such merger, consolidation or acquisition and do not extend to any assets other than those of the Person merged into, consolidated with or
acquired by the Issuer or such Subsidiary, plus renewals and extensions of such Liens on the same assets; 
 (3) Liens on
property (including Capital Stock) existing at the time of acquisition of the property by the Issuer or any Restricted Subsidiary of the Issuer; provided that such Liens were in existence prior to such acquisition, and were not incurred in
contemplation of, such acquisition, plus renewals and extensions of such Liens on the same assets; 
 (4) Liens (including
deposits and pledges) to secure the performance of public or statutory obligations, progress payments, surety or appeal bonds, performance bonds or other obligations of a like nature incurred in the ordinary course of business; 

(5) Liens to secure Purchase Money Indebtedness permitted by clause (xviii) of the definition of “Permitted Debt”
covering only the assets acquired, constructed or improved with or financed by such Indebtedness; 
 (6) Liens existing on the
Issue Date (other than Liens in favor of the lenders under the Credit Agreement), plus renewals and extensions of such Liens on the same assets; 

  
 20 

 (7) Liens for taxes, assessments or governmental charges or claims that are not yet
delinquent or that are being contested in good faith by appropriate proceedings promptly instituted and diligently concluded; provided that any reserve or other appropriate provision as is required in conformity with GAAP has been made
therefor; 
 (8) Liens imposed by law, such as carriers’, warehousemen’s, landlord’s, materialmen’s,
laborers’, employees’, suppliers’ and mechanics’ Liens, in each case, incurred in the ordinary course of business; 
 (9) survey exceptions, title defects, encumbrances, easements or reservations of, or rights of others for, licenses, rights-of-way, sewers, electric lines, telegraph and telephone lines and other similar
purposes, or zoning or other restrictions as to the use of real property that do not materially interfere with the ordinary conduct of the business of the Issuer and its Subsidiaries, taken as a whole; 

(10) Liens securing Indebtedness or other obligations of a Restricted Subsidiary owing to the Issuer or another Restricted Subsidiary
permitted to be incurred in accordance with Section 3.3; 
 (11) Liens to secure any Permitted Refinancing Indebtedness
permitted to be incurred under this Indenture; provided, however, that the new Lien shall be limited to all or part of the same property and assets that secured or, under the written agreements pursuant to which the original Lien
arose, could secure the original Indebtedness (plus improvements and accessions to, such property or proceeds or distributions thereof); 
 (12) Liens securing Indebtedness that does not exceed $2.5 million at any one time outstanding, and Obligations in respect thereof; 

(13) [Reserved]; 
 (14) security for the payment of workers’ compensation, unemployment insurance, other social security benefits or other insurance-related obligations (including, but not limited to, in respect of
deductibles, self-insured retention amounts and premiums and adjustments thereto) entered into in the ordinary course of business; 
 (15) deposits or pledges in connection with bids, tenders, leases and contracts (other than contracts for the payment of money) entered into in the ordinary course of business; 

(16) zoning restrictions, easements, licenses, reservations, provisions, encroachments, encumbrances, protrusion permits, servitudes,
covenants, conditions, waivers, restrictions on the use of property or minor irregularities of title (and with respect to leasehold interests, mortgages, obligations, liens and other encumbrances incurred, created, assumed or permitted to exist and
arising by, through or under a landlord or owner of the leased property, with or without consent of the lessee), in each case, not materially interfering with the ordinary conduct of the business of the Issuer and its Subsidiaries, taken as a whole;

  
 21 

 (17) leases, subleases, licenses or sublicenses to third parties entered into in the
ordinary course of business; 
 (18) Liens securing Hedging Obligations entered into to protect against fluctuations in
interest rates, exchange rates and commodity prices permitted under this Indenture; 
 (19) Liens arising out of judgments,
decrees, orders or awards (to the extent not constituting an Event of Default) in respect of which the Issuer shall in good faith be prosecuting an appeal or proceedings for review which appeal or proceedings shall not have been finally terminated,
or if the period within which such appeal or proceedings may be initiated shall not have expired; 
 (20) Liens on Capital
Stock of an Unrestricted Subsidiary that secure Indebtedness or other obligation of such Unrestricted Subsidiary; 
 (21) Liens
securing Treasury Management Obligations; 
 (22) any Liens arising from the precautionary filing of Uniform Commercial Code
financing statements regarding leases; 
 (23) Liens (i) of a collection bank arising under Section 4-2 10 of the
Uniform Commercial Code on items in the course of collection and (ii) in favor of banking institution encumbering deposits (including the right of set-off) and which are within the general parameters customary in the banking industry;

 (24) Liens encumbering reasonable customary initial deposits and margin deposits and similar Liens attaching to brokerage
accounts incurred in the ordinary course of business and not for speculative purposes; 
 (25) Liens on assets of any
Restricted Subsidiary securing Indebtedness of such Restricted Subsidiary (other than any guarantee of Indebtedness of the Issuer); 
 (26) Liens created or deemed to exist by the establishment of trusts for the purpose of satisfying government reimbursement program costs and other actions or claims pertaining to the same or related
matters or other medical reimbursement programs; 
 (27) Liens solely on any cash earned money deposits made by the Issuer or
any Restricted Subsidiary with any letter of intent or purchase agreement permitted hereunder; 
 (28) [Reserved]; and

 (29) Liens incurred in connection with a Qualified Receivables Transaction (which, in the case of the Issuer and its
Restricted Subsidiaries (other than Receivables Subsidiaries), shall be limited to receivables and related assets referred to in the definition of “Qualified Receivables Transaction”). 

  
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 “Permitted Payment Restriction” means, with respect to any Subsidiary, any
restriction that (i) becomes effective only upon the occurrence of (x) specified events under its charter or (y) a default by such Subsidiary in the payment of principal of or interest, a bankruptcy default, a default on any financial
covenant or any other material event of default, in each case on Indebtedness that was incurred by such Subsidiary in compliance with Section 3.3 and (ii) does not materially impair the Issuer’s ability to make scheduled payments of
cash interest and fees and to make required principal payments on the Notes, as determined in good faith by the Board of Directors. 
 “Permitted Payments to Parent” means, with respect to any Person: 
 (1)
payments, directly or indirectly, to any direct or indirect parent company of such Person to be used by such direct or indirect parent company of such Person to pay consolidated, combined or similar Federal, state and local taxes payable by such
parent company and directly attributable to (or arising as a result of) the operations of such Person and its Subsidiaries and (y) franchise or similar taxes and fees of such parent company required to maintain such parent company’s
corporate or other existence; provided that: 
 (a) the amount of such dividends, distributions or advances paid shall
not exceed the amount (x) that would be due with respect to a consolidated, combined or similar federal, state or local tax return for the Issuer and its Subsidiaries if the Issuer were the parent of such group for federal, state and local tax
purposes plus (y) the actual amount of such franchise or similar taxes and fees of such parent company required to maintain such parent company’s corporate or other existence, each as applicable; and 

(b) such payments are used by such parent company for such purposes within 90 days of the receipt of such payments; 

(2) payments, directly or indirectly, to any direct or indirect parent company of such Person if the proceeds thereof are used to pay
general corporate and overhead expenses (including salaries and other compensation of employees) incurred in the ordinary course of its business or of the business of such other parent company of such Person as a direct or indirect holding company
for such Person or used to pay fees and expenses (other than to Affiliates) relating to any unsuccessful debt or equity financing, in each case, only to the extent directly attributable to the operations of such Person and its Restricted
Subsidiaries; and 
 (3) so long as no Default exists at the time of such payment or would result therefrom, payments, directly
or indirectly, to any direct or indirect parent company of such Person if the proceeds thereof are used to pay amounts payable to the Permitted Holders to the extent permitted by Section 3.8(b)(xiii), solely to the extent such amounts are not
paid directly by such Person or any of its Subsidiaries; provided that any accelerated payment of periodic management fees under the Sponsor Management Agreement (other than upon termination thereof upon an initial public offering of common
stock, or change of control, of such Person or any direct or indirect parent company of such Person) shall constitute a Restricted Payment (whether or not such payment is made by the Issuer directly or through a dividend or distribution to the
parent company) not permitted by this clause (3) and shall be permitted only if such Person would be permitted to make a Restricted Payment under another exception under Section 3.4. 

  
 23 

 “Permitted Refinancing Indebtedness” means any Indebtedness of the Issuer or any
of its Restricted Subsidiaries issued in exchange for, or the net proceeds of which are used to extend, renew, refund, refinance, replace, defease or discharge other Indebtedness of the Issuer or any of its Restricted Subsidiaries; provided
that: 
 (1) the principal amount (or accreted value, if applicable) of such Permitted Refinancing Indebtedness does not exceed
the principal amount (or accreted value, if applicable) of the Indebtedness extended, renewed, refunded, refinanced, replaced, defeased or discharged (plus all accrued interest on the Indebtedness and the amount of all fees, commissions, discounts
and expenses, including premiums, incurred in connection therewith); 
 (2) either (a) such Permitted Refinancing
Indebtedness has a final maturity date equal to or later than the final maturity date of, and has a Weighted Average Life to Maturity equal to or greater than the Weighted Average Life to Maturity of, the Indebtedness being extended, renewed,
refunded, refinanced, replaced, defeased or discharged or (b) all scheduled payments on or in respect of such Permitted Refinancing Indebtedness (other than interest payments) shall be at least 91 days following the final scheduled maturity of
the Notes; 
 (3) if the Indebtedness being extended, renewed, refunded, refinanced, replaced, defeased or discharged is
subordinated in right of payment to the Notes, such Permitted Refinancing Indebtedness is subordinated in right of payment to the Notes on terms at least as favorable to the holders of Notes as those contained in the documentation governing the
Indebtedness being extended, renewed, refunded, refinanced, replaced, defeased or discharged; 
 (4) such Indebtedness is
incurred by the Issuer if the obligor on the Indebtedness being renewed, refunded, refinanced, replaced, defeased or discharged is the Issuer; and 
 (5) such Indebtedness is only secured if and to the extent and with the priority the Indebtedness being extended, renewed, refunded, refinanced, replaced, defeased or discharged is secured or would be
permitted to be secured pursuant to Section 3.5. 
 “Person” means any natural person, corporation, limited
liability company, trust, joint venture, association, company, partnership, governmental authority or other entity. 
 “PIK
Interest” means interest on the Notes, which is paid, at the Issuer’s election, by increasing the principal amount of the outstanding Notes or by issuing additional PIK Notes. 

“principal” of a Note means the principal of such Note, plus the premium, if any, payable on the Note which is due or overdue
or is to become due at the relevant time. 
 “Private Placement Legend” means the legend set forth in
Section 2.1(c) to be placed on all Notes issued under this Indenture except where otherwise permitted by the provisions hereof. 
 “Pro Forma Basis” means, with respect to any calculation for any Measurement Period: 

  
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 (1) Investments, acquisitions, mergers, consolidations and dispositions that have been made
by the specified Person or any of its Restricted Subsidiaries, or any Person or any of its Restricted Subsidiaries acquired by, merged or consolidated with the specified Person or any of its Restricted Subsidiaries, and including any related
financing transactions and including increases in ownership of Restricted Subsidiaries, during such Measurement Period or subsequent to the Measurement Period and on or prior to the date for which the calculation is being made (the “Calculation
Date”) will be given pro forma effect, including giving effect to Pro Forma Cost Savings, as if they had occurred on the first day of the Measurement Period; 
 (2) for purposes of the Fixed Charge Coverage Ratio, the Fixed Charges attributable to discontinued operations, as determined in accordance with GAAP, and operations or businesses (and ownership interests
therein) disposed of prior to the Calculation Date, will be excluded, but only to the extent that the obligations giving rise to such Fixed Charges will not be obligations of the specified Person or any of its Restricted Subsidiaries following the
Calculation Date; 
 (3) any Person that is a Restricted Subsidiary on the Calculation Date will be deemed to have been a
Restricted Subsidiary at all times during such Measurement Period; 
 (4) any Person that is not a Restricted Subsidiary on the
Calculation Date will be deemed not to have been a Restricted Subsidiary at any time during such Measurement Period; and 
 (5)
if any Indebtedness bears a floating rate of interest, the interest expense on such Indebtedness will be calculated as if the rate in effect on the Calculation Date had been the applicable rate for the entire Measurement Period (taking into account
any Hedging Obligation applicable to such Indebtedness). 
 The calculations above shall be made in good faith by a responsible
financial or accounting officer of the Issuer and shall take into account any Hedging Obligations of the Issuer and its Restricted Subsidiaries. Interest on a Capital Lease Obligation shall be deemed to accrue at an interest rate reasonably
determined by a responsible financial or accounting officer of the Issuer to be the rate of interest implicit in such Capital Lease Obligation in accordance with GAAP. For purposes of making the computation referred to above, interest on any
Indebtedness under a revolving credit facility computed on a pro forma basis shall be computed based upon the average daily balance of such Indebtedness during the applicable period. Interest on Indebtedness that may optionally be determined at an
interest rate based upon a factor of a prime or similar rate, a eurocurrency interbank offered rate, or other rate, shall be deemed to have been based upon the rate actually chosen, or, if none, then based upon such optional rate chosen as the
Issuer may designate. 
 “Pro Forma Cost Savings” means, with respect to any period, the reduction in net costs and
related adjustments that were directly attributable to an acquisition, merger, consolidation or disposition that (i) occurred during the four-quarter reference period or subsequent to the four-quarter reference period and on or prior to the
date of determination and calculated on a basis that is consistent with Regulation S-X under the Securities Act as in effect and applied as of May 7, 2010, 

  
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(ii) were actually implemented within 12 months after the date of the acquisition, merger, consolidation or disposition and prior to the date of determination that are supportable and
quantifiable by the underlying accounting records of such business or (iii) the Issuer reasonably determines are probable based upon specifically identifiable actions to be taken within 12 months of the date of the acquisition, merger,
consolidation or disposition and, in the case of each of clauses (i), (ii) and (iii), are described, as provided below, in an Officers’ Certificate, as if all such reductions in costs had been effected as of the beginning of such period.
Pro Forma Cost Savings described above shall be accompanied by an Officers’ Certificate delivered to the Trustee from the chief financial officer of the Issuer that outlines the actions taken or to be taken, the net cost savings achieved or to
be achieved from such actions and that, in the case of clause (iii) above, such savings have been determined to be probable. 
 “Purchase Money Indebtedness” means Indebtedness, including Capital Lease Obligations, Disqualified Stock or preferred stock of the Issuer or any Restricted Subsidiary incurred for the purpose
of financing all or any part of the purchase price of assets used in the business of the Issuer or any Restricted Subsidiary or the cost of installation, construction or improvement thereof; provided, however, that (1) the amount
of such Indebtedness shall not exceed such purchase price or cost and (2) such Indebtedness shall be incurred within 90 days after such acquisition of such asset by the Issuer or such Restricted Subsidiary or such installation, construction or
improvement. 
 “QIB” means any “qualified institutional buyer” (as defined in Rule 144A). “Qualified
Capital Stock” means any Capital Stock that is not Disqualified Stock. 
 “Qualified Equity Issuance” means an
underwritten public equity offering of Qualified Capital Stock of the Issuer or any direct or indirect parent company of the Issuer (which for the avoidance of doubt shall not include the Sponsors) pursuant to an effective registration statement
under the Securities Act that yields Qualified Equity Issuance Net Proceeds to either the Issuer or any direct or indirect parent company of the Issuer, of at least $25.0 million, whether or not, in the case of a Qualified Equity Issuance by any
direct or indirect parent company of the Issuer, such Qualified Equity Issuance Net Proceeds are contributed to the capital of the Issuer, other than (x) any such public sale to any entity that is an Affiliate of the Issuer and (y) any
public offering registered on Form S-8. 
 “Qualified Equity Issuance Net Proceeds” means the aggregate cash proceeds
received by the Issuer or any parent of the Issuer in respect of any Qualified Equity Issuance, net of the direct costs, fees and expenses relating to such Qualified Equity Issuance (including legal, accounting, transfer agent, printing and
investment banking fees, filing fees of the SEC or FINRA, and brokerage and sales commissions), and any taxes paid or payable as a result thereof. 
 “Qualified Proceeds” means any of the following or any combination of the following: 
 (1) cash or Cash Equivalents; 
 (2) the Fair Market Value of assets that are used
or useful in the Permitted Business; and 

  
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 (3) the Fair Market Value of the Capital Stock of any Person engaged primarily in a
Permitted Business if, in connection with the receipt by the Issuer or any of its Restricted Subsidiaries of such Capital Stock, such Person becomes a Subsidiary Guarantor or a Qualified Restricted Subsidiary or such Person is merged or consolidated
into the Issuer or a Subsidiary Guarantor or a Qualified Restricted Subsidiary; 
 provided that (i) for purposes of
Section 3.4(a)(3), Qualified Proceeds shall not include Excluded Contributions and (ii) the amount of Qualified Proceeds shall be reduced by the amount of payments made in respect of the applicable transaction which are permitted under
Section 3.8(b)(xiii)(i). 
 “Qualified Receivables Transaction” means any transaction or series of transactions
entered into by the Issuer or any of its Subsidiaries pursuant to which the Issuer or any of its Subsidiaries sells, conveys or otherwise transfers, or grants a security interest, to: 

(1) a Receivables Subsidiary (in the case of a transfer by the Issuer or any of its Subsidiaries, which transfer may be effected through
the Issuer or one or more of its Subsidiaries); and 
 (2) if applicable, any other Person (in the case of a transfer by a
Receivables Subsidiary), in each case, in any accounts receivable (including health care insurance receivables), instruments, chattel paper, general intangibles and similar assets (whether now existing or arising in the future, the
“Receivables”) of the Issuer or any of its Subsidiaries, and any assets related thereto, including, without limitation, all collateral securing such Receivables, all contracts, contract rights and all guarantees or other obligations in
respect of such Receivables, proceeds of such Receivables and any other assets, which are customarily transferred or in respect of which security interests are customarily granted in connection with receivables financings and asset securitization
transactions of such type, together with any related transactions customarily entered into in receivables financings and asset securitizations, including servicing arrangements. All determinations under this Indenture as to whether a particular
provision in respect of a receivables transaction is customary shall be made by the Issuer in good faith (which determination shall be conclusive). 
 “Qualified Restricted Subsidiary” means a majority-owned Restricted Subsidiary or a Wholly Owned Restricted Subsidiary that satisfies each of the following requirements: (1) except for
Permitted Payment Restrictions, there are no consensual encumbrances or restrictions, directly or indirectly, on the ability of such Restricted Subsidiary to (a) pay dividends or make any other distributions on its equity interest to the Issuer
or a Restricted Subsidiary or pay any Indebtedness owed to the Issuer or a Restricted Subsidiary or (b) make any loans or advances to the Issuer or a Restricted Subsidiary; (2) the Equity Interests of such Restricted Subsidiary are owned
by the Issuer and/or one or more of its Qualified Restricted Subsidiaries (without giving effect to the proviso in this definition) and, if it is not a Wholly Owned Restricted Subsidiary, one or more of (A) Strategic Investors,
(B) directors of such Restricted Subsidiary (only to the extent holding directors’ qualifying shares) and (C) any other Person to the extent ownership by such other Person is required as a result of changes in law occurring after the
Issue Date; and (3) the primary business of such Restricted Subsidiary is a Permitted Business; provided that, so long as the laws or regulations of the State of New York require that membership interests in

  
 27 

 
limited liability companies that own dialysis clinics in the State of New York be owned by individuals, a Restricted Subsidiary that operates one or more clinics located only in the State of New
York shall be deemed a Qualified Restricted Subsidiary if (i) the requirements of clause (1) and (3) of this definition are satisfied, (ii) a majority of its Equity Interests are owned by an officer of the Issuer who is party to
a written contract with the Issuer or a Restricted Subsidiary pursuant to which the Issuer or such Restricted Subsidiary shall have the right to repurchase all of such Equity Interests owned by such officer for a nominal amount and (iii) the
Issuer or a Restricted Subsidiary receives dividends and distributions from such Restricted Subsidiary as if it owned all of the Equity Interests owned by such officer. 
 “Receivables Fees” means distributions or payments made directly or by means of discounts with respect to any participation interest issued or sold in connection with, and other fees paid to a
Person that is not a Restricted Subsidiary in connection with, any Qualified Receivables Transaction. 
 “Receivables
Repurchase Obligation” means any obligation of a seller of receivables in a Qualified Receivables Transaction to repurchase receivables arising as a result of a breach of a representation, warranty or covenant or otherwise, including as a
result of a receivable or portion thereof becoming subject to any asserted defense, dispute, off-set or counterclaim of any kind as a result of any action taken by, any failure to take action by or any other event relating to the seller. 

“Receivables Subsidiary” means a Subsidiary of the Issuer which engages in no activities other than in connection with the
financing of accounts receivable and in businesses related or ancillary thereto and that is designated by the Board of Directors of the Issuer (as provided below) as a Receivables Subsidiary (A) no portion of the Indebtedness or any other
Obligations (contingent or otherwise) of which: 
 (1) is guaranteed by the Issuer or any Subsidiary of the Issuer (excluding
guarantees of Obligations (other than the principal of, and interest on, Indebtedness) pursuant to Standard Securitization Undertakings); 
 (2) is recourse to or obligates the Issuer or any Subsidiary of the Issuer in any way other than pursuant to Standard Securitization Undertakings; or 

(3) subjects any property or asset of the Issuer or any Subsidiary of the Issuer (other than accounts receivable and related assets as
provided in the definition of Qualified Receivables Transaction), directly or indirectly, contingently or otherwise, to the satisfaction thereof, other than pursuant to Standard Securitization Undertakings; and 

(B) with which neither the Issuer nor any Subsidiary of the Issuer has any material contract, agreement, arrangement or understanding other than on terms
no less favorable to the Issuer or such Subsidiary than those that might be obtained at the time from Persons who are not Affiliates of the Issuer, other than as may be customary in a Qualified Receivables Transaction including for fees payable in
the ordinary course of business in connection with servicing accounts receivable; and (C) with which neither the Issuer nor any Subsidiary of the Issuer has any obligation to maintain or preserve such Subsidiary’s financial condition or
cause such Subsidiary 

  
 28 

 
to achieve certain levels of operating results other than pursuant to representations, warranties, covenants and indemnities entered into in connection with a Qualified Receivables Transaction.
Any such designation by the Board of Directors of the Issuer will be evidenced to the Trustee by filing with the Trustee a certified copy of the resolution of the Board of Directors of the Issuer giving effect to such designation and an
Officers’ Certificate certifying that such designation complied with the foregoing conditions. 
 “Record Date”
for the interest payable on any applicable Interest Payment Date means February 15 and August 15 (whether or not a Business Day) next preceding such Interest Payment Date. 

“Registration Rights Agreement” means (i) the Registration Rights Agreement dated the Issue Date by and among the Issuer,
Merrill Lynch, Pierce, Fenner & Smith Incorporated and Barclays Capital Inc., as amended, supplemented or otherwise modified from time to time and (ii) any other registration rights agreement entered into in connection with an issuance
of Additional Notes in a private offering after the Issue Date. 
 “Regulation S” means Regulation S promulgated under
the Securities Act. 
 “Regulation S Global Note” means a Temporary Regulation S Global Note or Permanent Regulation S
Global Note, as applicable. 
 “Replacement Preferred Stock” means any Disqualified Stock of the Issuer or any of its
Restricted Subsidiaries issued in exchange for, or the net proceeds of which are used to redeem, refund, refinance, replace or discharge any Disqualified Stock of the Issuer or any of its Restricted Subsidiaries (other than intercompany Disqualified
Stock); provided that such Replacement Preferred Stock (i) is issued by the Issuer or by the Restricted Subsidiary who is the Issuer of the Disqualified Stock being redeemed, refunded, refinanced, replaced or discharged, (ii) does
not have an initial liquidation preference in excess of the liquidation preference plus accrued and unpaid dividends on the Disqualified Stock being redeemed, refunded, refinanced, replaced or discharged and (iii) does not require redemption,
repurchase or discharge at any time prior to the date on which the Disqualified Stock being redeemed, refunded, refinanced, replaced or discharged is required to be redeemed, repurchased or discharged. 

“Restricted Definitive Note” means a Definitive Note bearing the Private Placement Legend. 

“Restricted Global Note” means a Global Note bearing the Private Placement Legend. 

“Restricted Investment” means an Investment other than a Permitted Investment. 

“Restricted Period” means, in relation to the Initial Notes, the 40 consecutive days beginning on and including the later of
(A) the day on which the Initial Notes are offered to persons other than distributors (as defined in Regulation S under the Securities Act) and (B) the Issue Date; and, in relation to any Additional Notes that bear the Private Placement
Legend, it means the comparable period of 40 consecutive days. 

  
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 “Restricted Subsidiary” of a Person means any Subsidiary of the referent Person
that is not an Unrestricted Subsidiary. Unless otherwise specified, references to Restricted Subsidiaries shall refer to Restricted Subsidiaries of the Issuer. 
 “Rule 144” means Rule 144 promulgated under the Securities Act. “Rule 144A” means Rule 144A promulgated under the Securities Act. “Rule 903” means Rule 903 promulgated under
the Securities Act. “Rule 904” means Rule 904 promulgated under the Securities Act. 
 “SEC” means the
United States Securities and Exchange Commission. 
 “Secured Notes” means the $250 million aggregate principal amount
of 8.375% Senior Secured Notes due 2018 issued by ARH. 
 “Secured Notes Indenture” means the indenture dated
May 7, 2010 governing the Secured Notes. 
 “Securities Act” means the U.S. Securities Act of 1933, as amended.

 “Shelf Registration Statement” means the Shelf Registration Statement as defined in the Registration Rights
Agreement. 
 “Significant Subsidiary” means any Subsidiary that would be a “significant subsidiary” as
defined in Article 1, Rule 1-02(w)(1) or (2) of Regulation S-X, promulgated pursuant to the Securities Act, as such Regulation is in effect on the Issue Date. For purposes of determining whether an Event of Default has occurred, if any group of
Restricted Subsidiaries as to which a particular event has occurred and is continuing at any time would be, taken as a whole, a “Significant Subsidiary” then such event shall be deemed to have occurred with respect to a Significant
Subsidiary. 
 “Sponsor” means Centerbridge Capital Partners, L.P. 

“Sponsor Management Agreement” means the Management Agreement between ARH and the Sponsor dated as of May 7, 2010.

 “Standard Securitization Undertakings” means representations, warranties, covenants and indemnities entered into by
the Issuer or any Subsidiary of the Issuer which the Issuer has determined in good faith to be customary in a Qualified Receivables Transaction including, without limitation, those relating to the servicing of the assets of a Receivables Subsidiary,
it being understood that any Receivables Repurchase Obligation shall be deemed to be a Standard Securitization Undertaking. 

“Stated Maturity” means, with respect to any installment of interest or principal on any series of Indebtedness, the date on
which the payment of interest or principal was scheduled to be paid in the documentation governing such Indebtedness, and will not include any contingent obligations to repay, redeem or repurchase any such interest or principal prior to the date
originally scheduled for the payment thereof. 

  
 30 

 “Strategic Investors” means physicians, hospitals, health systems, other
healthcare providers, other healthcare companies and other similar strategic joint venture partners which joint venture partners are, directly or indirectly, actively involved in the day-to-day operations of providing dialysis- related services, or,
in the case of physicians, that have retired therefrom, individuals who are former owners or employees of dialysis clinics purchased by the Issuer, any of its Restricted Subsidiaries, and consulting firms that receive common stock solely as
consideration for consulting services performed. 
 “subsidiary” means, with respect to any Person (the
“parent”) at any date, any corporation, limited liability company, partnership, association or other entity the accounts of which would be consolidated with those of the parent in the parent’s consolidated financial statements if such
financial statements were prepared in accordance with GAAP as of such date. 
 “Subsidiary” means any subsidiary of
the Issuer. 
 “Subsidiary Guarantors” means the Restricted Subsidiaries of the Issuer that have executed and
delivered a Guarantee of the Notes pursuant to the terms of this Indenture and their respective successors and assigns, in each case, until the Guarantee of such Person has been released in accordance with the provisions of this Indenture.

 “Temporary Regulation S Global Note” means a temporary Global Note in the form of Exhibit A hereof bearing the
Global Note Legend, the Private Placement Legend, and the Temporary Regulation S Legend and deposited with or on behalf of and registered in the name of the Depositary or its nominee, issued in a denomination equal to the outstanding principal
amount of the Notes sold in reliance on Rule 903. 
 “Temporary Regulation S Legend” means the legend set forth in
Section 2.1(e). 
 “TIA” means the Trust Indenture Act of 1939 as in effect on the Issue Date, except as provided
in Section 9.6 hereof. 
 “Total Assets” means the total consolidated assets of the Issuer and its Restricted
Subsidiaries as set forth on the most recent consolidated balance sheet of the Issuer and its Restricted Subsidiaries prepared in accordance with GAAP. 
 “Transactions” means the Financing Transactions and the Merger Transaction. 
 “Treasury Management Obligations” means obligations under any agreement governing the provision of treasury or cash management services, including deposit accounts, funds transfer, automated
clearinghouse, zero balance accounts, returned check concentration, controlled disbursement, lock- box, account reconciliation and reporting and trade finance services. 
 “Treasury Rate” means, with respect to any Make-Whole Redemption Date, the yield to maturity at the time of computation of United States Treasury securities with a constant maturity (as compiled
and published in the most recent Federal Reserve Statistical Release H.15(519) that has become publicly available at least two business days prior to such Make-Whole Redemption Date (or, if such Statistical Release is no longer published, any
publicly available source of 

  
 31 

 
similar market data)) most nearly equal to the period from such Make-Whole Redemption Date to March 1, 2013; provided, however, that if the period from such Make-Whole
Redemption Date to March 1, 2013 is not equal to the constant maturity of a United States Treasury security for which a weekly average yield is given, the Treasury Rate shall be obtained by linear interpolation (calculated to the nearest
one-twelfth of a year) from the weekly average yields of United States Treasury securities for which such yields are given, except that if the period from such Make-Whole Redemption Date to March 1, 2013 is less than one year, the weekly
average yield on actually traded United States Treasury securities adjusted to a constant maturity of one year shall be used. 

“Trust Officer” means the Chairman of the Board, the President or any other officer or assistant officer of the Trustee
assigned by the Trustee to administer its corporate trust matters. 
 “Trustee” means Wilmington Trust FSB until a
successor replaces it and, thereafter, means the successor. 
 “Uniform Commercial Code” means the New York Uniform
Commercial Code, as in effect from time to time. 
 “Unrestricted Definitive Note” means one or more Definitive Notes
that do not bear and are not required to bear the Private Placement Legend. 
 “Unrestricted Global Note” means a
permanent Global Note substantially in the form of Exhibit A attached hereto that bears the Global Note Legend and that has the “Schedule of Exchanges of Interests in the Global Note” attached thereto, and that is deposited with or on
behalf of and registered in the name of the Depositary, representing Notes that do not bear the Private Placement Legend. 

“Unrestricted Subsidiary” means any Subsidiary of the Issuer that is designated by the Board of Directors of the Issuer as an
Unrestricted Subsidiary pursuant to a resolution of the Board of Directors and any Subsidiary of an Unrestricted Subsidiary. 

The Issuer may designate any Subsidiary of the Issuer (including any existing Subsidiary and any newly acquired or newly formed
Subsidiary) to be an Unrestricted Subsidiary unless such Subsidiary or any of its Subsidiaries owns any Equity Interests or Indebtedness of, or owns or holds any Lien on, any property of, the Issuer or any Subsidiary of the Issuer (other than solely
any Subsidiary of the Subsidiary to be so designated); provided that 
 (1) such designation complies with
Section 3.4; 
 (2) each of (a) the Subsidiary to be so designated and (b) its Subsidiaries has not at the time
of designation, and does not thereafter, incur any Indebtedness other than Non-Recourse Debt; 
 (3) is not party to any
agreement, contract, arrangement or understanding with the Issuer or any Restricted Subsidiary of the Issuer unless the terms of any such agreement, contract, arrangement or understanding are no less favorable to the Issuer or such Restricted
Subsidiary than those permitted under Section 3.8; 

  
 32 

 (4) is a Person with respect to which neither the Issuer nor any of its Restricted
Subsidiaries has any direct or indirect obligation to maintain or preserve such Person’s financial condition or to cause such Person to achieve any specified levels of operating results; and 

(5) has not guaranteed or otherwise directly or indirectly provided credit support for any Indebtedness of the Issuer or any of its
Restricted Subsidiaries. 
 “U.S. Government Obligations” means direct obligations (or certificates representing an
ownership interest in such obligations) of the United States of America (including any agency or instrumentality thereof) for the payment of which the full faith and credit of the United States of America is pledged and which are not callable at the
issuer’s option. 
 “U.S. Person” means a U.S. Person as defined in Rule 902(k) of Regulation S under the
Securities Act. 
 “Voting Stock” of any specified Person as of any date means the Capital Stock of such Person that
is at the time entitled to vote in the election of the Board of Directors of such Person. 
 “Weighted Average Life to
Maturity” means, when applied to any Indebtedness at any date, the number of years obtained by dividing: 
 (1) the sum of
the products obtained by multiplying (a) the amount of each then remaining installment, sinking fund, serial maturity or other required payments of principal, including payment at final maturity, in respect of the Indebtedness, by (b) the
number of years (calculated to the nearest one-twelfth) that will elapse between such date and the making of such payment; by 

(2) the then outstanding principal amount of such Indebtedness. 

“Wholly Owned Restricted Subsidiary” of any specified Person means a Restricted Subsidiary of such Person all of the
outstanding Capital Stock or other ownership interest of which (other than directors’ qualifying shares) will at that time be owned by such Person or by one or more Wholly Owned Restricted Subsidiaries of such Person. 

  
 33 

 SECTION 1.2. Other Definitions. 

 

			
	Term	  	Defined in
Section
	 “actual knowledge”
	  	7.2(g)
	 “Additional Notes”
	  	2.2
	 “Affiliate Transaction”
	  	3.8(a)
	 “Agent Member”
	  	2.1
	 “Asset Sale Offer”
	  	3.7(d)
	 “Bankruptcy Law”
	  	6.1
	 “Change of Control Offer”
	  	3.9(c)
	 “Change of Control Payment”
	  	3.9(b)
	 “Change of Control Payment Date”
	  	3.9(c)(3)
	 “Covenant Defeasance”
	  	8.1(c)
	 “Custodian”
	  	6.1
	 “Defaulted Interest”
	  	2.12
	 “DTC”
	  	2.1(b)
	 “Event of Default”
	  	6.1(a)
	 “Excess Proceeds”
	  	3.7(d)
	 “Exchange Offer Filing Date”
	  	3.2(a)
	 “Guarantor Obligations”
	  	10.1
	 “incur”
	  	3.3(a)
	 “Intercompany Loan Refinancing”
	  	3.3(b)(xvi)
	 “Intercompany Loan Refinancing Offer”
	  	3.20 (a)(ii)
	 “Make-Whole Redemption Date”
	  	5.1(b)
	 “Legal Defeasance”
	  	8.1(b)
	 “Offer Amount”
	  	5.9(a)
	 “Offer Period”
	  	5.9(a)
	 “Offer to Repurchase”
	  	5.9
	 “Pari Passu Debt”
	  	3.7(d)
	 “Paying Agent”
	  	2.3
	 “Payment Default”
	  	6.1(a)(v)(1)
	 “Permitted Debt”
	  	3.3(b)
	 “Permitted Parties”
	  	3.2(a)(3)
	 “PIK Notes”
	  	2.6(m)
	 “PIK Payment”
	  	2.6(m)
	 “Proceeds Amount”
	  	3.20(a)
	 “Purchase Date”
	  	5.9(a)
	 “Redemption Date”
	  	5.5
	 “Registrar”
	  	2.3
	 “Required Information”
	  	3.2(a)
	 “Restricted Payments”
	  	3.4(a)(3)
	 “Special Interest Payment Date”
	  	2.12(a)
	 “Special Record Date”
	  	2.12(a)
	 “Successor”
	  	4.1(a)(i)

  
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 SECTION 1.3. Rules of Construction. Unless the context otherwise requires:

 (a) a term has the meaning assigned to it; 
 (b) an accounting term not otherwise defined has the meaning assigned to it in accordance with GAAP; 
 (c) “or” is not exclusive; 
 (d) “including” means including
without limitation; 
 (e) words in the singular include the plural and words in the plural include the singular; 

(f) unsecured Indebtedness shall not be deemed to be subordinate or junior to secured Indebtedness merely by virtue of its nature as
unsecured Indebtedness; 
 (g) references to sections of, or rules under, the Securities Act or Exchange Act shall be deemed to
include substitute, replacement or successor sections or rules adopted by the SEC from time to time; 
 (h) unless the context
otherwise requires, any reference to an “Article,” “Section” or “clause” refers to an Article, Section or clause, as the case may be, of this Indenture; 

(i) the words “herein,” “hereof” and “hereunder” and any other words of similar import refer to this
Indenture as a whole and not any particular Article, Section, clause or other subdivision; and 
 (j) any requirement to pay
interest on the Notes shall include all Additional Interest required pursuant to the Registration Rights Agreement or Section 6.1. 
 SECTION 1.4. Incorporation by Reference of Trust Indenture Act. 

Whenever this Indenture refers to a provision of the TIA, the provision is incorporated by reference in and made a part hereof.

 The following TIA term used in this Indenture has the following meanings: 

“obligor” on the Notes means each of the Issuer and any successor obligor upon the Notes. 

All other terms used in this Indenture that are defined by the TIA, defined by reference to another statute or defined by the SEC rule
under the TIA have the meanings so assigned to them. 

  
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 ARTICLE II 
 THE NOTES 
 SECTION 2.1. Form and Dating. 

(a) The Notes and the Trustee’s certificate of authentication shall be substantially inthe form of Exhibit A hereto, the terms of
which are incorporated in and made a part hereof. The Notes may have notations, legends or endorsements approved as to form by the Issuer, and required by law, stock exchange rule, agreements to which the Issuer is subject or usage. Each Note shall
be dated the date of its authentication. The Notes shall be issuable only in denominations of $2,000 and integral multiples of $1,000 in excess thereof. 
 (b) The Notes shall initially be issued in the form of one or more Global Notes and The Depository Trust Company (“DTC”), its nominees, and their respective successors, shall act as the
Depositary with respect thereto. Each Global Note (i) shall be registered in the name of the Depositary for such Global Note or the nominee of such Depositary, (ii) shall be delivered by the Trustee to such Depositary or held by the
Trustee as custodian for the Depositary pursuant to such Depositary’s instructions, and (iii) shall bear a Global Note Legend in substantially the following form: 
 UNLESS THIS CERTIFICATE IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY TRUST COMPANY, A NEW YORK CORPORATION (“DTC”), TO THE COMPANY OR ITS AGENT FOR REGISTRATION OF TRANSFER,
EXCHANGE OR PAYMENT, AND ANY CERTIFICATE ISSUED IS REGISTERED IN THE NAME OF CEDE & CO. OR IN SUCH OTHER NAME AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC (AND ANY PAYMENT IS MADE TO CEDE & CO. OR TO SUCH OTHER ENTITY AS
IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL INASMUCH AS THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN INTEREST HEREIN. 

THIS NOTE IS A GLOBAL NOTE WITHIN THE MEANING OF THE INDENTURE AND IS REGISTERED IN THE NAME OF THE DEPOSITARY OR A NOMINEE OF THE
DEPOSITARY OR A SUCCESSOR DEPOSITARY. THIS NOTE IS NOT EXCHANGEABLE FOR SECURITIES REGISTERED IN THE NAME OF A PERSON OTHER THAN THE DEPOSITARY OR ITS NOMINEE EXCEPT IN THE LIMITED CIRCUMSTANCES DESCRIBED IN THE INDENTURE, AND NO TRANSFER OF THIS
NOTE (OTHER THAN A TRANSFER OF THIS NOTE AS A WHOLE BY THE DEPOSITARY TO A NOMINEE OF THE DEPOSITARY OR BY A NOMINEE OF THE DEPOSITARY TO THE DEPOSITARY OR ANOTHER NOMINEE OF THE DEPOSITARY OR BY THE DEPOSITARY OR ANY SUCH NOMINEE TO A SUCCESSOR
DEPOSITARY OR A NOMINEE OF SUCH SUCCESSOR DEPOSITARY) MAY BE REGISTERED EXCEPT IN THE LIMITED CIRCUMSTANCES DESCRIBED IN THE INDENTURE. 
 (c) Except as permitted by Section 2.6(g), any Note not registered under the Securities Act shall bear the following Private Placement Legend on the face thereof: 

  
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 THE SECURITY (OR ITS PREDECESSOR) EVIDENCED HEREBY WAS ORIGINALLY ISSUED IN A TRANSACTION
EXEMPT FROM REGISTRATION UNDER SECTION 5 OF THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND THE SECURITY EVIDENCED HEREBY MAY NOT BE OFFERED, SOLD OR OTHERWISE TRANSFERRED IN THE ABSENCE OF SUCH
REGISTRATION OR AN APPLICABLE EXEMPTION THEREFROM. EACH PURCHASER OF THE SECURITY EVIDENCED HEREBY IS HEREBY NOTIFIED THAT THE SELLER MAY BE RELYING ON THE EXEMPTION FROM THE PROVISIONS OF SECTION 5 OF THE SECURITIES ACT PROVIDED BY RULE 144A
THEREUNDER. THE HOLDER OF THE SECURITY EVIDENCED HEREBY AGREES FOR THE BENEFIT OF THE COMPANY THAT (A) SUCH SECURITY MAY BE RESOLD, PLEDGED OR OTHERWISE TRANSFERRED, ONLY (1)(a) INSIDE THE UNITED STATES TO A PERSON WHO THE SELLER
REASONABLY BELIEVES IS A QUALIFIED INSTITUTIONAL BUYER (AS DEFINED IN RULE 144A UNDER THE SECURITIES ACT) PURCHASING FOR ITS OWN ACCOUNT OR FOR THE ACCOUNT OF A QUALIFIED INSTITUTIONAL BUYER IN A TRANSACTION MEETING THE REQUIREMENTS OF RULE 144A
UNDER THE SECURITIES ACT, (b) OUTSIDE THE UNITED STATES TO A FOREIGN PERSON IN A TRANSACTION MEETING THE REQUIREMENTS OF RULE 903 OR RULE 904 OF REGULATION S UNDER THE SECURITIES ACT, (c) PURSUANT TO AN EXEMPTION FROM REGISTRATION UNDER
THE SECURITIES ACT PROVIDED BY RULE 144 THEREUNDER (IF APPLICABLE) OR (d) IN ACCORDANCE WITH ANOTHER EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT (AND BASED UPON AN OPINION OF COUNSEL ACCEPTABLE TO THE COMPANY IF THE
COMPANY SO REQUESTS), (2) TO THE COMPANY OR (3) PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT AND, IN EACH CASE, IN ACCORDANCE WITH ANY APPLICABLE SECURITIES LAWS OF ANY STATE OF THE UNITED STATES OR ANY OTHER APPLICABLE JURISDICTION AND
(B) THE HOLDER WILL, AND EACH SUBSEQUENT HOLDER IS REQUIRED TO, NOTIFY ANY PURCHASER OF THE SECURITY EVIDENCED HEREBY OF THE RESALE RESTRICTIONS SET FORTH IN CLAUSE (A) ABOVE. NO REPRESENTATION CAN BE MADE AS TO THE AVAILABILITY OF THE
EXEMPTION PROVIDED BY RULE 144 FOR RESALE OF THE SECURITY EVIDENCED HEREBY. 
 (d) Each Note issued hereunder shall bear an
Original Issue Discount Legend in substantially the following form on the face thereof: 
 THIS SECURITY HAS BEEN ISSUED WITH
ORIGINAL ISSUE DISCOUNT, FOR PURPOSES OF SECTIONS 1272, 1273, AND 1275 OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. UPON THE REQUEST OF THE HOLDER OF THIS SECURITY, THE COMPANY WILL PROMPTLY MAKE AVAILABLE TO THE HOLDER OF THIS SECURITY,
(I) THE ISSUE PRICE 

  
 37 

 
OF THE SECURITY, (II) THE AMOUNT OF ORIGINAL ISSUE DISCOUNT IN RESPECT THEREOF, (III) THE ISSUE DATE OF THE SECURITY, (IV) THE COMPARABLE YIELD OF THE SECURITY, AND (V) THE PROJECTED PAYMENT
SCHEDULE OF THE SECURITY, IN EACH CASE AS DETERMINED UNDER THE ORIGINAL ISSUE DISCOUNT RULES OF THE U.S. INTERNAL REVENUE CODE. PLEASE CONTACT: AMERICAN RENAL HOLDINGS COMPANY, INC., 66 CHERRY HILL DRIVE, BEVERLY, MASSACHUSETTS 01915, ATTN: JOHN
MCDONOUGH, TREASURER. 
 (e) The Temporary Regulation S Global Note shall bear a legend in substantially the following form:

 EXCEPT AS SET FORTH BELOW, BENEFICIAL OWNERSHIP INTERESTS IN THIS TEMPORARY REGULATION S GLOBAL NOTE WILL NOT BE EXCHANGEABLE
FOR INTERESTS IN THE PERMANENT REGULATION S GLOBAL NOTE OR ANY OTHER NOTE REPRESENTING AN INTEREST IN THE NOTES REPRESENTED HEREBY WHICH DO NOT CONTAIN A LEGEND CONTAINING RESTRICTIONS ON TRANSFER, UNTIL THE EXPIRATION OF THE “40-DAY
DISTRIBUTION COMPLIANCE PERIOD” (WITHIN THE MEANING OF RULE 903(b)(2) OF REGULATION S UNDER THE SECURITIES ACT) AND THEN ONLY UPON CERTIFICATION IN FORM REASONABLY SATISFACTORY TO THE TRUSTEE THAT SUCH BENEFICIAL INTERESTS ARE OWNED EITHER BY
NON-U.S. PERSONS OR U.S. PERSONS WHO PURCHASED SUCH INTERESTS IN A TRANSACTION THAT DID NOT REQUIRE REGISTRATION UNDER THE SECURITIES ACT. DURING SUCH 40-DAY DISTRIBUTION COMPLIANCE PERIOD, BENEFICIAL OWNERSHIP INTERESTS IN THIS TEMPORARY REGULATION
S GLOBAL NOTE MAY ONLY BE SOLD, PLEDGED OR TRANSFERRED (I) TO THE ISSUERS, (II) OUTSIDE THE UNITED STATES IN A TRANSACTION IN ACCORDANCE WITH RULE 904 OF REGULATION S UNDER THE SECURITIES ACT, OR (III) PURSUANT TO AN EFFECTIVE REGISTRATION
STATEMENT UNDER THE SECURITIES ACT, IN EACH OF CASES (I) THROUGH (III) IN ACCORDANCE WITH ANY APPLICABLE SECURITIES LAWS OF ANY STATE OF THE UNITED STATES. HOLDERS OF INTERESTS IN THIS TEMPORARY REGULATION S GLOBAL NOTE WILL NOTIFY ANY
PURCHASER OF THIS NOTE OF THE RESALE RESTRICTIONS REFERRED TO ABOVE, IF THEN APPLICABLE. 
 AFTER THE EXPIRATION OF THE
DISTRIBUTION COMPLIANCE PERIOD, BENEFICIAL INTERESTS IN THIS TEMPORARY REGULATION S GLOBAL NOTE MAY BE EXCHANGED FOR INTERESTS IN A RULE 144A GLOBAL NOTE ONLY IF (1) SUCH EXCHANGE OCCURS IN CONNECTION WITH A TRANSFER OF THE NOTES IN COMPLIANCE
WITH RULE 144A AND (2) THE TRANSFEROR OF THE REGULATION S GLOBAL NOTE FIRST DELIVERS TO THE TRUSTEE A WRITTEN 

  
 38 

 
CERTIFICATE (IN THE FORM ATTACHED TO THIS CERTIFICATE) TO THE EFFECT THAT THE REGULATION S GLOBAL NOTE IS BEING TRANSFERRED (A) TO A PERSON WHO THE TRANSFEROR REASONABLY BELIEVES TO BE A
QUALIFIED INSTITUTIONAL BUYER WITHIN THE MEANING OF RULE 144A, (B) TO A PERSON WHO IS PURCHASING FOR ITS OWN ACCOUNT OR THE ACCOUNT OF A QUALIFIED INSTITUTIONAL BUYER IN A TRANSACTION MEETING THE REQUIREMENTS OF RULE 144A, AND (C) IN
ACCORDANCE WITH ALL APPLICABLE SECURITIES LAWS OF THE STATES OF THE UNITED STATES AND OTHER JURISDICTIONS. 
 BENEFICIAL
INTERESTS IN A RULE 144A GLOBAL NOTE MAY BE TRANSFERRED TO A PERSON WHO TAKES DELIVERY IN THE FORM OF AN INTEREST IN THE REGULATION S GLOBAL NOTE, WHETHER BEFORE OR AFTER THE EXPIRATION OF THE 40-DAY DISTRIBUTION COMPLIANCE PERIOD, ONLY IF THE
TRANSFEROR FIRST DELIVERS TO THE TRUSTEE A WRITTEN CERTIFICATE (IN THE FORM ATTACHED TO THIS CERTIFICATE) TO THE EFFECT THAT SUCH TRANSFER IS BEING MADE IN ACCORDANCE WITH RULE 903 OR 904 OF REGULATION S OR RULE 144 (IF AVAILABLE). 

Members of, or participants in, the Depository (“Agent Members”) shall have no rights under this Indenture with respect to any
Global Note held on their behalf by the Depository, or the Trustee as its custodian and the Depository may be treated by the Issuer, the Trustee and any agent of the Issuer or the Trustee as the absolute owner of the Global Note for all purposes
whatsoever, including but not limited to notices and payments. Notwithstanding the foregoing, nothing herein shall prevent the Issuer, the Trustee or any agent of the Issuer or the Trustee from giving effect to any written certification, proxy or
other authorization furnished by the Depository or impair, as between the Depository and its Agent Members, the operation of customary practices governing the exercise of the rights of a Holder of any Note. Any notice to be delivered to DTC
(including, but not limited to, a notice of redemption) may be delivered electronically by the Trustee in accordance with applicable procedures of DTC. 
 SECTION 2.2. Form of Execution and Authentication. An Officer shall sign the Notes for the Issuer by manual or facsimile signature. 

If an Officer whose signature is on a Note no longer holds that office at the time the Note is authenticated, the Note shall nevertheless
be valid. 
 A Note shall not be valid until authenticated by the manual signature of the Trustee. The signature of the Trustee
shall be conclusive evidence that the Note has been authenticated under this Indenture. 
 The Trustee shall authenticate
(i) Initial Notes for original issue on the Issue Date in an aggregate principal amount of $135,000,000, (ii) from time to time PIK Notes (or shall increase the principal amount of any Global Note), (iii) pursuant to the Exchange
Offer, Exchange Notes from time to time for issue only in exchange for a like principal amount of Initial Notes and (iv)

  
 39 

 
subject to compliance with Sections 3.3 and 3.5, one or more series of Notes (“Additional Notes”) for original issue after the Issue Date (such Notes to be substantially in the form of
Exhibit A) in an unlimited amount (and if issued with a Private Placement Legend, the same principal amount of Exchange Notes in exchange therefor upon consummation of an Exchange Offer for such Additional Notes), in each case upon written order of
the Issuer in the form of an Officers’ Certificate, which Officers’ Certificate shall, in the case of any issuance of Additional Notes, certify that such issuance is in compliance with Sections 3.3 and 3.5, together with an enforceability
opinion that contains customary exceptions. In addition, each such Officers’ Certificate shall specify the amount of Notes to be authenticated, the date on which the Notes are to be authenticated, whether the securities are to be Initial Notes
(including whether such Notes shall be PIK Notes or an increase to the principal amount of any Global Note as a result of a PIK Payment), Exchange Notes or Additional Notes and the aggregate principal amount of Notes outstanding on the date of
authentication, and shall further specify the amount of such Notes to be issued as Global Notes or Definitive Notes. Such Notes shall initially be in the form of one or more Global Notes, which (i) shall represent, and shall be denominated in
an amount equal to the aggregate principal amount of, the Notes to be issued, (ii) shall be registered in the name of the Depositary or its nominee and (iii) shall be delivered by the Trustee to the Depositary or pursuant to the
Depositary’s instruction. All Notes issued under this Indenture shall vote and consent together on all matters as one class and no series of Notes shall have the right to vote or consent as a separate class on any matter. 

The Trustee may appoint an authenticating agent acceptable to the Issuer to authenticate Notes. Unless limited by the terms of such
appointment, an authenticating agent may authenticate Notes whenever the Trustee may do so. Each reference in this Indenture to authentication by the Trustee includes authentication by such agent. An authenticating agent has the same rights as an
Agent to deal with the Issuer or any Affiliate of the Issuer. 
 SECTION 2.3. Registrar and Paying Agent. The
Issuer shall maintain (i) an office or agency where Notes may be presented for registration of transfer or for exchange (including any co- registrar, the “Registrar”) and (ii) an office or agency where Notes may be presented for
payment (“Paying Agent”). The Registrar shall keep a register of the Notes and of their transfer and exchange. The Issuer may appoint one or more co-registrars and one or more additional paying agents. The term “Paying Agent”
includes any additional paying agent. The Issuer may change any Paying Agent, Registrar or co- registrar without prior notice to any Holder of a Note. The Issuer shall notify the Trustee in writing and the Trustee shall notify the Holders of the
Notes of the name and address of any Agent not a party to this Indenture. The Issuer may act as Paying Agent, Registrar or co-registrar. The Issuer shall enter into an appropriate agency agreement with any Agent not a party to this Indenture, which
shall incorporate the provisions of the TIA. The agreement shall implement the provisions hereof that relate to such Agent. The Issuer shall notify the Trustee in writing of the name and address of any such Agent. If the Issuer fails to maintain a
Registrar or Paying Agent, or fails to give the foregoing notice, the Trustee shall act as such, and shall be entitled to appropriate compensation in accordance with Section 7.11. 

The Issuer initially appoints the Trustee as Registrar, Paying Agent and agent for service of notices and demands in connection with the
Notes. 

  
 40 

 SECTION 2.4. Paying Agent to Hold Money in Trust. The Issuer shall require
each Paying Agent other than the Trustee to agree in writing that the Paying Agent shall hold in trust for the benefit of the Holders of the Notes or the Trustee all money held by the Paying Agent for the payment of principal of, premium, if any,
and Cash Interest on the Notes, and shall notify the Trustee in writing of any Default by the Issuer in making any such payment. While any such Default continues, the Trustee may require a Paying Agent to pay all money held by it to the Trustee. The
Issuer at any time may require a Paying Agent to pay all money held by such Paying Agent to the Trustee. Upon payment over to the Trustee, the Paying Agent (if other than the Issuer) shall have no further liability for the money delivered to the
Trustee. If the Issuer acts as Paying Agent, it shall segregate and hold in a separate trust fund for the benefit of the Holders of the Notes all money held by it as Paying Agent. 

SECTION 2.5. Lists of Holders of the Notes. The Trustee shall preserve in as current a form as is reasonably practicable
the most recent list available to it of the names and addresses of Holders of the Notes and shall otherwise comply with TIA § 312(a). If the Trustee is not the Registrar, the Issuer shall furnish to the Trustee at least seven Business Days
before each Interest Payment Date and at such other times as the Trustee may request in writing a list in such form and as of such date as the Trustee may reasonably require of the names and addresses of Holders of the Notes, including the aggregate
principal amount of the Notes held by each thereof, and the Issuer shall otherwise comply with TIA § 312(a). 
 SECTION
2.6. Transfer and Exchange. 
 (a) Transfer and Exchange of Global Notes. A Global Note may not be transferred
as a whole except by the Depositary to a nominee of the Depositary, by a nominee of the Depositary to the Depositary or to another nominee of the Depositary, or by the Depositary or any such nominee to a successor Depositary or a nominee of such
successor Depositary. Global Notes shall be exchanged by the Issuer for Definitive Notes, subject to any applicable laws, only (i) if the Issuer delivers to the Trustee notice from the Depositary that (A) the Depositary is unwilling or
unable to continue to act as Depositary for the Global Notes or (B) the Depositary is no longer a clearing agency registered under the Exchange Act and, in either case, the Issuer fails to appoint a successor Depositary after the date of such
notice from the Depositary, (ii) upon request of the Trustee or Holders of a majority of the aggregate principal amount of outstanding Notes if there shall have occurred and be continuing an Event of Default with respect to the Notes or
(iii) if the Issuer notifies the Trustee in writing that it elects to cause the issuance of Definitive Notes. In any such case, the Issuer shall notify the Trustee in writing that, upon surrender by the Participants and Indirect Participants of
their interests in such Global Note, certificated Notes shall be issued to each Person that such Participants, Indirect Participants and DTC jointly identify as being the beneficial owner of the related Notes. Global Notes also may be exchanged or
replaced, in whole or in part, as provided in Sections 2.7 and 2.10. Every Note authenticated and delivered in exchange for, or in lieu of, a Global Note or any portion thereof, pursuant to this Section 2.6 or Section 2.7 or 2.10 hereof,
shall be authenticated and delivered in the form of, and shall be, a Global Note. A Global Note may not be exchanged for another Note other than as provided in this Section 2.6. However, beneficial interests in a Global Note may be transferred
and exchanged as provided in Section 2.6(b), (c) or (i) below. 

  
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 (b) Transfer and Exchange of Beneficial Interests in the Global Notes. The transfer and
exchange of beneficial interests in the Global Notes shall be effected through the Depositary, in accordance with the provisions hereof and the Applicable Procedures. Beneficial interests in the Restricted Global Notes shall be subject to
restrictions on transfer comparable to those set forth in this Indenture to the extent required by the Securities Act. Transfers of beneficial interests in the Global Notes also shall require compliance with the applicable subparagraphs below.

 (i) Transfer of Beneficial Interests in the Same Global Note. Beneficial interests in any Restricted Global Note may be
transferred to Persons who take delivery thereof in the form of a beneficial interest in the same Restricted Global Note in accordance with the transfer restrictions set forth in the Private Placement Legend; provided, however, that
prior to the expiration of the Restricted Period, no transfer of beneficial interests in a Regulation S Global Note may be made to a U.S. Person or for the account or benefit of a U.S. Person (other than an Initial Purchaser) unless permitted by
applicable law and made in compliance with Sections 2.6(b)(ii) and (iii) below. Beneficial interests in any Unrestricted Global Note may be transferred to Persons who take delivery thereof in the form of a beneficial interest in an Unrestricted
Global Note. No written orders or instructions shall be required to be delivered to the Registrar to effect the transfers described in this Section 2.6(b)(i) unless specifically stated above. 

(ii) All Other Transfers and Exchanges of Beneficial Interests in Global Notes. In connection with all transfers and exchanges of
beneficial interests that are not subject to Section 2.6(b)(i) above, the transferor of such beneficial interest must deliver to the Registrar either (A) (1) a written order from a Participant or an Indirect Participant given to the
Depositary in accordance with the Applicable Procedures directing the Depositary to credit or cause to be credited a beneficial interest in another Global Note in an amount equal to the beneficial interest to be transferred or exchanged and
(2) instructions given in accordance with the Applicable Procedures containing information regarding the Participant account to be credited with such increase, or (B) (1) if Definitive Notes are at such time permitted to be issued
pursuant to this Indenture, a written order from a Participant or an Indirect Participant given to the Depositary in accordance with the Applicable Procedures directing the Depositary to cause to be issued a Definitive Note in an amount equal to the
beneficial interest to be transferred or exchanged and (2) instructions given by the Depositary to the Registrar containing information regarding the Person in whose name such Definitive Note shall be registered to effect the transfer or
exchange referred to in (1) above. Upon consummation of an Exchange Offer by the Issuer in accordance with Section 2.6(i) below, the requirements of this Section 2.6(b)(ii) shall be deemed to have been satisfied upon receipt by the
Registrar of the instructions contained in the Letter of Transmittal delivered by the holder of such beneficial interests in the Restricted Global Notes (or delivered in accordance with Applicable Procedures). Upon satisfaction of all of the
requirements for transfer or exchange of beneficial interests in Global Notes contained in this Indenture and the Notes or otherwise applicable under the Securities Act, the Trustee shall adjust the principal amount of the relevant Global Note(s)
pursuant to Section 2.6(m) below. 
 (iii) Transfer of Beneficial Interests to Another Restricted Global Note. A beneficial
interest in any Restricted Global Note may be transferred to a Person who takes delivery thereof in the form of a beneficial interest in another Restricted Global Note if the transfer complies with the requirements of Section 2.6(b)(ii) above
and the Registrar receives the following: 

  
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 (A) if the transferee will take delivery in the form of a beneficial interest in a 144A
Global Note, then the transferor must deliver a certificate in the form of Exhibit B hereto, including the certifications in item (1) thereof; and 
 (B) if the transferee will take delivery in the form of a beneficial interest in a Regulation S Global Note, then the transferor must deliver a certificate in the form of Exhibit B hereto, including the
certifications in item (2) thereof. 
 (iv) Transfer and Exchange of Beneficial Interests in a Restricted Global Note for
Beneficial Interests in an Unrestricted Global Note. A beneficial interest in any Restricted Global Note may be exchanged by any holder thereof for a beneficial interest in an Unrestricted Global Note or transferred to a Person who takes delivery
thereof in the form of a beneficial interest in an Unrestricted Global Note if the exchange or transfer complies with the requirements of Section 2.6(b)(ii) above, and 
 (A) such exchange or transfer is effected pursuant to the Exchange Offer in accordance with the Registration Rights Agreement and the holder of the beneficial interest to be transferred, in the case of an
exchange, or the transferee, in the case of a transfer, certifies in the applicable Letter of Transmittal that it is not (1) a Broker-Dealer, (2) a Person participating in the distribution of the Exchange Notes or (3) a Person who is
an “affiliate” (as defined in Rule 144) of the Issuer; 
 (B) such transfer is effected pursuant to a Shelf
Registration Statement in accordance with the Registration Rights Agreement; 
 (C) such transfer is effected by a
Broker-Dealer pursuant to an Exchange Offer Registration Statement and such Broker-Dealer complies with the terms of the Registration Rights Agreement; or 
 (D) the Registrar receives the following: 
 (y) if the holder of
such beneficial interest in a Restricted Global Note proposes to exchange such beneficial interest for a beneficial interest in an Unrestricted Global Note, a certificate from such holder in the form of Exhibit C hereto, including the certifications
in item (1)(a) thereof; or 
 (z) if the holder of such beneficial interest in a Restricted Global Note
proposes to transfer such beneficial interest to a Person who shall take delivery thereof in the form of a beneficial interest in an Unrestricted Global Note, a certificate from such holder in the form of Exhibit B hereto, including the applicable
certifications in item (4) thereof; 

  
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 and, in each such case set forth in this subparagraph (D), if the Registrar so requests or if the Applicable
Procedures so require, an Opinion of Counsel in form reasonably acceptable to the Registrar to the effect that such exchange or transfer is in compliance with the Securities Act and that the restrictions on transfer contained in this Indenture and
in the Private Placement Legend are no longer required in order to maintain compliance with the Securities Act. 
 If any such transfer is
effected pursuant to subparagraph (B) or (D) above at a time when an Unrestricted Global Note has not yet been issued, the Issuer shall issue and, upon receipt of an authentication order in accordance with Section 2.2, the Trustee
shall authenticate one or more Unrestricted Global Notes in an aggregate principal amount equal to the aggregate principal amount of beneficial interests transferred pursuant to subparagraph (B) or (D) above. 

Beneficial interests in an Unrestricted Global Note cannot be exchanged for, or transferred to Persons who take delivery thereof in the
form of, a beneficial interest in a Restricted Global Note. 
 (c) Transfer and Exchange of Beneficial Interests for Definitive
Notes. 
 (i) Transfer and Exchange of Beneficial Interests in Restricted Global Notes for Restricted Definitive Notes. Subject
to Section 2.6(a), if any holder of a beneficial interest in a Restricted Global Note proposes to exchange such beneficial interest for a Restricted Definitive Note or to transfer such beneficial interest to a Person who takes delivery thereof
in the form of a Restricted Definitive Note, then upon receipt by the Registrar of the following documentation: 
 (A) if the
holder of such beneficial interest in a Restricted Global Note proposes to exchange such beneficial interest for a Restricted Definitive Note, a certificate from such holder in the form of Exhibit C hereto, including the certifications in item
(2)(a) thereof; 
 (B) if such beneficial interest is being transferred to a QIB in accordance with Rule 144A under the
Securities Act, a certificate to the effect set forth in Exhibit B hereto, including the certifications in item (1) thereof; 
 (C) if such beneficial interest is being transferred to a Non-U.S. Person in an offshore transaction in accordance with Rule 903 or Rule 904 under the Securities Act, a certificate to the effect set forth
in Exhibit B hereto, including the certifications in item (2) thereof; and 
 (D) if such beneficial interest is being
transferred to the Issuer or any of its Subsidiaries, a certificate to the effect set forth in Exhibit B hereto, including the certifications in item (3)(b) thereof; or 
 the Trustee shall cause the aggregate principal amount of the applicable Global Note to be reduced accordingly pursuant to Section 2.6(m) below, and the Issuer shall execute and the Trustee shall
authenticate and deliver to the Person designated in the certificate a Restricted Definitive Note in the appropriate principal amount. Any Restricted Definitive Note issued in exchange for a beneficial interest in a Restricted Global Note pursuant
to this Section 2.6(c) shall be registered in such name or names and in such authorized denomination or denominations as 
  

  
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the holder of such beneficial interest shall instruct the Registrar through instructions from the Depositary and the Participant or Indirect Participant. The Trustee shall deliver such Restricted
Definitive Notes to the Persons in whose names such Notes are so registered. Any Restricted Definitive Note issued in exchange for a beneficial interest in a Restricted Global Note pursuant to this Section 2.6(c)(i) shall bear the Private
Placement Legend and shall be subject to all restrictions on transfer contained therein. 
 (ii) Transfer and Exchange of
Beneficial Interests in Restricted Global Notes for Unrestricted Definitive Notes. Subject to Section 2.6(a), a holder of a beneficial interest in a Restricted Global Note may exchange such beneficial interest for an Unrestricted Definitive
Note or may transfer such beneficial interest to a Person who takes delivery thereof in the form of an Unrestricted Definitive Note only if: 
 (A) such exchange or transfer is effected pursuant to an Exchange Offer in accordance with the Registration Rights Agreement and the holder of such beneficial interest, in the case of an exchange, or the
transferee, in the case of a transfer, certifies in the applicable Letter of Transmittal that it is not (1) a Broker-Dealer, (2) a Person participating in the distribution of the Exchange Notes or (3) a Person who is an
“affiliate” (as defined in Rule 144) of the Issuer; 
 (B) such transfer is effected pursuant to a Shelf Registration
Statement in accordance with the Registration Rights Agreement; 
 (C) such transfer is effected by a Broker-Dealer pursuant to
the Exchange Offer Registration Statement and such Broker-Dealer complies with the terms of the Registration Rights Agreement; or 
 (D) the Registrar receives the following: 
 (y) if the holder of
such beneficial interest in a Restricted Global Note proposes to exchange such beneficial interest for a Definitive Note that does not bear the Private Placement Legend, a certificate from such holder in the form of Exhibit C hereto, including the
certifications in item (1)(b) thereof; or 
 (z) if the holder of such beneficial interest in a Restricted
Global Note proposes to transfer such beneficial interest to a Person who shall take delivery thereof in the form of a Definitive Note that does not bear the Private Placement Legend, a certificate from such holder in the form of Exhibit B hereto,
including the applicable certifications in item (4) thereof, 
 and, in each such case set forth in this subparagraph (D), if the Registrar
so requests or if the Applicable Procedures so require, an Opinion of Counsel in form reasonably acceptable to the Registrar to the effect that such exchange or transfer is in compliance with the Securities Act and that the restrictions on transfer
contained in this Indenture and in the Private Placement Legend are no longer required in order to maintain compliance with the Securities Act. 

  
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 (iii) Transfer and Exchange of Beneficial Interests in Unrestricted Global Notes for
Unrestricted Definitive Notes. Subject to Section 2.6(a), if any holder of a beneficial interest in an Unrestricted Global Note proposes to exchange such beneficial interest for a Definitive Note or to transfer such beneficial interest to a
Person who takes delivery thereof in the form of a Definitive Note, then, upon satisfaction of the conditions set forth in Section 2.6(b)(ii) above, the Trustee shall cause the aggregate principal amount of the applicable Global Note to be
reduced accordingly pursuant to Section 2.6(m) below, and the Issuer shall execute and the Trustee shall authenticate and deliver to the Person designated in the certificate a Definitive Note in the appropriate principal amount. Any Definitive
Note issued in exchange for a beneficial interest pursuant to this Section 2.6(c)(iii) shall be registered in such name or names and in such authorized denomination or denominations as the holder of such beneficial interest shall instruct the
Registrar through instructions from the Depositary and the Participant or Indirect Participant. The Trustee shall deliver such Definitive Notes to the Persons in whose names such Notes are so registered. Any Definitive Note issued in exchange for a
beneficial interest pursuant to this Section 2.6(c)(iii) shall not bear the Private Placement Legend. 
 (d) Transfer and
Exchange of Definitive Notes for Beneficial Interests. 
 (i) Transfer and Exchange of Restricted Definitive Notes for
Beneficial Interests in Restricted Global Notes. If any Holder of a Restricted Definitive Note proposes to exchange such Note for a beneficial interest in a Restricted Global Note or to transfer such Restricted Definitive Notes to a Person who takes
delivery thereof in the form of a beneficial interest in a Restricted Global Note, then, upon receipt by the Registrar of the following documentation: 
 (A) if the Holder of such Restricted Definitive Note proposes to exchange such Note for a beneficial interest in a Restricted Global Note, a certificate from such Holder in the form of Exhibit C hereto,
including the certifications in item (2)(b) thereof; 
 (B) if such Restricted Definitive Note is being transferred to a QIB in
accordance with Rule 144A under the Securities Act, a certificate to the effect set forth in Exhibit B hereto, including the certifications in item (1) thereof; or 
 (C) if such Restricted Definitive Note is being transferred to a Non-U.S. Person in an offshore transaction in accordance with Rule 903 or Rule 904 under the Securities Act, a certificate to the effect
set forth in Exhibit B hereto, including the certifications in item (2) thereof; 
 the Trustee shall cancel the Restricted Definitive
Note, increase or cause to be increased the aggregate principal amount of, in the case of clause (A) above, the appropriate Restricted Global Note, in the case of clause (B) above, the 144A Global Note, and in the case of clause
(C) above, the Regulation S Global Note. 
 (ii) Transfer and Exchange of Restricted Definitive Notes for Beneficial
Interests in Unrestricted Global Notes. A Holder of a Restricted Definitive Note may exchange such Note for a beneficial interest in an Unrestricted Global Note or transfer such Restricted Definitive Note to a Person who takes delivery thereof in
the form of a beneficial interest in an Unrestricted Global Note only if: 

  
 46 

 (A) such exchange or transfer is effected pursuant to the Exchange Offer in accordance with
the Registration Rights Agreement and the Holder, in the case of an exchange, or the transferee, in the case of a transfer, certifies in the applicable Letter of Transmittal that it is not (1) a Broker-Dealer, (2) a Person participating in
the distribution of the Exchange Notes or (3) a Person who is an “affiliate” (as defined in Rule 144) of the Issuer; 
 (B) such transfer is effected pursuant to a Shelf Registration Statement in accordance with the Registration Rights Agreement; 
 (C) such transfer is effected by a Broker-Dealer pursuant to an Exchange Offer Registration Statement and such Broker-Dealer complies with the terms of the Registration Rights Agreement; or 

(D) the Registrar receives the following: 
 (y) if the Holder of such Definitive Notes proposes to exchange such Notes for a beneficial interest in an Unrestricted Global Note, a certificate from such Holder in the form of Exhibit C hereto,
including the certifications in item (1)(c) thereof; or 
 (z) if the Holder of such Definitive Notes
proposes to transfer such Notes to a Person who shall take delivery thereof in the form of a beneficial interest in an Unrestricted Global Note, a certificate from such Holder in the form of Exhibit B hereto, including the applicable certifications
in item (4) thereof; 
 and, in each such case set forth in this subparagraph (D), if the Registrar so requests or if the Applicable
Procedures so require, an Opinion of Counsel in form reasonably acceptable to the Registrar to the effect that such exchange or transfer is in compliance with the Securities Act and that the restrictions on transfer contained in this Indenture and
in the Private Placement Legend are no longer required in order to maintain compliance with the Securities Act. 
 Upon
satisfaction of the conditions of any of the subparagraphs in this Section 2.6(d)(ii), the Trustee shall cancel the Definitive Notes and increase or cause to be increased the aggregate principal amount of the Unrestricted Global Note.

 (iii) Transfer and Exchange of Unrestricted Definitive Notes for Beneficial Interests in Unrestricted Global Notes. A Holder
of an Unrestricted Definitive Note may exchange such Note for a beneficial interest in an Unrestricted Global Note or transfer such Unrestricted Definitive Notes to a Person who takes delivery thereof in the form of a beneficial interest in an
Unrestricted Global Note at any time. Upon receipt of a request for such an exchange or transfer, the Trustee shall cancel the applicable Unrestricted Definitive Note and increase or cause to be increased the aggregate principal amount of one of the
Unrestricted Global Notes. 

  
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 If any such exchange or transfer from an Unrestricted Definitive Note or a Restricted
Definitive Note, as the case may be, to a beneficial interest is effected pursuant to Section 2.6(d)(ii)(B), (d)(ii)(D) or (d)(iii) above at a time when an Unrestricted Global Note has not yet been issued, the Issuer shall issue and, upon
receipt of an authentication order in accordance with Section 2.2, the Trustee shall authenticate one or more Unrestricted Global Notes in an aggregate principal amount equal to the principal amount of Unrestricted Definitive Notes or
Restricted Definitive Notes, as the case may be, so transferred. 
 (e) Transfer and Exchange of Definitive Notes for Definitive
Notes. Upon request by a Holder of Definitive Notes and such Holder’s compliance with the provisions of this Section 2.6(e), the Registrar shall register the transfer or exchange of Definitive Notes. Prior to such registration of transfer
or exchange, the requesting Holder shall present or surrender to the Registrar the Definitive Notes duly endorsed or accompanied by a written instruction of transfer in form satisfactory to the Registrar duly executed by such Holder or its attorney,
duly authorized in writing. In addition, the requesting Holder shall provide any additional certifications, documents and information, as applicable, required pursuant to the following provisions of this Section 2.6(e). 

(f) Transfer of Restricted Definitive Notes to Restricted Definitive Notes. Any Restricted Definitive Note may be transferred to and
registered in the name of Persons who take delivery thereof in the form of a Restricted Definitive Note if the Registrar receives the following: 
 (A) if the transfer will be made pursuant to Rule 144A under the Securities Act, then the transferor must deliver a certificate in the form of Exhibit B hereto, including the certifications in item
(1) thereof; 
 (B) if the transfer will be made pursuant to Rule 903 or Rule 904, then the transferor must deliver a
certificate in the form of Exhibit B hereto, including the certifications in item (2) thereof; and 
 (C) if the transfer
will be made pursuant to any other exemption from the registration requirements of the Securities Act, then the transferor must deliver a certificate in the form of Exhibit B hereto, including, if the Issuer so requests, a certification and/or
Opinion of Counsel in form reasonably acceptable to the Issuer to the effect that such transfer is in compliance with the Securities Act. 
 (g) Transfer and Exchange of Restricted Definitive Notes for Unrestricted Definitive Notes. Any Restricted Definitive Note may be exchanged by the Holder thereof for an Unrestricted Definitive Note or
transferred to a Person or Persons who take delivery thereof in the form of an Unrestricted Definitive Note if 
 (A) such
exchange or transfer is effected pursuant to an Exchange Offer in accordance with the Registration Rights Agreement and the Holder, in the case of an exchange, or the transferee, in the case of a transfer, certifies in the applicable Letter of
Transmittal that it is not (1) a Broker-Dealer, (2) a Person participating in the distribution of the Exchange Notes or (3) a Person who is an “affiliate” (as defined in Rule 144) of the Issuer; 

  
 48 

 (B) any such transfer is effected pursuant to a Shelf Registration Statement in accordance
with the Registration Rights Agreement; 
 (C) any such transfer is effected by a Broker-Dealer pursuant to an Exchange Offer
Registration Statement and such Broker-Dealer complies with the terms of the Registration Rights Agreement; or 
 (D) the
Registrar receives the following: 
 (y) if the Holder of such Restricted Definitive Notes proposes to exchange
such Notes for an Unrestricted Definitive Note, a certificate from such Holder in the form of Exhibit C hereto, including the certifications in item (1)(d) thereof; or 

(z) if the Holder of such Restricted Definitive Notes proposes to transfer such Notes to a Person who shall take delivery
thereof in the form of an Unrestricted Definitive Note, a certificate from such Holder in the form of Exhibit B hereto, including the applicable certifications in item (4) thereof; 
 and, in each such case set forth in this subparagraph (D), if the Registrar so requests, an Opinion of Counsel in form reasonably acceptable to the Issuer to the effect that such exchange or transfer is
in compliance with the Securities Act and that the restrictions on transfer contained in this Indenture and in the Private Placement Legend are no longer required in order to maintain compliance with the Securities Act. 

(h) Transfer of Unrestricted Definitive Notes to Unrestricted Definitive Notes. A Holder of Unrestricted Definitive Notes may transfer
such Notes to a Person who takes delivery thereof in the form of an Unrestricted Definitive Note. Upon receipt of a request to register such a transfer, the Registrar shall register the Unrestricted Definitive Notes pursuant to the instructions from
the Holder thereof. 
 (i) Exchange Offer. Upon the occurrence of an Exchange Offer in accordance with the Registration Rights
Agreement, the Issuer shall issue and, upon receipt of an authentication order in accordance with Section 2.2 hereof, the Trustee shall authenticate (i) one or more Unrestricted Global Notes in an aggregate principal amount equal to the
principal amount of the beneficial interests in the Restricted Global Notes tendered for acceptance by Persons that make the certifications in the applicable Letters of Transmittal required by Section 2(a) of the Registration Rights Agreement,
and accepted for exchange in an Exchange Offer and (ii) subject to Section 2.6(a) Definitive Notes in an aggregate principal amount equal to the principal amount of the Restricted Definitive Notes accepted for exchange in an Exchange
Offer. Concurrently with the issuance of such Notes, the Trustee shall cause the aggregate principal amount of the applicable Restricted Global Notes to be reduced accordingly, and the Issuer shall execute and the Trustee shall authenticate and
deliver to the Persons designated by the Holders of Restricted Definitive Notes so accepted Unrestricted Definitive Notes in the appropriate principal amounts. 
 (j) Temporary Regulation S Global Note. 

  
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 (1) Notes offered and sold in reliance on Regulation S shall be issued initially in the
form of the Temporary Regulation S Global Note, which shall be deposited on behalf of the purchasers of the Notes represented thereby with the Notes Custodian and registered in the name of the Depositary or the nominee of the Depositary for the
accounts of designated agents holding on behalf of Euroclear or Clearstream, duly executed by the Issuer and authenticated by the Trustee as hereinafter provided. 
 (2) During the Restricted Period, beneficial ownership interests in Temporary Regulation S Global Notes may only be sold, pledged or transferred (i) to the Issuer, (ii) in an offshore
transaction in accordance with Rule 904 of Regulation S (other than a transaction resulting in an exchange for an interest in a Permanent Regulation S Global Note) or (iii) pursuant to an effective registration statement under the Securities
Act, in each case in accordance with any applicable securities laws of any State of the United States; and beneficial interests in a 144A Global Note may be transferred to a Person who takes delivery in the form of an interest in a Regulation S
Global Note, whether before or after the expiration of the Restricted Period, only if the transferor first delivers to the Trustee a written certificate to the effect that such transfer is being made in accordance with Rule 903 or 904 of Regulation
S or Rule 144 (if applicable). 
 (3) The Restricted Period shall be terminated upon the receipt by the Trustee of: 

(A) a written certificate from the Depositary, together with copies of certificates from Euroclear and Clearstream certifying that they
have received certification of non-United States beneficial ownership of 100% of the aggregate principal amount of each Temporary Regulation S Global Note (except to the extent of any beneficial owners thereof who acquired an interest therein during
the Restricted Period pursuant to another exemption from registration under the Securities Act and who shall take delivery of a beneficial ownership interest in a 144A Global Note bearing a Private Placement Legend, all as contemplated by
Section 2.06(j) hereof); and 
 (B) an Officer’s Certificate and Opinion of Counsel from the Issuer. 

(4) Within a reasonable period after expiration or termination of the Restricted Period, beneficial interests in each Temporary
Regulation S Global Note shall be exchanged for beneficial interests in a Permanent Regulation S Global Note upon delivery to DTC of the certification of compliance and the transfer of applicable Notes pursuant to the Applicable Procedures.
Simultaneously with the authentication of the corresponding Permanent Regulation S Global Note, the Trustee shall cancel the corresponding Temporary Regulation S Global Note. The aggregate principal amount of a Temporary Regulation S Global Note and
a Permanent Regulation S Global Note may from time to time be increased or decreased by adjustments made on the records of the Trustee and the Depositary or its nominee, as the case may be, in connection with transfers of interest as hereinafter
provided. 
 (5) Notwithstanding anything to the contrary in this Sections 2.6, a beneficial interest in the Temporary
Regulation S Global Note may not be exchanged for a 

  
 50 

 
Definitive Note or transferred to a Person who takes delivery thereof in the form of a Definitive Note prior to (x) the expiration of the Restricted Period and (y) the receipt by the
Registrar of any certificates required pursuant to Rule 903(b)(3)(ii)(B) of the Securities Act, except in the case of a transfer pursuant to an exemption from the registration requirements of the Securities Act other than Rule 903 or Rule 904.

 (k) Private Placement Legend. 
 (A) Except as permitted by subparagraph (B) below, each Global Note (other than an Unrestricted Global Note) and each Definitive Note (and all Notes issued in exchange therefor or substitution
thereof) shall bear the Private Placement Legend. 
 (B) Notwithstanding the foregoing, any Global Note or Definitive Note
issued pursuant to subparagraph (b)(iv), (c)(ii), (c)(iii), (d)(ii), (d)(iii), (e)(ii), (e)(iii) or (f) of this Section 2.6 (and all Notes issued in exchange therefor or substitution thereof) shall not bear the Private Placement Legend.

 (l) Global Note Legend. Each Global Note shall bear the Global Note Legend. 

(m) Cancellation and/or Adjustment of Global Notes. At such time as all beneficial interests in a particular Global Note have been
exchanged for Definitive Notes or a particular Global Note has been redeemed, repurchased or canceled in whole and not in part, each such Global Note shall be returned to or retained and canceled by the Trustee in accordance with Section 2.11
hereof. At any time prior to such cancellation, if any beneficial interest in a Global Note is exchanged for or transferred to a Person who will take delivery thereof in the form of a beneficial interest in another Global Note or for Definitive
Notes, the principal amount of Notes represented by such Global Note shall be reduced accordingly and an endorsement shall be made on such Global Note by the Trustee or by the Depositary at the direction of the Trustee to reflect such reduction; and
if the beneficial interest is being exchanged for or transferred to a Person who will take delivery thereof in the form of a beneficial interest in another Global Note, such other Global Note shall be increased accordingly and an endorsement shall
be made on such Global Note by the Trustee or by the Depositary at the direction of the Trustee to reflect such increase. 
 On
any Interest Payment Date on which the Company pays PIK Interest (a “PIK Payment”) with respect to a Global Note, the Trustee shall increase the principal amount of such Global Note by an amount equal to the interest payable, rounded down
to the nearest whole dollar, for the relevant interest period on the principal amount of such Global Note as of the relevant record date for such Interest Payment Date, to the credit of the Holders on such Record Date and an adjustment shall be made
on the books and records of the Trustee with respect to such Global Note to reflect such increase. On any Interest Payment Date on which the Company makes a PIK Payment by issuing Definitive Notes (a “PIK Note”), the principal amount of
any such PIK Note issued to any Holder, for the relevant interest period as of the relevant Record Date for such Interest Payment Date, shall be rounded down to the nearest whole dollar. 

(n) General Provisions Relating to Transfers and Exchanges. 

  
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 (i) To permit registrations of transfers and exchanges, the Issuer shall execute and the
Trustee shall authenticate Global Notes and Definitive Notes upon the Issuer’s order in accordance with Section 2.2 or at the Registrar’s request. 
 (ii) No service charge shall be made to a holder of a beneficial interest in a Global Note or to a Holder of a Definitive Note for any registration of transfer or exchange, but the Issuer may require
payment of a sum sufficient to cover any transfer tax or similar governmental charge payable in connection therewith (other than any such transfer taxes or similar governmental charge payable upon exchange or transfer pursuant to Sections 2.2, 2.10,
3.7, 3.9 and 5.7). 
 (iii) The Registrar shall not be required to register the transfer of or exchange any Note selected for
redemption in whole or in part, except for the unredeemed portion of any Note being redeemed in part. 
 (iv) All Global Notes
and Definitive Notes issued upon any registration of transfer or exchange of Global Notes or Definitive Notes shall be the valid obligations of the Issuer, evidencing the same debt, and entitled to the same benefits hereof, as the Global Notes or
Definitive Notes surrendered upon such registration of transfer or exchange. 
 (v) Neither the Registrar nor the Issuer shall
be required (A) to issue, to register the transfer of or to exchange any Notes during a period beginning at the opening of business on a Business Day 15 days before the mailing of a notice of redemption of Notes and ending at the close of
business on the day of such mailing or (B) to register the transfer of or to exchange any Note so selected for redemption in whole or in part, except the unredeemed portion of any Note being redeemed in part. 

(vi) Prior to due presentment for the registration of a transfer of any Note, the Trustee, any Agent and the Issuer may deem and treat
the Person in whose name any Note is registered as the absolute owner of such Note for the purpose of receiving payment of principal of and interest on such Notes and for all other purposes, and none of the Trustee, any Agent or the Issuer shall be
affected by notice to the contrary. 
 (vii) The Trustee shall authenticate Global Notes and Definitive Notes in accordance with
the provisions of Section 2.2. 
 (viii) All certifications, certificates and Opinions of Counsel required to be submitted
to the Registrar pursuant to this Section 2.6 to effect a registration of transfer or exchange may be submitted by facsimile. 
 (ix) The Trustee shall have no obligation or duty to monitor, determine or inquire as to compliance with any restrictions on transfer imposed under this Indenture or under applicable law with respect to
any transfer of any interest in any Note (including any transfers between or among Participants or Indirect Participants) other than to require delivery of such certificates and other documentation or evidence as are expressly required by, and to do
so if and when expressly required by the terms of, this Indenture, and to examine the same to determine substantial compliance as to form with the express requirements hereof. 

  
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 (x) Neither the Trustee nor any Agent shall have any responsibility for any actions taken or
not taken by the Depositary. 
 SECTION 2.7. Replacement Note. If any mutilated Note is surrendered to the
Trustee, or the Issuer and the Trustee receive evidence to their satisfaction of the destruction, loss or theft of any Note, the Issuer shall issue and the Trustee, upon the written order of the Issuer signed by two Officers of the Issuer, shall
authenticate a replacement Note if the Trustee’s requirements for replacements of Notes are met. The Holder must supply indemnity or security sufficient in the judgment of the Trustee (with respect to the Trustee) and the Issuer (with respect
to the Issuer) to protect the Issuer, the Trustee, any Agent or any authenticating agent from any loss which any of them may suffer if a Note is replaced. The Issuer and the Trustee may charge for their fees and expenses in replacing a Note
including amounts to cover any tax, assessment, fee or other governmental charge that may be imposed in relation thereto. 

Every replacement Note is an obligation of the Issuer. 
 SECTION 2.8. Outstanding Notes. The Notes outstanding at any time are all the Notes authenticated by the Trustee except for those canceled by it, those delivered to it for
cancellation and those described in this Section 2.8 as not outstanding. 
 If a Note is replaced pursuant to
Section 2.7, it ceases to be outstanding unless the Trustee receives proof satisfactory to it that the replaced Note is held by a protected purchaser. 
 If the principal amount of any Note is considered paid under Section 3.1 hereof, it shall cease to be outstanding and interest on it shall cease to accrue. 

Subject to Section 2.9, a Note does not cease to be outstanding because the Issuer, a Subsidiary of the Issuer or an Affiliate of
the Issuer holds the Note. 
 SECTION 2.9. Treasury Notes. In determining whether the Holders of the required
principal amount of Notes have concurred in any direction, waiver or consent, Notes owned by the Issuer, any Subsidiary of the Issuer or any Affiliate of the Issuer shall be considered as though not outstanding, except that for purposes of
determining whether the Trustee shall be protected in relying on any such direction, waiver or consent, only Notes which a Trust Officer actually knows to be owned by the Issuer, any Subsidiary of the Issuer, or any Affiliate of the Issuer shall be
considered as not outstanding. Notwithstanding the foregoing, Notes that are to be acquired by the Issuer, any Subsidiary of the Issuer or an Affiliate of the Issuer pursuant to an exchange offer, tender offer or other agreement shall not be deemed
to be owned by the Issuer, a Subsidiary of the Issuer or an Affiliate of the Issuer until legal title to such Notes passes to the Issuer, such Subsidiary or such Affiliate, as the case may be. Upon request of the Trustee, the Issuer shall promptly
furnish to the Trustee an Officer’s Certificate listing and identifying all Notes, if any, known by the Issuer to be owned or held by or for the account of any of the above- described persons, and the Trustee shall be entitled to accept such
Officer’s Certificate as conclusive evidence of the facts therein set forth and of the fact that all Notes not listed therein are outstanding for the purpose of any such determination. 

  
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 SECTION 2.10. Temporary Notes. Until Definitive Notes are ready
for delivery, the Issuer may prepare and the Trustee shall upon written order of the Issuer signed by two Officers of the Issuer authenticate temporary Notes. Temporary Notes shall be substantially in the form of Definitive Notes but may have
variations that the Issuer and the Trustee consider appropriate for temporary Notes. Without unreasonable delay, the Issuer shall prepare and the Trustee, upon receipt of the written order of the Issuer signed by two Officers of the Issuer, shall
authenticate Definitive Notes in exchange for temporary Notes. Until such exchange, temporary Notes shall be entitled to the same rights, benefits and privileges as Definitive Notes. 

SECTION 2.11. Cancellation. The Issuer at any time may deliver Notes to the Trustee for cancellation. The Registrar
and Paying Agent shall forward to the Trustee any Notes surrendered to them for registration of transfer, exchange or payment. The Trustee shall cancel all Notes surrendered for registration of transfer, exchange, payment, replacement or
cancellation and shall dispose of all canceled Notes in its customary manner (subject to the record retention requirements of the Exchange Act), and upon the written request of the Issuer, the Trustee shall deliver copies of such canceled Notes to
the Issuer. The Issuer may not issue new Notes to replace Notes that it has redeemed or paid or that have been delivered to the Trustee for cancellation. 
 SECTION 2.12. Payment of Interest; Defaulted Interest. Interest on any Note which is payable, and is punctually paid or duly provided for, on any Interest Payment Date shall be paid to the
Person in whose name such Note (or one or more predecessor Notes) is registered at the close of business on the regular Record Date for such interest at the office or agency of the Issuer maintained for such purpose pursuant to Section 2.3.

 Any interest on any Note which is payable, but is not paid when the same becomes due and payable and such nonpayment
continues for a period of 30 days shall forthwith cease to be payable to the Holder on the regular Record Date by virtue of having been such Holder, and such defaulted interest and (to the extent lawful) interest on such defaulted interest at the
rate borne by the Notes (such defaulted interest and interest thereon herein collectively called “Defaulted Interest”) shall be paid by the Issuer, at its election in each case, as provided in clause (a) or (b) below: 

(a) The Issuer may elect to make payment of any Defaulted Interest to the Persons in whose names the Notes (or their respective
predecessor Notes) are registered at the close of business on a Special Record Date (as defined below) for the payment of such Defaulted Interest, which shall be fixed in the following manner. The Issuer shall notify the Trustee in writing of the
amount of Defaulted Interest proposed to be paid on each Note and the date (not less than 30 days after such notice unless a shorter period shall be acceptable to the Trustee) of the proposed payment (the “Special Interest Payment Date”),
and at the same time the Issuer shall deposit with the Trustee an amount of money equal to the aggregate amount proposed to be paid in respect of such Defaulted Interest or shall make arrangements satisfactory to the Trustee for such deposit prior
to the date of the proposed payment, such money when deposited to be held in trust for the benefit of the Persons entitled to such Defaulted Interest as in this clause provided. Thereupon the Trustee shall fix a record date (the “Special Record
Date”) for the payment of such Defaulted Interest, which shall be not more than 15 days and not less than 10 days prior to the Special Interest Payment Date and not less than 10 days after the receipt by the Trustee of the notice of

  
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the proposed payment. The Trustee shall promptly notify the Issuer of such Special Record Date, and in the name and at the expense of the Issuer, shall cause notice of the proposed payment of
such Defaulted Interest and the Special Record Date and Special Interest Payment Date therefor to be given in the manner provided for in Section 12.1, not less than 10 days prior to such Special Record Date. Notice of the proposed payment of
such Defaulted Interest and the Special Record Date and Special Interest Payment Date therefor having been so given, such Defaulted Interest shall be paid on the Special Interest Payment Date to the Persons in whose names the Notes (or their
respective predecessor Notes) are registered at the close of business on such Special Record Date and shall no longer be payable pursuant to the following clause (b). 
 (b) The Issuer may make payment of any Defaulted Interest in any other lawful manner not inconsistent with the requirements of any securities exchange on which the Notes may be listed, and upon such
notice as may be required by such exchange, if, after notice given by the Issuer to the Trustee of the proposed payment pursuant to this clause (b), such manner of payment shall be deemed practicable by the Trustee. 

Notwithstanding the foregoing, if any such Interest Payment Date (other than an Interest Payment Date at maturity) would otherwise be a
day that is not a Business Day, then the Interest Payment Date shall be postponed to the next succeeding Business Day (except if that Business Day falls in the next succeeding calendar month, then interest shall be paid on the immediately preceding
Business Day). If the maturity date of the Notes is a day that is not a Business Day, all payments to be made on such day shall be made on the next succeeding Business Day, with the same force and effect as if made on the maturity date. In either of
such cases, no additional interest shall be payable as a result of such delay in payment. 
 Subject to the foregoing provisions
of this Section, each Note delivered under this Indenture upon registration of transfer of or in exchange for or in lieu of any other Note shall carry the rights to interest accrued and unpaid, and to accrue, which were carried by such other Note.

 SECTION 2.13. CUSIP Numbers. The Issuer in issuing the Notes may use “CUSIP” numbers (if then
generally in use). The Trustee shall not be responsible for the use of CUSIP numbers, and the Trustee makes no representation as to their correctness as printed on any Note or notice to Holders. The Issuer shall promptly notify the Trustee in
writing of any change in the CUSIP numbers. 
 SECTION 2.14. Record Date. The Record Date for purposes of
determining the identity of Holders of the Notes entitled to vote or consent to any action by vote or consent authorized or permitted under this Indenture shall be determined as provided for in TIA § 316(c). 

SECTION 2.15. Tax Treatment. The Issuer agrees, and by acceptance of a beneficial interest in Notes each beneficial owner
of the Notes will be deemed to have agreed, for U.S. federal income tax purposes, to treat the Notes as indebtedness that is subject to the regulations governing contingent payment debt instruments and to be bound by the Issuer’s determination
of the “comparable yield” and “projected payment schedule” with respect to the Notes. 

  
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 ARTICLE III 
 COVENANTS 
 SECTION 3.1. Payment of Notes. The Issuer
shall promptly pay the principal of, premium, if any, and interest on the Notes on the dates and in the manner provided in the Notes and in this Indenture. Principal, premium, if any, and interest shall be considered paid on the date due if on such
date the Trustee or the Paying Agent holds in accordance with this Indenture money sufficient to pay all principal, premium, if any, and interest then due and the Trustee or the Paying Agent, as the case may be, is not prohibited from paying such
money to the Holders on that date pursuant to the terms of this Indenture. 
 The Issuer shall pay interest on overdue principal
at the rate specified therefor in the Notes. 
 Notwithstanding anything to the contrary contained in this Indenture, the Issuer
may, to the extent it is required to do so by law, deduct or withhold income or other similar taxes imposed by the United States of America from principal or interest payments hereunder. 

SECTION 3.2. Reports. 
 (a) Prior to the Exchange Offer Filing Date. Prior to the filing of the Exchange Offer Registration Statement or the Shelf Registration Statement (the “Exchange Offer Filing Date”): 

(1) Whether or not required by the SEC, the Issuer shall furnish to the Trustee and to Cede & Co., the nominee of DTC, and the
beneficial holders of Notes: 
 (i) within 90 days after the end of each fiscal year, substantially all annual financial
information that would be required to be contained in a filing with the SEC on Form 10-K if the Issuer were required to file this Form (but only to the extent similar information is included in the Offering Memorandum and the financial statements
included herein) and shall include a “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and a report on the annual financial statements by the Issuer’s certified independent accountants;

 (ii) within 45 days after the end of each of the three fiscal quarters of each fiscal year, substantially all interim
quarterly financial information that would be required to be contained in a filing with the SEC on Form 10-Q if the Issuer were required to file this Form (but only to the extent similar information is included in the Offering Memorandum and the
financial statements included herein) and shall include a “Management’s Discussion and Analysis of Financial Condition and Results of Operations”; and 
 (iii) within 5 business days after the occurrence of each event that would have been required to be reported in a Current Report on Form 8-K if the Issuer were required to file this Form, current reports
containing substantially all of the information that would be required to be filed in a Current Report on Form 8-K pursuant to Sections 1, 2 and 4 and Items 3.03 (with respect to the Notes), 5.01, 5.02 and 5.03 (other than compensation information)
of Form 8-K if the Issuer had been a reporting company under the Exchange Act; provided, however, that no 

  
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such current report shall be required to be furnished if the Issuer determines in its good faith judgment that such event is not material to Holders of the Notes or the business, assets,
operations or financial positions of the Issuer and its Restricted Subsidiaries, taken as a whole. 
 (2) Notwithstanding
Section 3 .02(a)( 1), in no event: (A) shall the Issuer be required to comply with Section 302, 404 or 906 of the Sarbanes-Oxley Act of 2002, or related Items 307 and 308 of Regulation S-K promulgated by the SEC, or Item 301
(with respect to any period prior to January 1, 2007) or 302 of Regulation S-K or Item 10(e) of Regulation S-K (with respect to any non-GAAP financial measures contained therein), in each case, as in effect on the date of this Indenture,
or (B) shall any reports be required to contain the separate financial information for acquired businesses as contemplated by Rule 3-10 of Regulation S-X promulgated by the SEC. 

(3) The Issuer shall either (A) maintain a website (which may be nonpublic, but shall not restrict the recipients of such
information from trading in securities) to which holders of Notes, prospective investors, securities analysts and market makers that, prior to the Exchange Offer Filing Date, certify that they are qualified institutional buyers (collectively,
“Permitted Parties”) are given access and to which the information required by the preceding paragraphs (the “Required Information”) is posted; or (B) distribute via electronic mail the Required Information to Beneficial
Owners of the Notes and prospective investors that certify that they are Permitted Parties who request to receive such distributions. 
 (b) From and After the Exchange Offer Filing Date. From and after the Exchange Offer Filing Date: (1) Whether or not required by the rules and regulations of the SEC, so long as any Notes are
outstanding, the Issuer shall furnish to the Trustee and to Cede & Co., the nominee of DTC, and the holders of Notes, within the time periods that are applicable to the Issuer (or, if not applicable, would be if the Issuer were required to
file such reports under Section 13(a) or 15(d) of the Exchange Act as a non-accelerated filer): 
 (i) all quarterly and
annual financial information that would be required to be contained in a filing with the SEC on Forms 10-Q and 10-K, if the Issuer were required to file such Forms, including a “Management’s Discussion and Analysis of Financial Condition
and Results of Operations” that describes the Issuer’s consolidated financial condition and results of operation and, with respect to the annual information only, a report thereon by the Issuer’s independent registered public
accountants but not any assessment, attestation or audit of internal controls pursuant to Section 404 of the Sarbanes-Oxley Act or rules and regulations promulgated thereunder; and 

(ii) all current reports that would be required to be filed with the SEC on Form 8-K if the Issuer were required to file such reports.

 (1) The Issuer shall file a copy of all of the information and reports referred to in clauses (i) and (ii) of
Section 3.2(b) with the SEC for public availability within the time periods specified in the SEC’s rules and regulations for a company required to file reports under Section 13(a) or 15(d) of the Exchange Act (unless the SEC will not
accept such a filing) and make such information available to securities analysts and prospective investors upon request. The Issuer agrees that it shall not take any action for the purpose of causing the SEC not

  
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to accept such filings. If, notwithstanding the foregoing, the SEC will not accept such filings for any reason, the Issuer shall post the reports specified in the preceding sentence on its
website within the time periods that would apply if the Issuer were required to file those reports with the SEC. 
 (2)
Notwithstanding the foregoing, such requirements shall be deemed satisfied prior to the commencement of the Exchange Offer or the effectiveness of the Shelf Registration Statement (A) by the filing with the SEC of the Exchange Offer
Registration Statement or Shelf Registration Statement (or any other similar registration statement), and any amendments thereto, with such financial information that satisfies Regulation S-X, subject to exceptions consistent with the presentation
of financial information in the Offering Memorandum, to the extent filed within the times specified above, or (B) by posting reports that would be required to be filed substantially in the form required by the SEC (subject to the limitations
set forth above) on the Issuer’s website (or that of any of its parent companies) or providing such reports to the Trustee within 15 days after the time the Issuer would be required to file such information with the SEC if it were subject to
Section 13 or 15(d) of the Exchange Act, the financial information (including a “Management’s Discussion and Analysis of Financial Condition and Results of Operation”) that would be required to be included in such reports,
subject to exceptions consistent with the presentation of financial information in the Offering Memorandum, to the extent filed within the times specified above. 
 (c) Before and After the Exchange Offer Filing Date . For so long as any Notes are outstanding, 
 (1) The Issuer shall: 
 (i) within 15 business days after the annual and quarterly
information required pursuant to the above is furnished to the Trustee or filed with the SEC, hold a conference call for Permitted Parties to discuss such reports and the results of operations for the relevant reporting period; and 

(ii) issue a press release to any U.S. nationally recognized wire service or employ other means commercially reasonably expected to reach
Permitted Parties no fewer than three business days prior to the date of the conference call required to be held in accordance with clause (i) above, announcing the time and date of such conference call and either including all information
necessary to access the call or directing Permitted Parties to contact the appropriate person at the Issuer to obtain such information; 

provided that, after an initial public offering of common stock of the Issuer or any direct or indirect parent company of the Issuer, no separate
press release or conference call shall be required to comply with the foregoing if the Issuer or any direct or indirect parent company of the Issuer conducts customary earnings conference calls and issues press releases in connection therewith.

 Notwithstanding anything contrary herein, so long as the Issuer does not (i) have any material assets (other than Capital Stock of its
Subsidiaries), (ii) engage in any trade or business or (iii) conduct any business activity, it shall be entitled to comply with this covenant by disclosing its 

  
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financial information in the form of a footnote to the financial statements of ARH or a parent of ARH that is a Subsidiary of the Issuer; provided that for the fiscal year ended
December 31, 2010 only, the Issuer shall be entitled to comply with this covenant by furnishing to the Trustee and to Cede & Co., the nominee of DTC and the beneficial holders of Notes the audited financial statements of ARH relating
to such period (irrespective of whether such financial statements contain footnote disclosure with respect to the Issuer) and unaudited financial statements of the Issuer relating to such period, in each case, within 90 days after the end of such
fiscal year. 
 (2) The Issuer shall furnish to any Beneficial Owner of Notes or to any prospective purchaser of Notes in
connection with any sale thereof, upon their request, the information required to be delivered pursuant to Rule 144A(d)(4) under the Securities Act. The Issuer shall also comply with the provisions of Section 314(a) of the TIA. 

SECTION 3.3. Limitation on Indebtedness and Issuance of Disqualified Stock and Preferred Stock. 

(a) The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, directly or indirectly, create, incur, issue,
assume, guarantee or otherwise become directly or indirectly liable, contingently or otherwise, with respect to (collectively, “incur”) any Indebtedness (including Acquired Debt), and the Issuer shall not issue any Disqualified Stock and
shall not permit any of its Restricted Subsidiaries to issue any shares of preferred stock; provided, however, that (i) the Issuer or any Guarantor (other than ARH or any of its Restricted Subsidiaries) may incur Indebtedness
(including Acquired Debt) or issue Disqualified Stock or preferred stock, if the Fixed Charge Coverage Ratio of the Issuer would be at least 2.00 to 1.00 and (ii) ARH or any of its Restricted Subsidiaries may incur Indebtedness (including
Acquired Debt) or issue Disqualified Stock or preferred stock, if the Fixed Charge Coverage Ratio of ARH would be at least 2.00 to 1.00. 
 (b) The provisions of Section 3.3(a) shall not prohibit the incurrence of any of the following items of Indebtedness or the issuance of any of the following items of Disqualified Stock or preferred
stock (collectively, “Permitted Debt”): 
 (i) the incurrence by any Restricted Subsidiary of the Issuer of
Indebtedness under Credit Facilities in an aggregate principal amount at any one time outstanding under this clause (i) not to exceed the greater of (a) $25.0 million and (b) an amount equal to 50% of Consolidated EBITDA, calculated
on a Pro Forma Basis, for the most recently ended four full fiscal quarters for which internal financial statements are available immediately preceding the date of any incurrence under this clause (i), less the aggregate amount of all Net
Proceeds of Asset Sales of the Issuer or any Restricted Subsidiary applied since the Issue Date to repay any Indebtedness under a Credit Facility pursuant to Section 3.7, less the aggregate amount of term loans prepaid or revolving
commitments reduced pursuant to Section 3.20; 
 (ii) the incurrence by the Issuer and the Restricted Subsidiaries of the
Existing Indebtedness outstanding on the Issue Date; 
 (iii) the incurrence by the Issuer of Indebtedness represented by the
Notes to be issued on the Issue Date, the Exchange Notes to be issued pursuant to the Registration Rights Agreement or any PIK Notes issued from time to time to pay PIK Interest in accordance with the terms of this Indenture; 

  
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 (iv)(1) Acquired Debt or Disqualified Stock or preferred stock of any Person that is
acquired by the Issuer or any of its Restricted Subsidiaries or that consolidates or merges with or into a Restricted Subsidiary in accordance with the terms of this Indenture; provided, however, that (i) such Acquired Debt,
Disqualified Stock or preferred stock existed prior to such acquisition, consolidation or merger and was not incurred or issued in connection therewith, or in contemplation thereof; and (ii) after giving effect thereto, (a) in the case of
any Acquired Debt or Disqualified Stock or preferred stock of any Person that is acquired by the Issuer or any of its Restricted Subsidiaries (other than ARH or any of its Restricted Subsidiaries), the Issuer would be permitted to incur at least
$1.00 of additional Indebtedness under Section 3.3(a)(i) and (b) in the case of any Acquired Debt or Disqualified Stock or preferred stock of any Person that is acquired by ARH or any of its Restricted Subsidiaries or that consolidates or
merges with or into ARH or any of its Restricted Subsidiaries, ARH would be permitted to incur at least $1.00 of additional Indebtedness under Section 3.3(a)(ii); or 
 (2) Acquired Debt or Disqualified Stock or preferred stock of any Person that consolidates or merges into the Issuer in accordance with the terms of this Indenture; provided, however, that
(i) such Acquired Debt, Disqualified Stock or preferred stock existed prior to such consolidation or merger and was not incurred or issued in connection therewith, or in contemplation thereof; and (ii) after giving effect thereto, the
Consolidated Fixed Charge Coverage Ratio of the Issuer and the Restricted Subsidiaries is equal to or greater than immediately prior to the incurrence of such Acquired Debt, Disqualified Stock or preferred stock; 

(v) the incurrence by the Issuer or any of its Restricted Subsidiaries of Permitted Refinancing Indebtedness or Replacement Preferred
Stock in exchange for, or the net proceeds of which are used to renew, refund, refinance, replace, defease or discharge any Indebtedness (other than intercompany Indebtedness) or any Disqualified Stock or preferred stock that was permitted by this
Indenture to be incurred under Section 3.3(a) or clauses (ii) or (iii) of this Section 3.3(b) or this clause (v); 
 (vi) the incurrence by the Issuer or any Restricted Subsidiary of Indebtedness owing to the Issuer and any Restricted Subsidiary; provided, however, that: 

(1) if the Issuer is the obligor on such Indebtedness, such Indebtedness must be expressly subordinated to the prior payment in full in
cash of all Obligations with respect to the Notes, except to the extent such subordination would violate any applicable law, rule or regulation; and 
 (2)(i) any subsequent issuance or transfer of Equity Interests that results in any such Indebtedness being owed to a Person other than the Issuer or a Restricted Subsidiary of the Issuer and (ii) any
sale or other transfer of any such Indebtedness to a Person that is not either the Issuer or a Restricted Subsidiary of the Issuer, shall be deemed, in each case, to constitute a new incurrence of such Indebtedness by the Issuer or such Restricted
Subsidiary, as the case may be, which new incurrence is not permitted by this clause; 

  
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 (vii) the issuance by any Restricted Subsidiary to the Issuer or to any Restricted
Subsidiary of shares of preferred stock; provided, however, that: 
 (1) any subsequent issuance or transfer of
Equity Interests that results in any such preferred stock being held by a Person other than the Issuer or a Restricted Subsidiary of the Issuer, and 
 (2) any sale or other transfer of any such preferred stock to a Person that is not either the Issuer or a Restricted Subsidiary of the Issuer, shall be deemed, in each case, to constitute a new issuance
of such preferred stock by such Restricted Subsidiary which new issuance is not permitted by this clause (vii); 
 (viii) the
incurrence by the Issuer or any of its Restricted Subsidiaries of Hedging Obligations for the purpose of limiting interest rate, currency or commodity risk; 
 (ix) the guarantee by the Issuer or any Restricted Subsidiary of Indebtedness of the Issuer or a Restricted Subsidiary that was permitted to be incurred by another provision of this covenant;
provided that if the Indebtedness being guaranteed is subordinated to the Notes, then the guarantee shall be subordinated to the same extent as the Indebtedness guaranteed; 

(x) the incurrence by the Issuer or any of its Restricted Subsidiaries of Indebtedness in respect of workers’ compensation claims,
self-insurance obligations, bankers’ acceptances, letters of credit, performance bonds, surety bonds, appeal bonds or other similar bonds in the ordinary course of business; 

(xi) the incurrence by the Issuer or any of its Restricted Subsidiaries of Indebtedness arising from the honoring by a bank or other
financial institution of a check, draft or similar instrument inadvertently (except in the case of daylight overdrafts) drawn against insufficient funds in the ordinary course of business, so long as such Indebtedness is extinguished within five
business days; 
 (xii) the incurrence of Indebtedness arising from agreements of the Issuer or a Restricted Subsidiary
providing for indemnification, adjustment of purchase price, holdback, contingency payment obligations or similar obligations, in each case, incurred or assumed in connection with the disposition or acquisition of any business, assets or Capital
Stock of the Issuer or any Restricted Subsidiary; 
 (xiii) Indebtedness of the Issuer or any of its Restricted Subsidiaries
supported by a letter of credit issued pursuant to any Credit Facilities, in a principal amount not in excess of the stated amount of such letter of credit; 
 (xiv) the incurrence of Indebtedness resulting from endorsements of negotiable instruments for collection in the ordinary course of business; 

(xv) the incurrence of Indebtedness or Disqualified Stock by Qualified Restricted Subsidiaries, in an aggregate amount not to exceed (net
of unrestricted cash and Cash Equivalents held by any Qualified Restricted Subsidiary not included in the calculation under clause (xvi) of this Section 3.3(b), up to the amount of Indebtedness of such Qualified Restricted

  
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Subsidiary under this clause (xv)) at any time outstanding, the greater of (x) $25.0 million and (y) an amount equal to 50% of Consolidated EBITDA, calculated on a Pro Forma Basis, for
the most recently ended four full fiscal quarters for which internal financial statements are available immediately preceding the date of any incurrence under this clause (xv); 

(xvi) if the Consolidated Leverage Ratio of ARH and its Restricted Subsidiaries would not be greater than 4.50 to 1.00, (a) the
incurrence of Permitted Refinancing Indebtedness or Replacement Preferred Stock by Qualified Restricted Subsidiaries of ARH incurred to refinance Indebtedness owed, or Disqualified Stock issued, to ARH or any of its Restricted Subsidiaries in
accordance with clause (vi) of this Section 3.3(b), or (b) the sale to any Person that is not the Issuer or any of its Subsidiaries of any Indebtedness owed, or Disqualified Stock issued, by a Qualified Restricted Subsidiary to the
Issuer or a Restricted Subsidiary in accordance with clause (vi) of this Section 3.3(b) (either clause (a) or (b), an “Intercompany Loan Refinancing”), in an aggregate principal amount under this clause (xvi) not to
exceed (net of unrestricted cash and Cash Equivalents held by any Qualified Restricted Subsidiary not included in the calculation under clause (xv) of this Section 3.3(b), up to the amount of Indebtedness of such Qualified Restricted
Subsidiary under this clause (xvi)) at any time outstanding, the greater of (x) $25.0 million and (y) an amount equal to 50% of Consolidated EBITDA of ARH and its Restricted Subsidiaries, calculated on a Pro Forma Basis, for the most
recently ended of four full fiscal quarters for which internal financial statements are available immediately preceding the date of any incurrence under this clause (xvi); 
 (xvii) Indebtedness of the Issuer or a Restricted Subsidiary in respect of netting services, overdraft protection and otherwise in connection with deposit accounts; provided that such Indebtedness
remains outstanding for ten business days or less; 
 (xviii) Purchase Money Indebtedness incurred by the Issuer or any
Restricted Subsidiary, and refinancings thereof, in an aggregate amount not to exceed at any time outstanding $15.0 million; 

(xix) the incurrence or issuance by the Issuer or any of its Restricted Subsidiaries of additional Indebtedness, Disqualified Stock or
preferred stock in an aggregate principal amount (or accreted value or liquidation preference, as applicable) at any time outstanding, including all Permitted Refinancing Indebtedness and all Replacement Preferred Stock incurred to renew, refund,
refinance, replace, defease or discharge any Indebtedness, Disqualified Stock and preferred stock incurred or issued pursuant to this clause (xix), not to exceed $15.0 million; 

(xx) Indebtedness in respect of promissory notes issued to Strategic Investors in connection with repurchases of Equity Interests
permitted by Section 3.4(b)(vii); 
 (xxi) Indebtedness owed by the Issuer or any Restricted Subsidiary to future, current
or former officers, directors, employees or consultants thereof, their respective estates, spouses or former spouses, in each case to finance the purchase or redemption of Equity Interests of the Issuer or any direct or indirect parent company of
the Issuer to the extent described in Section 3.4(b) (viii); 

  
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 (xxii) Indebtedness representing deferred compensation to employees of the Issuer and the
Restricted Subsidiaries incurred in the ordinary course of business; 
 (xxiii) Indebtedness of the Issuer or any Restricted
Subsidiary consisting of (i) the financing of insurance premiums or (ii) take-or-pay obligations contained in supply arrangements, in each case, in the ordinary course of business; 

(xxiv) Indebtedness incurred by the Issuer or any Restricted Subsidiary constituting reimbursement obligations with respect to letters of
credit issued in the ordinary course of business, including letters of credit in respect of workers’ compensation claims, health, disability or other employee benefits, or property, casualty or liability insurance, or other Indebtedness with
respect to reimbursement-type obligations regarding workers’ compensation claims; provided that upon the drawing of such letters of credit or the incurrence of such Indebtedness, such obligations are reimbursed within 45 days following
such drawing or incurrence; 
 (xxv) Indebtedness of the Issuer or any Restricted Subsidiary to the extent the proceeds of such
Indebtedness are substantially concurrent with the incurrence thereof deposited and used to defease the Notes as provided for under Section 8.1; 
 (xxvi) incurrence by the Issuer or any of its Restricted Subsidiaries of Contribution Indebtedness; 
 (xxvii) Indebtedness in respect of bid, performance or surety bonds or obligations of a similar nature issued for the account of the Issuer or any Restricted Subsidiary in the ordinary course of business,
including guarantees or obligations of the Issuer or any Restricted Subsidiary with respect to letters of credit supporting such bid, performance or surety obligations (in each case other than for an obligation for money borrowed); 

(xxviii) Indebtedness in the form of earn-outs, contingent payments, seller notes, indemnification, incentive, non-compete, consulting or
similar arrangements in connection with Permitted Investments or in connection with the acquisition or disposition of any business or assets of the Issuer or any Restricted Subsidiary or Equity Interests of a Restricted Subsidiary, other than
guarantees of Indebtedness incurred by any Person acquiring all or any portion of such business, assets or Equity Interests for the purpose of financing or in contemplation of any such acquisition; provided that (a) any amount of such
obligations included on the face of the balance sheet of the Issuer or any Restricted Subsidiary shall not be permitted under this clause (xxviii) and (b) in the case of a disposition, the maximum aggregate liability in respect of all such
obligations outstanding under this clause (xxviii) shall at no time exceed the gross proceeds actually received by the Issuer and the Restricted Subsidiaries in connection with such disposition; 

(xxix) Standard Securitization Undertakings incurred in a Qualified Receivables Transaction permitted under this Indenture; or

 (xxx) Guarantees by American Renal Holdings Intermediate Company, LLC of Indebtedness of ARH. 

  
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 (c) For purposes of determining compliance with this Section 3.3, in the event that an
item of proposed Indebtedness meets the criteria of more than one of the categories of Permitted Debt described in paragraphs (a) or (b) of this Section 3.3, the Issuer shall be permitted to classify such item of Indebtedness on the
date of its incurrence, or later reclassify all or a portion of such item of Indebtedness, in any manner that complies with this covenant except that Indebtedness under the Credit Agreement outstanding on the Issue Date shall be deemed to have been
incurred in reliance on the exception provided by Section 3.3(b)(i). The accrual of interest, the accretion or amortization of original issue discount, the payment of interest on any Indebtedness in the form of additional Indebtedness with the
same terms, the reclassification of preferred stock as Indebtedness due to a change in accounting principles, and the payment of dividends on Disqualified Stock or preferred stock in the form of additional shares of the same class of Disqualified
Stock or preferred stock shall not be deemed to be an incurrence of Indebtedness or an issuance of Disqualified Stock or preferred stock for purposes of this covenant; provided, in each such case, that the amount thereof is included in Fixed
Charges of the Issuer as accrued (other than the reclassification of preferred stock as Indebtedness due to a change in accounting principles). 
 (d) The amount of any Indebtedness outstanding as of any date shall be: 
 (i) the
accreted value of the Indebtedness, in the case of any Indebtedness issued with original issue discount; and 
 (ii) in respect
of Indebtedness of another Person secured by a Lien on the assets of the specified Person, the lesser of: 
 (1) the Fair
Market Value of such assets at the date of determination; and 
 (2) the amount of the Indebtedness of the other Person.

 (e) For purposes of determining compliance with the covenants described in this Section 3.3, for any periods or dates
that the Issuer does not have historical financial statements available, it shall be entitled to use and rely on the financial statements of its predecessor, successor or consolidated subsidiaries, as the case may be. 

SECTION 3.4. Limitation on Restricted Payments. 

(a) The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, directly or indirectly: 

(i) declare or pay any dividend or make any other payment or distribution on account of the Issuer’s or any of its Restricted
Subsidiaries’ Equity Interests (including, without limitation, any payment in connection with any merger or consolidation involving the Issuer or any of its Restricted Subsidiaries) or to the direct or indirect holders of the Issuer’s or
any of its Restricted Subsidiaries’ Equity Interests in their capacity as such (other than dividends or distributions payable in Equity Interests (other than Disqualified Stock) of the Issuer); 

  
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 (ii) purchase, redeem or otherwise acquire or retire for value (including, without
limitation, in connection with any merger or consolidation involving the Issuer) any Equity Interests of the Issuer or any direct or indirect parent of the Issuer; 
 (iii) make any payment on or with respect to, or purchase, repurchase, redeem, defease or otherwise acquire or retire for value any Indebtedness of the Issuer that is contractually subordinated to the
Notes (excluding any intercompany Indebtedness between or among the Issuer and any of its Restricted Subsidiaries), except (i) a payment of interest or principal at the Stated Maturity thereof or (ii) the purchase, repurchase, redemption,
defeasance or other acquisition or retirement of any such subordinated Indebtedness purchased in anticipation of satisfying a sinking fund obligation, principal installment or payment at final maturity, in each case within one year of the date of
such purchase, repurchase, redemption, defeasance or other acquisition or retirement; or 
 (iv) make any Restricted Investment
(all such payments and other actions set forth in these clauses (i) through (iv) above being collectively referred to as “Restricted Payments”), unless, at the time of and after giving effect to such Restricted Payment:

 (1) no Default or Event of Default has occurred and is continuing or would occur as a consequence of such Restricted
Payment; 
 (2)(i) in the case of any Restricted Payment by the Issuer or any of its Restricted Subsidiaries (other than ARH
and its Subsidiaries), the Issuer would, at the time of such Restricted Payment and after giving pro forma effect thereto as if such Restricted Payment had been made at the beginning of the Measurement Period, have been permitted to incur at least
$1.00 of additional Indebtedness pursuant to the Fixed Charge Coverage Ratio test set forth in Section 3.3(a)(i); and (ii) in the case of any Restricted Payment by ARH or any of its Restricted Subsidiaries, ARH would, at the time of such
Restricted Payment and after giving pro forma effect thereto as if such Restricted Payment had been made at the beginning of the Measurement Period, have been permitted to incur at least $1.00 of additional Indebtedness pursuant to the Fixed Charge
Coverage Ratio test set forth in Section 3.3(a)(ii); and 
 (3) such Restricted Payment, together with the aggregate
amount of all other Restricted Payments made by the Issuer and its Restricted Subsidiaries since May 7, 2010 (including Restricted Payments permitted by clauses (i) and (xiv) of Section 3.4(b), but excluding all other clauses of
Section 3.4(b)), is less than the sum, without duplication, of: 
 (a)(i) in the case of any Restricted Payment by the
Issuer or any of its Restricted Subsidiaries (other than ARH and its Subsidiaries), 50% of the Consolidated Net Income of the Issuer for the period (taken as one accounting period), and (ii) in the case of any Restricted Payment by ARH or any
of its Restricted Subsidiaries, 50% of the Consolidated Net Income of ARH for the period (taken as one accounting period), in each case, from the beginning of the fiscal quarter commencing after May 7, 2010 to the end of the Issuer’s or
ARH’s, as applicable, most recently ended fiscal quarter for which internal financial statements are available at the time of such Restricted Payment (or, if such Consolidated Net Income for such period is a deficit, less 100% of such deficit);
plus 

  
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 (b) 100% of the aggregate Qualified Proceeds received by the Issuer since May 7, 2010
as a contribution to its equity capital (other than Disqualified Stock) or from the issue or sale (other than to a Subsidiary of the Issuer) of Equity Interests of the Issuer (other than Disqualified Stock and Excluded Contributions) or from the
issue or sale (other than to a Subsidiary of the Issuer) of convertible or exchangeable Disqualified Stock or convertible or exchangeable debt securities of the Issuer that have been converted into or exchanged for such Equity Interests of the
Issuer (other than Disqualified Stock); plus 
 (c) an amount equal to the net reduction in Investments by the Issuer and
its Restricted Subsidiaries resulting from (A) the sale or other disposition (other than to the Issuer or a Restricted Subsidiary) of any Restricted Investment that was made after May 7, 2010 and (B) repurchases, redemptions and
repayments of such Restricted Investments and the receipt of any dividends or distributions from such Restricted Investments (other than, in each case, to the extent such Investment was made by the Issuer or any Restricted Subsidiary of the Issuer
pursuant to clause (xv) or (xviii) of Section 3.4(b) and such amounts received have been applied to increase availability under either such clause); plus 
 (d) to the extent that any Unrestricted Subsidiary of the Issuer designated as such after May 7, 2010 is redesignated as a Restricted Subsidiary after May 7, 2010, an amount equal to the lesser
of (A) the Fair Market Value of the Issuer’s interest in such Subsidiary immediately prior to such redesignation and (B) the aggregate amount of the Issuer’s Investments in such Subsidiary that was previously treated as a
Restricted Payment (other than, in each case, to the extent such Investment was made by the Issuer or any Restricted Subsidiary of the Issuer pursuant to clause (xv) or (xviii) of Section 3.4(b) and such amounts received have been
applied to increase availability under either such clause); plus 
 (e) in the event the Issuer and/or any Restricted
Subsidiary of the Issuer makes any Investment in a Person that, as a result of or in connection with such Investment, becomes a Restricted Subsidiary of the Issuer, an amount equal to the existing Investment of the Issuer and/or any of its
Restricted Subsidiaries in such Person that was previously treated as a Restricted Payment (other than to the extent such Investment was made by the Issuer or any Restricted Subsidiary of the Issuer pursuant to clause (xv) or (xviii) of
Section 3.4(b) and such amounts received have been applied to increase availability under either such clause). 
 (b) The
provisions of Section 3.4(a) shall not prohibit: 
 (i) the payment of any dividend or other distribution or the
consummation of any irrevocable redemption within 60 days after the date of declaration of the dividend or giving of the redemption notice, as the case may be, if at the date of declaration or notice, the dividend or redemption payment would have
complied with the provisions of this Indenture; 
 (ii) the making of any Restricted Payment in exchange for, or out of the net
cash proceeds of the substantially concurrent sale (other than to a Subsidiary of the Issuer) of, Equity Interests of the Issuer (other than Disqualified Stock) or from the substantially concurrent contribution of equity capital to the Issuer (other
than Disqualified Stock); provided that the amount of any such net cash proceeds that are utilized for any such Restricted Payment shall be excluded from Section 3.4(a)(3)(b); 

  
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 (iii) the repurchase, redemption, defeasance or other acquisition or retirement for value of
Indebtedness of the Issuer that is contractually subordinated to the Notes with the net cash proceeds from a substantially concurrent incurrence of Permitted Refinancing Indebtedness, or from the substantially concurrent sale (other than to a
Subsidiary of the Issuer) of, Equity Interests of the Issuer (other than Disqualified Stock) or from the substantially concurrent contribution of equity capital to the Issuer (other than Disqualified Stock); provided that the amount of any
such net cash proceeds that are utilized for any such Restricted Payment shall be excluded from Section 3.4(a)(3)(b); 

(iv) the declaration and payment of regularly scheduled or accrued dividends to holders of any class or series of Disqualified Stock of
the Issuer or any Restricted Subsidiary of the Issuer which Disqualified Stock was issued after the Issue Date in accordance with the provisions of Section 3.3; 
 (v) the repurchase, redemption or other acquisition or retirement for value of Disqualified Stock of the Issuer or any Restricted Subsidiary of the Issuer made by exchange for, or out of the proceeds of
the substantially concurrent sale of Replacement Preferred Stock that is permitted to be incurred pursuant to Section 3.3; 

(vi) the payment of any dividend (or any similar distribution) by a Restricted Subsidiary of the Issuer to the holders of its Equity
Interests, including payments to non-Affiliates on a pro rata basis; 
 (vii) the repurchase, redemption or other
acquisition or retirement for value of any Equity Interests of a Qualified Restricted Subsidiary owned by a Strategic Investor if such repurchase, redemption or other acquisition or retirement for value is made for consideration not in excess of the
Fair Market Value of such Equity Interests (a) pursuant to any repurchase obligation to such Strategic Investor or (b) if no Default exists or would result therefrom; 

(viii) the repurchase, redemption or other acquisition or retirement for value of any Equity Interests of the Issuer or any Restricted
Subsidiary of the Issuer held by any current or former officer, director, employee or consultant of the Issuer or any of its Restricted Subsidiaries, and any dividend payment or other distribution by the Issuer or a Restricted Subsidiary to any
direct or indirect parent holding company of the Issuer utilized for the repurchase, redemption or other acquisition or retirement for value of any Equity Interests of such direct or indirect parent holding company held by any current or former
officer, director, employee or consultant of the Issuer or any of its Restricted Subsidiaries or such parent holding company, in each case, pursuant to any equity subscription agreement, stock option agreement, shareholders’ agreement or
similar agreement or benefit plan or other agreement of any kind; provided that the aggregate price paid for all such repurchased, redeemed, acquired or retired Equity Interests may not exceed $5.0 million in any fiscal year (it being
understood, however, that unused amounts permitted to be paid pursuant to this proviso are available to be carried over to subsequent fiscal years but in no event shall the aggregate price paid for all such repurchased, redeemed, acquired or retired
Equity Interests exceed $10.0 million in any year); provided further that such amount in any fiscal year may be further increased by an amount not to exceed: 

  
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 (1) the net cash proceeds from the sale of Equity Interests of the Issuer (other than
Disqualified Stock) and, to the extent contributed to the Issuer as equity capital (other than Disqualified Stock), Equity Interests of any direct or indirect parent company of the Issuer, in each case to members of management, directors or
consultants of the Issuer, any of its Subsidiaries or any direct or indirect parent company of the Issuer that occurs after the Issue Date, to the extent the cash proceeds from the sale of such Equity Interests have not otherwise been applied to the
payment of Restricted Payments by virtue of Section 3.4(a)(3)(b) (and, to the extent utilized pursuant to this clause (viii), such amount shall be excluded from Section 3.4(a)(3)(b)), and excluding Excluded Contributions, plus

 (2) the cash proceeds of key man life insurance policies received by the Issuer and its Restricted Subsidiaries after the
Issue Date, less 
 (3) the amount of any Restricted Payments previously made pursuant to clauses (1) and
(2) of this clause (viii); 
 and provided, further, that cancellation of Indebtedness owing to the Issuer or any Restricted
Subsidiary from members of management of the Issuer, any of the Issuer’s direct or indirect parent companies or any of the Issuer’s Restricted Subsidiaries in connection with a repurchase of Equity Interests of the Issuer or any of its
direct or indirect parent companies shall not be deemed to constitute a Restricted Payment for purposes of this covenant or any other provision of this Indenture; 
 (ix) the repurchase of Equity Interests deemed to occur upon the exercise of options, rights or warrants to the extent such Equity Interests represent a portion of the exercise price of those options,
rights or warrants; 
 (x) the repurchase, redemption, defeasance or other acquisition or retirement for value of Indebtedness
of the Issuer that is contractually subordinated to the Notes with any Excess Proceeds that remain after consummation of an Asset Sale Offer; 
 (xi) after the occurrence of a Change of Control and within 60 days after the completion of the offer to repurchase the Notes pursuant to Section 3.9 (including the purchase of the Notes tendered),
any purchase or redemption of Indebtedness of the Issuer that is contractually subordinated to the Notes required pursuant to the terms thereof as a result of such Change of Control at a purchase or redemption price not to exceed 101% of the
outstanding principal amount thereof, plus any accrued and unpaid interest; 
 (xii) cash payments in lieu of fractional shares
issuable as dividends on preferred stock or upon the conversion of any preferred stock or convertible debt securities of the Issuer or any of its Restricted Subsidiaries; 
 (xiii) Permitted Payments to Parent; 
 (xiv) the payment: 

(1) by the Issuer or any Restricted Subsidiary to any direct or indirect parent of the Issuer, which payment is used by the Person
receiving such payment, following the 

  
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first initial public offering of common Equity Interests by such Person, to pay dividends of up to 6% per annum of the net proceeds received by such Person in such public offering (or any
subsequent public offering of common Equity Interests of such Person) that are contributed to the Issuer as equity capital (other than Disqualified Stock), or 
 (2) by the Issuer, following the first initial public offering of common Equity Interests by the Issuer, to pay dividends of up to 6% per annum of the net proceeds received by or contributed to the
Issuer in such public offering (or any subsequent public offering of common Equity Interests by the Issuer) 
 (excluding, in the case of both
clause (1) and clause (2), public offerings of common Equity Interests registered on Form S-8 and any other public sale to the extent the proceeds thereof are Excluded Contributions); 

(xv) Investments that are made with Excluded Contributions; 
 (xvi)(a) to the extent not previously paid, payment of fees and reimbursement of other expenses to the Permitted Holders in connection with the Merger Transaction as described in the Offering Memorandum
under the caption “Certain Relationships and Related Party Transactions”; and (b) to the extent not previously paid, all payments to be made under the Merger Agreement and all other payments made or to be made in connection with the
Merger Transaction, including payments to stockholders, and holders of options and warrants for common stock, of the merger consideration (or, in the case of options and warrants, the merger consideration less the exercise price thereof), and all
payments made to former stockholders of the Issuer or its Subsidiaries who validly exercised appraisal rights, in connection with the Merger Transaction; 
 (xvii) the payment of a dividend or other distribution to the holders of Equity Interests of the Issuer with (a) the net proceeds of the offering of Notes received on the Issue Date and (b) cash
and cash equivalents held by the Issuer on the Issue Date; 
 (xviii) other Restricted Payments in an aggregate amount taken
together with all other Restricted Payments made pursuant to this clause (xviii) not to exceed the greater of (a) $15.0 million and (b) 3.0% of Total Assets at the time made; and 

(xix) purchases of receivables pursuant to a Receivables Repurchase Obligation and distributions or payments of Receivables Fees and any
other payments, in each case, in connection with a Qualified Receivables Transaction; 
 provided that in the case of clause (iv), (x),
(xi), (xiv) or (xviii) of this Section 3.4(b) no Default shall exist or result therefrom. 
 (c) The amount of
all Restricted Payments (other than cash) shall be the Fair Market Value on the date of the Restricted Payment of the asset(s) or securities proposed to be transferred or issued by the Issuer or such Restricted Subsidiary, as the case may be,
pursuant to the Restricted Payment. The Fair Market Value of any assets or securities that are required to be valued by this covenant shall, if the Fair Market Value thereof exceeds $15.0 million, be determined by the Board of Directors of the
Issuer, whose resolution with respect thereto shall be delivered to the Trustee. 

  
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 (d) For purposes of determining compliance with the provisions set forth in this
Section 3.4, in the event that a Restricted Payment meets the criteria of more than one of the types of Restricted Payments described in Section 3.4(b), the Issuer, in its sole discretion, may order and classify, and from time to time may
reorder and reclassify, such Restricted Payment if it would have been permitted at the time such Restricted Payment was made and at the time of any such reclassification. 
 SECTION 3.5. Limitation on Liens. The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, directly or indirectly, create, incur, assume or otherwise cause or
suffer to exist or become effective any Lien of any kind, on or with respect to any of their property or assets, now owned or hereafter acquired or any interest therein or any income or profits therefrom, other than Permitted Liens unless, in each
case: (i) in the case of Liens securing subordinated Indebtedness, the Notes are secured by a Lien on such property, assets or proceeds that is senior in priority to such Liens or (ii) in all other cases, the Notes are equally and ratably
secured. Any Lien which is granted to secure the Notes under this Section 3.5 shall be automatically released and discharged at the same time as the release of the Liens that gave rise to the obligation to secure the Notes under this
Section 3.5. 
 SECTION 3.6. Limitation on Restrictions on Distributions from Restricted Subsidiaries.

 (a) The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, directly or indirectly, create or
permit to exist or become effective any consensual encumbrance or restriction on the ability of any Restricted Subsidiary to: 

(i) pay dividends or make any other distributions on its Capital Stock to the Issuer or any of its Restricted Subsidiaries, or with
respect to any other interest or participation in, or measured by, its profits, or pay any indebtedness owed to the Issuer or any of its Restricted Subsidiaries; 
 (ii) make loans or advances to the Issuer or any of its Restricted Subsidiaries; or 
 (iii) sell, lease or transfer any of its properties or assets to the Issuer or any of its Restricted Subsidiaries. 
 (b) The restrictions in Section 3.6(a) shall not apply to encumbrances or restrictions existing under or by reason of: 
 (i) agreements governing Existing Indebtedness and the Credit Agreement as in effect on the Issue Date; 
 (ii) this Indenture and the Notes; 

  
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 (iii) applicable law, rule, regulation or order, including any requirement of any
governmental healthcare programs; 
 (iv) any instrument or agreement governing Indebtedness or Capital Stock of a Restricted
Subsidiary acquired by the Issuer or any of its Restricted Subsidiaries as in effect at the time of such acquisition (except to the extent such Indebtedness or Capital Stock was incurred in connection with or in contemplation of such acquisition),
which encumbrance or restriction is not applicable to any Person, or the properties or assets of any Person, other than the Person or any of its Subsidiaries, or the property or assets of the Person or any of its Subsidiaries, so acquired;
provided that, in the case of Indebtedness, such Indebtedness was permitted by the terms of this Indenture to be incurred; 
 (v) customary non-assignment provisions in contracts, leases, subleases, licenses and sublicenses entered into in the ordinary course of business; 

(vi) customary restrictions in leases (including capital leases), security agreements or mortgages or other purchase money obligations
for property acquired in the ordinary course of business that impose restrictions on the property purchased or leased of the nature described in Section 3.6(a)(iii); 
 (vii) any agreement for the sale or other disposition of all or substantially all the Capital Stock or the assets of a Restricted Subsidiary that restricts distributions by that Restricted Subsidiary
pending the sale or other disposition; 
 (viii) any instrument or agreement governing Permitted Refinancing Indebtedness;
provided that the restrictions contained therein are not materially more restrictive (as determined in good faith by the Issuer), taken as a whole, than those contained in the agreements governing the Indebtedness being refinanced;

 (ix) Liens permitted to be incurred pursuant to Section 3.5 that limit the right of the debtor to dispose of the assets
subject to such Liens; 
 (x) restrictions on cash or other deposits or net worth imposed by customers under contracts entered
into in the ordinary course of business; 
 (xi) customary provisions imposed on the transfer of copyrighted or patented
materials; 
 (xii) customary provisions restricting dispositions of real property interests set forth in any reciprocal
easement agreements of the Issuer or any Restricted Subsidiary; 
 (xiii) contracts entered into in the ordinary course of
business, not relating to any Indebtedness, and that do not, individually or in the aggregate, detract from the value of property or assets of the Issuer or any Restricted Subsidiary of the Issuer in any manner material to the Issuer or any
Restricted Subsidiary of the Issuer; 

  
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 (xiv) restrictions on the transfer of property or assets required by any regulatory
authority having jurisdiction over the Issuer or any Restricted Subsidiary of the Issuer or any of their businesses; 
 (xv) any
instrument or agreement governing Indebtedness or preferred stock of any Restricted Subsidiary that is incurred or issued subsequent to the Issue Date and not in violation of Section 3.4; provided that the Issuer’s Board of
Directors determines in good faith that restrictions are (A) no less favorable to the Issuer, taken as a whole, than the provisions contained in the Credit Agreement or in the Senior Secured Indenture, in each case, as in effect on the Issue
Date or (B) not reasonably likely to have a materially adverse effect on the Issuer’s ability to make principal and interest payments on the Notes; 
 (xvi) customary provisions in joint venture and other similar agreements, including agreements related to the ownership and operation of dialysis clinics, relating solely to such joint venture or
facilities or the Persons who own Equity Interests therein; 
 (xvii) any amendments, modifications, restatements, renewals,
increases, supplements, refundings, replacements or refinancings of the Indebtedness, preferred stock, Liens, agreements, contracts, licenses, leases, subleases, instruments or obligations referred to in clauses (i), (ii), (iv) and (xv) of
this Section 3.6(b); provided, however, that such amendments, modifications, restatements, renewals, increases, supplements, refundings, replacements or refinancings are not materially more restrictive, taken as a whole (as
determined by the Issuer in good faith), than those restrictions contained in the Indebtedness, preferred stock, Liens, agreements, contracts, licenses, leases, subleases, instruments or obligations referred to in clauses (i), (ii), (iv) and
(xv) of this Section 3.6(b), as applicable prior to such amendment, modification, restatement, renewal, increase, supplement, refunding, replacement or refinancing; 
 (xviii) customary provisions in connection with a Qualified Receivables Transaction; and 
 (xix) restrictions in Management Agreements that require the payment of management fees to the Issuer or one of its Restricted Subsidiaries prior to payment of dividends or distributions. 

For purposes of determining compliance with this Section 3.6, (i) the priority of any preferred stock in receiving dividends or liquidating
distributions prior to dividends or liquidating distributions being paid on common stock shall not be deemed a restriction on the ability to make distributions on Capital Stock and (ii) the subordination of loans or advances made to the Issuer
or a Restricted Subsidiary of the Issuer to other Indebtedness incurred by the Issuer or any such Restricted Subsidiary shall not be deemed a restriction on the ability to make loans or advances. 

SECTION 3.7. Limitation on Sales of Assets. 

(a) The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, consummate an Asset Sale unless: 

  
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 (i) the Issuer (or the Restricted Subsidiary, as the case may be) receives consideration at
the time of the Asset Sale at least equal to the Fair Market Value of the assets or Equity Interests issued or sold or otherwise disposed of; and 
 (ii) at least 75% of the consideration received in the Asset Sale by the Issuer or such Restricted Subsidiary is in the form of cash. For purposes of this Section 3.7(a)(ii), each of the following
shall be deemed to be cash: 
 (1) Cash Equivalents; 
 (2) any liabilities (as shown on the Issuer’s most recent consolidated balance sheet) of the Issuer or any Restricted Subsidiary (other than contingent liabilities and liabilities that are by their
terms subordinated to the Notes) that are assumed by the transferee of any such assets pursuant to an agreement that releases the Issuer or such Restricted Subsidiary from further liability; 

(3) any securities, notes or other obligations received by the Issuer or any such Restricted Subsidiary from such transferee that are
converted by the Issuer or such Restricted Subsidiary into cash within 180 days of receipt, to the extent of the cash received in that conversion; 
 (4)(i) any Designated Noncash Consideration received by the Issuer or a Restricted Subsidiary; provided, however, that (x) any such Designated Noncash Consideration that is converted
into Cash Equivalents shall be treated as Net Proceeds in the manner set forth below and (y) in the event such Designated Noncash Consideration is an Investment, such Designated Noncash Consideration shall reduce amounts available under clause
(16) of the definition of “Permitted Investments,” as determined by the Issuer, and (ii) any Designated Noncash Consideration the Fair Market Value of which, when taken together with all other Designated Noncash Consideration
received pursuant to this subclause (ii) (and not subsequently converted into Cash Equivalents that are treated as Net Proceeds of an Asset Sale), does not exceed the greater of $15.0 million and 3% of Total Assets at the time of receipt since
the Issue Date, with the Fair Market Value of each item of Designated Noncash Consideration being measured at the time received and without giving effect to subsequent changes in value; and 

(5) any Capital Stock, Investments or assets permitted by clause (ii) or (iv) of Section 3.7(b). 

(b) Within 365 days after the receipt of any Net Proceeds from an Asset Sale the Issuer (or the applicable Restricted Subsidiary, as the
case may be) may apply such Net Proceeds at its option: 
 (i) to repay, prepay or otherwise discharge any (x) Indebtedness
of any Restricted Subsidiary of the Issuer or (y) secured Indebtedness of the Issuer; provided that, in either case, if such Indebtedness is revolving credit Indebtedness, the Issuer shall effect a corresponding reduction of commitment with
respect thereto; provided that, with respect to any Indebtedness of any Restricted Subsidiary that is not prepayable or redeemable at the option of such Restricted Subsidiary at par, if an offer to purchase such Indebtedness of any Restricted

  
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Subsidiaries is made in accordance with the terms of such Indebtedness, the obligation to permanently reduce Indebtedness of a Restricted Subsidiary will be deemed to be satisfied to the extent
of the amount of the offer that is not at such time permitted to be dividended by the Issuer’s Restricted Subsidiaries to the Issuer, whether or not accepted in such offer by the holders of such Indebtedness, and the amount of Net Proceeds from
such Asset Sale will be deemed to be reduced by such amount; 
 (ii) to (x) acquire Capital Stock of a Person primarily
engaged in a Permitted Business, if, after giving effect thereto, such Person is or becomes a Restricted Subsidiary or a Qualified Restricted Subsidiary of the Issuer or (y) make Investments pursuant to clause (16) of the definition of
“Permitted Investments”; 
 (iii) to make capital expenditures; or 

(iv) to acquire assets (other than Indebtedness and Capital Stock) to be used by the Issuer or the applicable Restricted Subsidiary in a
Permitted Business; 
 provided that (a) the requirements of clauses (ii) through (iv) of this Section 3.7(b) shall
be deemed to be satisfied if an agreement (including a lease, whether a capital lease or an operating lease) committing to make the acquisitions or expenditures referred to in any of clauses (ii) through (iv) of this Section 3.7(b) is
entered into by the Issuer or the applicable Restricted Subsidiary within 365 days after the receipt of such Net Proceeds with the good faith expectation that such Net Proceeds shall be applied to satisfy such commitment in accordance with such
agreement within 180 days of such commitment and if such Net Proceeds are not so applied within such 180-day period, then such Net Proceeds shall constitute Excess Proceeds (as defined below), and (b) the requirement of clause (ii)(x) of this
Section 3.7(b) shall be deemed to be satisfied with respect to any Net Proceeds from the sale or issuance of Equity Interests of a Qualified Restricted Subsidiary to the extent an amount equal to such Net Proceeds was used as described in
clause (ii)(x) of this Section 3.7(b) within 365 days prior to the receipt of such Net Proceeds. 
 (c) Pending the final
application of any Net Proceeds, the Issuer may temporarily reduce revolving credit borrowings or otherwise invest the Net Proceeds in any manner that is not prohibited by this Indenture. 

(d) Any Net Proceeds from Asset Sales that are not applied or invested as provided in the third paragraph of this covenant shall
constitute “Excess Proceeds.” When the aggregate amount of Excess Proceeds exceeds $10.0 million (or if less, at the Issuer’s option, provided not less than $5.0 million), within ten business days thereof, the Issuer shall make an
offer (“Asset Sale Offer”) to all holders of Obligations and all holders of other Indebtedness that ranks pari passu in right of payment with the Notes (“Pari Passu Debt”) containing provisions similar to those set forth in this
Indenture with respect to offers to purchase or redeem with the proceeds of sales of assets. 
 (e) The offer price in any Asset
Sale Offer shall be equal to 100% of the principal amount plus accrued and unpaid interest and Additional Interest, if any, to the date of purchase, and shall be payable in cash. If any Excess Proceeds remain after consummation of an Asset Sale

  
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Offer, the Issuer may use those Excess Proceeds for any purpose not otherwise prohibited by this Indenture. If the aggregate principal amount of the Notes and Pari Passu Debt tendered into such
Asset Sale Offer exceeds the amount of Excess Proceeds, the Trustee shall select the Notes, and the representative(s) for the holders of Pari Passu Debt shall select such Pari Passu Debt to be purchased and prepaid, on a pro rata basis;
provided, however, adjustments are made so that no Notes or Pari Passu Debt in an unauthorized denomination is repurchased in part. Upon completion of each Asset Sale Offer, the amount of Excess Proceeds shall be reset at zero. 

(f) The Issuer shall comply with the requirements of Rule 14e-1 under the Exchange Act and any other securities laws and regulations
thereunder to the extent those laws and regulations are applicable in connection with each repurchase of Notes pursuant to an Asset Sale Offer. To the extent that the provisions of any securities laws or regulations conflict with the Asset Sale
provisions of this Indenture, the Issuer shall comply with the applicable securities laws and regulations and shall not be deemed to have breached its obligations under the Asset Sale provisions of this Indenture by virtue of such compliance.

 SECTION 3.8. Limitation on Affiliate Transactions. 

(a) The Issuer shall not, and shall not permit any of its Restricted Subsidiaries to, make any payment to, or sell, lease, transfer or
otherwise dispose of any of its properties or assets to, or purchase any property or assets from, or enter into or make or amend any transaction, contract, agreement, understanding, loan, advance or guarantee with, or for the benefit of, any
Affiliate of the Issuer involving aggregate consideration in excess of $2.5 million (each, an “Affiliate Transaction”), unless: 
 (i) the Affiliate Transaction is on terms that, taken as a whole, are not materially less favorable to the Issuer or the relevant Restricted Subsidiary than those that would have been obtained in a
comparable transaction by the Issuer or such Restricted Subsidiary with an unrelated Person; and 
 (ii) the Issuer delivers to
the Trustee (i) with respect to any Affiliate Transaction or series of related Affiliate Transactions involving aggregate consideration in excess of $15.0 million, an Officers’ Certificate certifying that such Affiliate Transaction
complies with this covenant and that such Affiliate Transaction has been approved by a majority of the members of the Board of Directors of the Issuer, together with a certified copy of the resolutions of the Board of Directors of the Issuer
approving such Affiliate Transaction or Affiliate Transactions; and (ii) with respect to any Affiliate Transaction or series of related Affiliate Transactions involving aggregate consideration in excess of $20.0 million, an opinion as to the
fairness to the Issuer or such Restricted Subsidiary of such Affiliate Transaction from a financial point of view issued by an accounting, appraisal or investment banking firm of national standing. 

(b) The following items shall not be deemed to be Affiliate Transactions and, there- fore, shall not be subject to the provisions of
Section 3.8(a): 

  
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 (i) any employment agreement, employee benefit plan, officer or director indemnification
agreement or any similar arrangement entered into by the Issuer or any of its Restricted Subsidiaries in the ordinary course of business and payments pursuant thereto; 
 (ii) transactions between or among the Issuer and/or its Restricted Subsidiaries; 

(iii) transactions with a Person (other than an Unrestricted Subsidiary of the Issuer) that is an Affiliate of the Issuer solely because
the Issuer owns, directly or through a Restricted Subsidiary, an Equity Interest in, or controls, such Person; 
 (iv) payment
of reasonable directors’ fees; 
 (v) any issuance of Equity Interests (other than Disqualified Stock) of the Issuer to
Affiliates of the Issuer; 
 (vi) Permitted Investments or Restricted Payments that do not violate the provisions of
Section 3.4; 
 (vii) payment of fees and the reimbursement of other expenses to the Permitted Holders in connection with
the Merger Transaction as described in the Offering Memorandum under the caption “Certain Relationships and Related Transactions”; 
 (viii) loans (or cancellation of loans) or advances to employees in the ordinary course of business; 
 (ix) transactions with joint ventures, Unrestricted Subsidiaries, customers, suppliers, contractors, joint venture partners (including, without limitation, physicians) or purchasers or sellers of goods or
services, in each case which are in the ordinary course of business (including, without limitation, pursuant to joint venture agreements) and otherwise in compliance with the terms of this Indenture, and which are fair to the Issuer or its
Restricted Subsidiaries, as applicable, in the reasonable determination of the Board of Directors, chief executive officer or chief financial officer of the Issuer or its Restricted Subsidiaries, as applicable, or are on terms at least as favorable
as might reasonably have been obtained at such time from an unaffiliated party; 
 (x) the existence of, or the performance by
the Issuer or any Restricted Subsidiary of their obligations, if any, or obligations of any direct or indirect parent company of the Issuer under the terms of, any subscription, registration rights or stockholders agreement, partnership agreement or
limited liability company agreement or similar agreement to which any direct or indirect parent company of the Issuer, the Issuer or any Restricted Subsidiary is a party as of the Issue Date and any similar agreements which the Issuer, any
Restricted Subsidiary or any direct or indirect parent company of the Issuer may enter into thereafter; provided, however, that the entering into by the Issuer or any Restricted Subsidiary or the performance by the Issuer or any
Restricted Subsidiary of obligations under any future amendment to any such existing agreement or under any similar agreement entered into after the Issue Date shall only be permitted by this clause to the extent that the terms of any such amendment
or new agreement, taken as a whole, are not materially disadvantageous to the Holders of the Notes, as determined in good faith by the Board of Directors, chief executive officer or chief financial officer of the Issuer; 

  
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 (xi) the Merger Transaction, including all payments made or to be made in connection with
the Merger Transaction as described in the Offering Memorandum; 
 (xii) the entering into of any tax sharing agreement or
arrangement and making any payments thereunder that are Permitted Payments to Parent; 
 (xiii)(i) payments by the Issuer or any
of its Restricted Subsidiaries to the Sponsor and/or any of its Affiliates for any financial advisory, financing, underwriting or placement services or in respect of other investment banking activities, including, without limitation, in connection
with acquisitions or divestitures, which payments are approved by the majority of the disinterested members of the Board of Directors of the Issuer in good faith in an aggregate amount for all such fees for any transaction not to exceed 2.00% of the
aggregate value of such transaction and (ii) fees payable pursuant to the Sponsor Management Agreement as in effect on the Issue Date or as amended in a manner not adverse in any material respect to the holders of Notes; 

(xiv) the issuance of Equity Interests (other than Disqualified Stock) in the Issuer or any Restricted Subsidiary for compensation
purposes in the ordinary course of business; 
 (xv) any lease or sublease entered into between the Issuer or any Restricted
Subsidiary, as lessee, and any Affiliate of the Issuer, as lessor or sublessor, which is approved by a majority of the disinterested members of the Board of Directors of the Issuer in good faith; 

(xvi) intellectual property licenses in the ordinary course of business; 

(xvii) Existing Indebtedness and any other obligations pursuant to an agreement existing on the Issue Date as described in the Offering
Memorandum, including any amendment thereto (so long as such amendment is not adverse to the holders of the Notes in any material respect); 
 (xviii) transactions in which the Issuer or any Restricted Subsidiary delivers to the Trustee a letter from an accounting, appraisal or investment banking firm of national standing stating that such
transaction is fair to the Issuer or such Restricted Subsidiary from a financial point of view and which are approved by a majority of the disinterested members of the Board of Directors of the Issuer in good faith; and 

(xix) customary transactions pursuant to a Qualified Receivables Transactions. 

SECTION 3.9. Change of Control. 
 (a) If a Change of Control occurs, each Holder of Notes shall have the right to require the Issuer to repurchase all or any part (equal to $2,000 or an integral multiple of $1,000 in excess thereof (or if
a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess thereof in respect of PIK Notes)) of that Holder’s Notes pursuant to a Change of Control Offer on the terms set forth in this
Section 3.9. 

  
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 (b) In the Change of Control Offer, the Issuer shall offer a change of control payment (the
“Change of Control Payment”) in cash equal to 101% of the aggregate principal amount of Notes purchased plus accrued and unpaid interest and Additional Interest, if any, on the Notes purchased to the date of purchase, subject to the rights
of Holders of Notes on the relevant Record Date to receive interest due on the relevant Interest Payment Date. 
 (c) Within 30
days following any Change of Control, the Issuer shall mail a notice to each Holder with a copy to the Trustee (the “Change of Control Offer”) stating: 
 (1) that a Change of Control has occurred and that such Holder has the right to require the Issuer to purchase such Holder’s Notes at a purchase price in cash equal to 101% of the principal amount
thereof on the date of purchase, plus accrued and unpaid interest, if any, to the date of purchase (subject to the right of Holders of record on the relevant Record Date to receive interest on the relevant Interest Payment Date); 

(2) the circumstances and relevant facts regarding such Change of Control; 

(3) the purchase date, which date shall be no earlier than 30 days nor later than 60 days from the date such notice is mailed (the
“Change of Control Payment Date”); and 
 (4) the instructions, as determined by the Issuer, consistent with this
Section 3.9, that a Holder must follow in order to have its Notes purchased. 
 (d) On the Change of Control Payment Date,
the Issuer will, to the extent lawful: 
 (1) accept for payment all Notes or portions of Notes properly tendered pursuant to
the Change of Control Offer; 
 (2) deposit with the paying agent an amount equal to the Change of Control Payment in respect
of all Notes or portions of Notes properly tendered; and 
 (3) deliver or cause to be delivered to the Trustee the Notes
properly accepted together with an Officers’ Certificate stating the aggregate principal amount of Notes or portions of Notes being purchased by the Issuer. 
 (e) Holders electing to have a Note purchased shall be required to surrender the Note, with an appropriate form duly completed, to the Issuer at the address specified in the notice at least three Business
Days prior to the purchase date. Holders shall be entitled to withdraw their election if the Trustee or the Issuer receives not later than one Business Day prior to the purchase date, a telegram, telex facsimile transmission or letter setting forth
the name of the Holder, the principal amount at maturity of the Note which was delivered for purchase by the Holder and a statement that such Holder is withdrawing his selection to have such Note purchased. 

  
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 (f) On the Change of Control Payment Date, all Notes purchased by the Issuer under this
Section 3.9 shall be delivered by the Issuer to the Trustee for cancellation, and the Issuer shall pay the purchase price plus accrued and unpaid interest, if any, to the Holders entitled thereto. With respect to any Note purchased in part, the
Issuer will issue a new Note in a principal amount equal at maturity to the unpurchased portion of the original Note in the name of the holder upon cancellation of the original Note. 

(g) The paying agent will promptly mail to each Holder of Notes properly tendered the Change of Control Payment for such Notes, and the
Trustee will, upon its receipt of an Issuer order promptly authenticate and mail (or cause to be transferred by book entry) to each Holder a new Note equal in principal amount to any unpurchased portion of the Notes surrendered, if any. The Issuer
will publicly announce the results of the Change of Control Offer on or as soon as practicable after the Change of Control Payment Date. 
 (h) The Issuer shall not be required to make a Change of Control Offer following a Change of Control if a third party makes the Change of Control Offer in the manner, at the times and otherwise in
compliance with the requirements set forth in this Indenture applicable to a Change of Control Offer made by the Issuer and purchases all Notes validly tendered and not withdrawn under such Change of Control Offer. Additionally, the Issuer shall not
be required to make a Change of Control Offer or purchase the Notes as described under this Section 3.9 to the extent that the Issuer has mailed a notice to exercise its right to redeem all Notes pursuant to Article V at any time prior to the
time by which consummation of a Change of Control Offer is required, unless and until there is a default in payment of the applicable redemption price. Notwithstanding anything to the contrary herein, a Change of Control Offer may be made in advance
of a Change of Control, conditional upon such Change of Control, if a definitive agreement is in place for the Change of Control at the time of making of the Change of Control Offer. 

(i) The Issuer shall comply, to the extent applicable, with the requirements of Section 14(e) of the Exchange Act and any other
securities laws or regulations in connection with the repurchase of Notes as a result of a Change of Control. To the extent that the provisions of any securities laws or regulations conflict with the provisions of this Section 3.9, the Issuer
shall comply with the applicable securities laws and regulations and shall not be deemed to have breached its obligations under this Section 3.9 by virtue of its compliance with such securities laws or regulations. 

SECTION 3.10. [Reserved]. 
 SECTION 3.11. Future Guarantors. After the Issue Date, the Issuer will cause each of its Restricted Subsidiaries that guarantees any Indebtedness of the Issuer to guarantee the Notes in
accordance with Article X. Each future Guarantee by a Guarantor will be limited to an amount not to exceed the maximum amount that can be guaranteed by that Restricted Subsidiary without rendering the Guarantee, as it relates to such Guarantor,
voidable under applicable law relating to fraudulent conveyance or fraudulent transfer or similar laws affecting the rights of creditors generally. 

  
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 SECTION 3.12. Limitation on Line of Business. The Issuer shall not, and shall
not permit any of its Restricted Subsidiaries to, engage in any business other than Permitted Businesses, except to such extent as would not be material to the Issuer and its Restricted Subsidiaries taken as a whole. 

SECTION 3.13. Compliance Certificate. The Issuer shall deliver to the Trustee within 120 days after the end of each fiscal
year of the Issuer (commencing with the fiscal year ending December 31, 2010) an Officers’ Certificate stating whether or not the signers know of any Default or Event of Default that occurred during such period. If they do, the certificate
shall describe the Default or Event of Default, its status and what action the Issuer is taking or proposes to take with respect thereto. 
 SECTION 3.14. Statement by Officers as to Default. The Issuer shall deliver to the Trustee, within 30 days after the knowledge thereof if such event is still continuing, written notice in
the form of an Officers’ Certificate of any Event of Default or any event which, with notice or the lapse of time or both, would constitute an Event of Default under Section 6.1, which shall include their status and what action the Issuer
is taking or proposing to take in respect thereof. 
 SECTION 3.15. [Reserved]. 

SECTION 3.16. No Layering of Debt. The Issuer shall not directly or indirectly, incur any Indebtedness that is or purports
to be by its terms (or by the terms of any agreement governing such Indebtedness) subordinated to any other Indebtedness of the Issuer, unless such Indebtedness is also by its terms (or by the terms of any agreement governing such Indebtedness) made
expressly subordinate to the Notes, to the same extent and in the same manner as such Indebtedness is subordinated to such other Indebtedness of the Issuer. 
 For purposes of the foregoing, no Indebtedness shall be deemed to be subordinated in right of payment to any other Indebtedness of the Issuer solely by virtue of being unsecured or secured by a junior
priority Lien or by virtue of the fact that the holders of such Indebtedness have entered into inter- creditor agreements or other arrangements giving one or more of such holders priority over the other holders in the collateral held by them.

 SECTION 3.17. [Reserved]. 
 SECTION 3.18. Designation of Restricted and Unrestricted Subsidiaries. 
 (a) The Board of Directors of the Issuer may designate any Restricted Subsidiary to be an Unrestricted Subsidiary if that designation would not cause a Default. If a Restricted Subsidiary is designated as
an Unrestricted Subsidiary, the aggregate Fair Market Value of all outstanding Investments owned by the Issuer and its Restricted Subsidiaries in the Subsidiary designated as an Unrestricted Subsidiary shall be deemed to be an Investment made as of
the time of the designation and shall reduce the amount available for Restricted Payments pursuant to Section 3.4 or under one or more clauses of the definition of Permitted Investments, as determined by the Issuer. That designation shall only
be permitted if the Investment would be permitted at that time and if the Restricted Subsidiary otherwise meets the definition of an Unrestricted Subsidiary. 

  
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 (b) Any designation of a Subsidiary of the Issuer as an Unrestricted Subsidiary will be
evidenced to the Trustee by filing with the Trustee a certified copy of a resolution of the Board of Directors of the Issuer giving effect to such designation and an Officers’ Certificate certifying that such designation complied with the
preceding conditions and was permitted pursuant to Section 3.4. If, at any time, any Unrestricted Subsidiary would fail to meet the preceding requirements as an Unrestricted Subsidiary, it will thereafter cease to be an Unrestricted Subsidiary
for purposes of this Indenture and any Indebtedness of such Subsidiary will be deemed to be incurred by a Restricted Subsidiary of the Issuer as of such date and, if such Indebtedness is not permitted to be incurred as of such date under
Section 3.3, the Issuer will be in default of such covenant. The Board of Directors of the Issuer may at any time designate any Unrestricted Subsidiary to be a Restricted Subsidiary of the Issuer; provided that such designation will be
deemed to be an incurrence of Indebtedness and Liens by a Restricted Subsidiary of the Issuer of any outstanding Indebtedness and Liens of such Unrestricted Subsidiary, and such designation will only be permitted if (1) such Indebtedness and
Liens are permitted under Sections 3.3 and 3.5 and (2) such designation would not cause a Default. 
 SECTION 3.19.
Payments for Consent. The Issuer shall not, and shall not permit any of its Subsidiaries to, directly or indirectly, pay or cause to be paid any consideration to or for the benefit of any Holder of Notes for or as an inducement to
any consent, waiver or amendment of any of the terms or provisions of this Indenture, the Notes or the Registration Rights Agreement unless such consideration is offered to be paid and is paid to all Holders of the Notes that consent, waive or agree
to amend in the time frame set forth in the solicitation documents relating to such consent, waiver or agreement. 
 SECTION
3.20. Intercompany Loan Refinancing. 
 (a) Subject to the following proviso, promptly following
receipt of Net Proceeds from any Intercompany Loan Refinancing, the Issuer shall, to the extent thereof: 
 (i) repay, prepay or
otherwise discharge any (x) Indebtedness of any Restricted Subsidiary of the Issuer or (y) secured Indebtedness of the Issuer; provided that, in either case, if such Indebtedness is revolving credit Indebtedness, the Issuer shall
effect a corresponding reduction of commitment with respect thereto; provided that, with respect to any Indebtedness of any Restricted Subsidiary that is not prepayable or redeemable at the option of such Restricted Subsidiary at par, if an
offer to purchase such Indebtedness of any Restricted Subsidiaries is made in accordance with the terms of such Indebtedness, the obligation to permanently reduce Indebtedness of a Restricted Subsidiary shall be deemed to be satisfied to the extent
of the amount of the offer that is not at such time permitted to be dividended by the Issuer’s Restricted Subsidiaries to the Issuer, whether or not accepted in such offer by the holders of such Indebtedness, and the amount of Net Proceeds from
such Intercompany Loan Refinancing shall be deemed to be reduced by such amount; or 
 (ii) make an offer to purchase the Notes
at a price in cash equal to 100% of the principal amount thereof, plus accrued and unpaid interest and Additional Interest, if any, to the date of purchase and if applicable, to make an offer to purchase or prepay to the holders of Pari Passu Debt
that by its terms requires the Issuer to make an offer to purchase or prepay such Pari Passu Debt upon an Intercompany Loan Refinancing (the “Intercompany Loan Refinancing Offer”), and to purchase or prepay such Pari Passu Debt on a pro
rata basis with the Notes; 

  
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 provided that the Issuer is not required to repay, prepay or discharge Indebtedness or make an offer
to purchase Notes pursuant to clauses (i) and/or (ii) of this Section 3.20(a) until the aggregate amount of proceeds received from one or more Intercompany Loan Refinancings (“Proceeds Amount”) exceeds $4.0 million.

 (b) Pending the final application of any such proceeds, the Issuer may temporarily reduce revolving credit borrowings or
otherwise invest such proceeds in any manner that is not prohibited by this Indenture. If any such proceeds remain after consummation of the offer(s), as applicable, referred to above, the Issuer may use those proceeds for any purposes not
prohibited by this Indenture and the Proceeds Amount shall be reset at zero. 
 (c) The Issuer shall comply with the
requirements of Rule 14e-1 under the Exchange Act and any other securities laws and regulations thereunder to the extent such laws or regulations are applicable in connection with the purchase of Notes pursuant to an Intercompany Loan Refinancing
Offer. To the extent that the provisions of any applicable securities laws or regulations conflict with the Intercompany Loan Refinancing Offer provisions of this Indenture, the Issuer shall comply with the applicable securities laws and regulations
and shall not be deemed to have breached its obligations under the Intercompany Loan Refinancing Offer provisions of this Indenture by virtue of such compliance. 
 SECTION 3.21. Stay, Extension and Usury Laws. The Issuer and each of the Guarantors, if any, covenant (to the extent that they may lawfully do so) that they shall not at any time
insist upon, plead, or in any manner whatsoever claim or take the benefit or advantage of, any stay, extension or usury law wherever enacted, now or at any time hereafter in force, that may affect the covenants or the performance of this Indenture;
and the Issuer and each of the Guarantors, if any, (to the extent that they may lawfully do so) hereby expressly waive all benefit or advantage of any such law, and covenant that they shall not, by resort to any such law, hinder, delay or impede the
execution of any power herein granted to the Trustee, but shall suffer and permit the execution of every such power as though no such law has been enacted. 
 ARTICLE IV 
 MERGER; CONSOLIDATION OR SALE OF ASSETS 

SECTION 4.1. When the Issuer May Merge or Otherwise Dispose of Assets. 

(a) The Issuer shall not, directly or indirectly: (1) consolidate or merge with or into another Person (whether or not the Issuer is
the surviving Person); or (2) sell, assign, transfer, convey or otherwise dispose of all or substantially all of the properties or assets of the Issuer and its Restricted Subsidiaries taken as a whole, in one or more related transactions, to
another Person, unless: 
 (i) either: (a) the Issuer is the surviving Person; or (b) the Person formed by or
surviving any such consolidation or merger (if other than the Issuer) or to which such sale, assignment, transfer, conveyance or other disposition has been made (collectively, the “Successor”) is a corporation or a limited liability
company organized or existing under the laws of the United States, any state of the United States or the District of Columbia; 

  
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 (ii) the Successor assumes all the obligations of the Issuer under the Notes, this Indenture
and the Registration Rights Agreement pursuant to a supplemental indenture and other agreements to effectuate such assumption; provided, however, that at all times, a corporation organized and existing under the laws of the United
States of America, any State thereof or the District of Columbia must be a co-issuer or the issuer of the Notes if such surviving Person is not a corporation; 
 (iii) immediately after such transaction, no Default exists; 
 (iv) the Issuer or
the Successor would, on the date of such transaction after giving proforma effect thereto and any related financing transactions as if the same had occurred at the beginning of the applicable four-quarter period: 

(1) be permitted to incur at least $1.00 of additional Indebtedness pursuant to the Fixed Charge Coverage Ratio test set forth in
Section 3.3(a); or 
 (2) have a Fixed Charge Coverage Ratio that is greater than the Fixed Charge Coverage Ratio of the
Issuer immediately prior to such transaction; 
 (v) the Issuer shall have delivered to the Trustee an Officers’
Certificate and Opinion of Counsel (in a customary form including customary qualifications) stating that such consolidation, merger, amalgamation or transfer and such supplemental indenture, if any, comply with this Indenture and that such
supplemental indenture, amendments, supplements or other instruments, if any, comply with this Indenture and to the effect that such amendments, supplements or other instruments are enforceable; 

In addition, the Issuer shall not, directly or indirectly, lease all or substantially all of the properties and assets of it and its
Restricted Subsidiaries taken as a whole, in one or more related transactions, to any other Person. 
 (b) Clauses
(iii) and (iv) of Section 4.1(a) shall not apply to: 
 (i) a merger of the Issuer with an Affiliate for the sole
purpose and effect of reincorporating the Issuer in another jurisdiction; 
 (ii) any consolidation or merger, or any sale,
assignment, transfer, conveyance, lease or other disposition of assets between or among the Issuer and the Restricted Subsidiaries; and 
 (iii) the consolidation or merger, or sale, assignment, transfer, conveyance, lease or other disposition of all or part of its assets, by any Restricted Subsidiary to the Issuer. 

  
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 ARTICLE V 
 REDEMPTION OF NOTES 
 SECTION 5.1. Optional Redemption.

 (a) On or after March 1, 2013, the Issuer may, on one or more occasions, redeem all or any portion of the Notes, at
the redemption prices (expressed as percentages of principal amount) set forth below plus accrued and unpaid interest and Additional Interest, if any, on the Notes to be redeemed, to the applicable redemption date, if redeemed during the
twelve-month period beginning on March 1 of the years indicated below, subject to the rights of Holders of Notes on the relevant Record Date to receive interest on the relevant Interest Payment Date: 

 

					
	Year	  	Percentage	 
	 2013
	  	 	105.000	% 
	 2014
	  	 	102.500	% 
	 2015 and thereafter
	  	 	100.000	% 

 (b) Before March 1, 2013, the Issuer may, on one or more occasions, redeem all or any portion of the
Notes, at a redemption price equal to 100% of the principal amount thereof plus the Applicable Premium as of, and accrued and unpaid interest and Additional Interest, if any, to, the date of redemption (a “Make-Whole Redemption Date”).

 (c) Unless the Issuer defaults in the payment of the redemption price, interest and Additional Interest will cease to accrue
on the Notes or portions thereof called for redemption on the applicable Redemption Date. 
 SECTION 5.2. Mandatory
Redemption Upon Certain Equity Issuances. 
 (a) The Issuer will be required to redeem the maximum principal amount of
Notes that is in minimum denominations of $2,000 and an integral multiple of $1,000 in excess thereof (or if a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess thereof) that may be redeemed
out of any Qualified Equity Issuance Net Proceeds at a price in cash (A) in an amount equal to, prior to March 1, 2013, 105.00% of the principal amount thereof and (B) thereafter, in an amount equal to the redemption price applicable
to such Notes on the date on which notice of such redemption is given as set forth above under Section 5.1(a), in each case, plus accrued and unpaid interest and Additional Interest, if any, to the date fixed for the closing of such redemption,
in accordance with the procedures set forth in this Indenture. Not later than 90 days following the receipt of the Qualified Equity Issuance Net Proceeds from any Qualified Equity Issuance, the Issuer will mail a notice of redemption to each Holder
with a copy to the Trustee (such redemption, a “Qualified Equity Issuance Redemption”) stating: 
 (i) that a
Qualified Equity Issuance has occurred, the amount of Qualified Equity Issuance Net Proceeds received by the Issuer, and that the Issuer will redeem such Holder’s Notes or a portion thereof, as set forth in Section 5.9, at a purchase price
in cash in an amount equal to, as applicable, 105.00% of the principal amount or the redemption price applicable to such Notes on the date on which the notice of such redemption is given as set forth

  
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above under Section 5.1(a), in each case, plus accrued and unpaid interest thereon and Additional Interest thereon, if any, to the date of redemption (subject to the right of Holders of record on
a Record Date to receive interest on the relevant Interest Payment Date); 
 (ii) the circumstances and relevant facts regarding
such Qualified Equity Issuance, and the maximum principal amount of Notes that may be redeemed by the Issuer in the Qualified Equity Issuance Redemption; and 
 (iii) the redemption date (which shall be no earlier than 30 days nor later than 90 days from the date such notice is mailed). 
 (b) Notice of a Qualified Equity Issuance Redemption may be delivered in advance of a Qualified Equity Issuance, conditional upon such Qualified Equity Issuance, if a definitive agreement is in place for
the Qualified Equity Issuance at the time of delivery of the notice of such Qualified Equity Issuance Redemption. 
 (c) Except
as provided above, the Issuer is not required to make mandatory redemption or sinking fund payments with respect to the Notes. 

SECTION 5.3. Election to Redeem; Notice to Trustee of Optional and Mandatory Redemptions. If the Issuer
elects to redeem Notes pursuant to Section 5.1, the Issuer shall furnish to the Trustee, at least five Business Days for Global Notes and 10 calendar days for Definitive Notes before notice of redemption is required to be mailed or caused to be
mailed to Holders pursuant to Section 5.5, an Officers’ Certificate setting forth (a) the paragraph or subparagraph of such Note and/or Section of this Indenture pursuant to which the redemption shall occur, (b) the Redemption
Date, (c) the principal amount of the Notes to be redeemed and (d) the redemption price. The Issuer shall deliver to the Trustee such documentation and records as shall enable the Trustee to select the Notes to be redeemed pursuant to
Section 5.4. 
 SECTION 5.4. Selection by Trustee of Notes to Be Redeemed. If less than all of the
Notes are to be redeemed at any time, the Trustee shall select Notes for redemption on a pro rata basis (subject to DTC procedures) unless otherwise required by law, the Depositary or applicable stock exchange requirements; provided, however, that
no Notes in an unauthorized denomination shall be redeemed in part. No Notes of $2,000 or less can be redeemed in part (of if a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess thereof). If
any Note is to be redeemed in part only, the notice of redemption relating to such Note shall state the portion of the principal amount thereof to be redeemed. A new Note in principal amount equal to the unredeemed portion thereof shall be issued in
the name of the Holder thereof upon cancellation of the original Note in accordance with Section 5.8. 
 The Trustee shall
promptly notify the Issuer in writing of the Notes selected for redemption and, in the case of any Notes selected for partial redemption, the principal amount thereof to be redeemed. 

For all purposes of this Indenture, unless the context otherwise requires, all provisions relating to redemption of Notes shall relate,
in the case of any Note redeemed or to be redeemed only in part, to the portion of the principal amount of such Note which has been or is to be redeemed. 

  
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 SECTION 5.5. Notice of Redemption. The Issuer shall mail or cause to be
mailed by first class mail, a notice of redemption to each Holder whose Notes are to be redeemed at its registered address not less than 30 nor more than 60 days prior to a date fixed for redemption (a “Redemption Date”), to each Holder of
Notes to be redeemed. The Trustee may give notice of redemption in the Issuer’s name and at the Issuer’s expense; provided, however, that redemption notices may be mailed more than 60 days prior to a Redemption Date if the
notice is issued in connection with Article VIII. 
 All notices of redemption shall state: 

(a) the Redemption Date, 
 (b) the redemption price and the amount of accrued interest, if any, to, but excluding, the Redemption Date payable as provided in Section 5.7, if any, 

(c) if less than all outstanding Notes are to be redeemed, the identification of the particular Notes (or portion thereof) to be
redeemed, as well as the aggregate principal amount of Notes to be redeemed and the aggregate principal amount of Notes to be outstanding after such partial redemption, 
 (d) in case any Note is to be redeemed in part only, the notice which relates to such Note shall state that on and after the Redemption Date, upon surrender of such Note, the Holder shall receive, without
charge, a new Note or Notes of authorized denominations for the principal amount thereof remaining unredeemed, 
 (e) that on
the Redemption Date the redemption price (and accrued interest, if any, to, but excluding, the Redemption Date payable as provided in Section 5.7) shall become due and payable upon each such Note, or the portion thereof, to be redeemed, and,
unless the Issuer defaults in making the redemption payment, that interest on Notes called for redemption (or the portion thereof) shall cease to accrue on and after said date, 

(f) the place or places where such Notes are to be surrendered for payment of the redemption price and accrued interest, if any,

 (g) the name and address of the Paying Agent, 
 (h) that Notes called for redemption must be surrendered to the Paying Agent to collect the redemption price, 
 (i) the CUSIP number, and that no representation is made as to the accuracy or correctness of the CUSIP number, if any, listed in such notice or printed on the Notes, and 

(j) the Section of this Indenture pursuant to which the Notes are to be redeemed. 

  
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 At the Issuer’s request, the Trustee will give the notice of redemption in the
Issuer’s name and at its expense; provided, however, that the Issuer shall have delivered to the Trustee, at least 45 days prior to the redemption date, an Officers’ Certificate requesting that the Trustee give such notice
and setting forth the information to be stated in such notice as provided in the preceding paragraph. 
 SECTION 5.6.
Deposit of Redemption Price. Prior to 10:00 a.m. New York City time, on any Redemption Date, the Issuer shall deposit with the Trustee or with a Paying Agent (or, if the Issuer is acting as its own Paying Agent, segregate and hold in
trust as provided in Section 2.4) an amount of money sufficient to pay the redemption price of, and accrued interest on, all the Notes which are to be redeemed on that date. 

SECTION 5.7. Notes Payable on Redemption Date. Notice of redemption having been given as aforesaid, the Notes so to be
redeemed shall, on the Redemption Date, become due and payable at the redemption price therein specified (together with accrued interest, if any, to, but excluding, the Redemption Date), and from and after such date (unless the Issuer shall default
in the payment of the redemption price and accrued interest) such Notes shall cease to bear interest. Upon surrender of any such Note for redemption in accordance with said notice, such Note shall be paid by the Issuer at the redemption price,
together with accrued interest, if any, to, but excluding, the Redemption Date (subject to the rights of Holders of record on the relevant Record Date to receive interest due on the relevant Interest Payment Date). 

If any Note called for redemption shall not be so paid upon surrender thereof for redemption, the principal (and premium, if any) shall,
until paid, bear interest from the Redemption Date at the rate borne by the Notes. 
 If a Redemption Date is on or after a
Record Date and on or before the related Interest Payment Date, the accrued and unpaid interest, if any, shall be paid to the Person in whose name the Note is registered at the close of business on such Record Date, and no additional interest shall
be payable to Holders whose Notes shall be subject to redemption by the Issuer. 
 SECTION 5.8. Notes Redeemed in
Part. Any Note which is to be redeemed only in part (pursuant to the provisions of this Article) shall be surrendered at the office or agency of the Issuer maintained for such purpose pursuant to Section 2.3 (with, if the Issuer so
requires, due endorsement by, or a written instrument of transfer in form satisfactory to the Issuer duly executed by, the Holder thereof or such Holder’s attorney duly authorized in writing), and the Issuer shall execute, and the Trustee shall
authenticate and make available for delivery to the Holder of such Note at the expense of the Issuer, a new Note or Notes, of any authorized denomination as requested by such Holder, in an aggregate principal amount equal to and in exchange for the
unredeemed portion of the principal of the Note so surrendered, provided that each such new Note shall be in a principal amount of $2,000 and integral multiples of $1,000 in excess thereof. 

SECTION 5.9. Offer to Repurchase. In the event that, pursuant to Section 3.7 or 3.20, the Issuer is
required to commence an offer to all Holders to purchase the Notes (an “Offer to Repurchase”), it shall follow the procedures specified below. 

  
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 (a) The Offer to Repurchase shall remain open for a period of at least 20 Business Days
following its commencement and not more than 30 Business Days, except to the extent that a longer period is required by applicable law (the “Offer Period”). No later than five Business Days after the termination of the Offer Period (the
“Purchase Date”), the Issuer shall apply all Excess Proceeds or Proceeds Amount, as applicable (the “Offer Amount”) to the purchase of Notes and other Pari Passu Debt, if any, (in each instance, on a pro rata basis, if
applicable) or, if less than the Offer Amount has been tendered, all Notes and other Indebtedness tendered in response to the Offer to Repurchase. Payment for any Notes so purchased shall be made pursuant to Section 3.1. 

(b) If the Purchase Date is on or after an interest Record Date and on or before the related Interest Payment Date, any accrued and
unpaid interest and Additional Interest, if any, shall be paid to the Person in whose name a Note is registered at the close of business on such Record Date, and no additional interest shall be payable to Holders who tender Notes pursuant to the
Offer to Repurchase. 
 (c) Upon the commencement of an Offer to Repurchase, the Issuer shall send, by first class mail, a
notice to the Trustee and each of the Holders, with a copy to the Trustee. The notice shall contain all instructions and materials necessary to enable such Holders to tender Notes pursuant to the Offer to Repurchase. The notice, which shall govern
the terms of the Offer to Repurchase, shall state: 
 (i) that the Offer to Repurchase is being made pursuant to this
Section 5.9 and Section 3.7 or 3.20, as applicable, and the length of time the Offer to Repurchase shall remain open; 

(ii) the Offer Amount, the purchase price and the Purchase Date; 

(iii) that any Note not tendered or accepted for payment shall continue to accrue in- terest; 

(iv) that, unless the Issuer defaults in making such payment, any Note accepted for payment pursuant to the Offer to Repurchase shall
cease to accrue interest after the Purchase Date; 
 (v) that Holders electing to have a Note purchased pursuant to an Offer to
Repurchase may elect to have Notes purchased in a minimum amount of $2,000 or an integral multiple of $1,000 in excess thereof only (or if a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess
thereof); 
 (vi) that Holders electing to have Notes purchased pursuant to any Offer to Repurchase shall be required to
surrender the Note, with the form entitled “Option of Holder to Elect Purchase” attached to the Notes completed, or transfer by book-entry transfer, to the Issuer, a Depositary, if appointed by the Issuer, or a Paying Agent at the address
specified in the notice at least three days before the Purchase Date; 
 (vii) that Holders shall be entitled to withdraw their
election if the Issuer, the Depositary or the Paying Agent, as the case may be, receives, not later than on the expiration of the Offer Period, a telegram, telex, facsimile transmission or letter setting forth the name of the Holder, the principal
amount of the Note the Holder delivered for purchase and a statement that such Holder is withdrawing his election to have such Note purchased; 

  
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 (viii) that, if the aggregate principal amount of Notes and Pari Passu Debt, if any,
surrendered by Holders thereof exceeds the Offer Amount, the Trustee shall select the Notes, and the representative(s) for the holders of Pari Passu Debt, if any, shall select such other Pari Passu Debt to be purchased or prepaid, on a pro rata
basis based on the principal amount of Notes, other Pari Passu Debt, if any, surrendered (with such adjustments as may be deemed appropriate by the Issuer so that only Notes in denominations of $2,000, or integral multiples of $1,000 in excess
thereof, shall be purchased (or if a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess thereof)); and 
 (ix) that Holders whose Notes were purchased only in part shall be issued new Notes equal in principal amount to the unpurchased portion of the Notes surrendered (or transferred by book-entry transfer).

 (d) On or before the Purchase Date, the Issuer shall, to the extent lawful, accept for payment, on a pro rata basis to the
extent necessary, the Offer Amount of Notes or portions thereof tendered pursuant to the Offer to Repurchase, or if less than the Offer Amount has been tendered, all Notes tendered, and shall deliver or cause to be delivered to the Trustee the Notes
properly accepted together with an Officer’s Certificate stating that such Notes or portions thereof were accepted for payment by the Issuer in accordance with the terms of this Section 5.9. The Issuer, the Depositary or the Paying Agent,
as the case may be, shall promptly (but in any case not later than five days after the Purchase Date) mail or deliver to each tendering Holder an amount equal to the purchase price of the Notes tendered by such Holder and accepted by the Issuer for
purchase, and the Issuer shall promptly issue a new Note, and the Trustee, upon written request from the Issuer, shall authenticate and mail or deliver (or cause to be transferred by book entry) such new Note to such Holder, in a principal amount
equal to any unpurchased portion of the Note surrendered. Any Note not so accepted shall be promptly mailed or delivered by the Issuer to the Holder thereof. The Issuer shall publicly announce the results of the Offer to Repurchase on the Purchase
Date. 
 ARTICLE VI 
 DEFAULTS AND REMEDIES 
 SECTION 6.1. Events of Default.

 (a) Each of the following is an Event of Default: 

(i) default for 30 days in the payment when due of interest on, or Additional Interest, if any, with respect to, the Notes; 

(ii) default in the payment when due (at maturity, upon redemption or otherwise) of the principal of, or premium, if any, on, the Notes;

  
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 (iii) failure by the Issuer or any of its Restricted Subsidiaries to comply with the
provisions of Section 4.1 or failure by the Issuer to comply with the provisions pursuant to Section 5.2; 
 (iv) failure
by the Issuer or any of its Restricted Subsidiaries for 60 days after notice to the Issuer by the Trustee or the holders of at least 25% in aggregate principal amount of the Notes then outstanding to comply with any of the other agreements or
covenants in this Indenture; 
 (v) default under any mortgage, indenture or instrument under which there may be issued or by
which there may be secured or evidenced any Indebtedness for money borrowed by the Issuer or any of its Significant Subsidiaries (or the payment of which is guaranteed by the Issuer or any of its Significant Subsidiaries), whether such Indebtedness
or guarantee now exists, or is created after the Issue Date, if that default: 
 (1) is caused by a failure to pay principal at
the final Stated Maturity of such Indebtedness (a “Payment Default”); or 
 (2) results in the acceleration of such
Indebtedness prior to its express maturity; 
 and, in each case, the principal amount of such Indebtedness, together with the principal amount
of any other such Indebtedness under which there has been a Payment Default or the maturity of which has been so accelerated, aggregates $10.0 million or more; 
 (vi) with respect to any judgment or decree for the payment of money (net of any amount covered by insurance issued by a reputable and creditworthy insurer that has not contested coverage or reserved
rights with respect to an underlying claim) in excess of $10.0 million or its foreign currency equivalent against the Issuer or any Significant Subsidiary, the failure by the Issuer or such Significant Subsidiary, as applicable, to pay such judgment
or decree, which judgment or decree has remained outstanding for a period of 60 days after such judgment or decree became final and nonappealable without being paid, discharged, waived or stayed; 

(vii) the Issuer, ARH or any Significant Subsidiary pursuant to or within the meaning of any Bankruptcy Law: 

(1) commences a voluntary case; 
 (2) consents to the entry of an order for relief against it in any voluntary case; 
 (3) consents to the appointment of a Custodian of it or for any substantial part of its property; or 
 (4) makes a general assignment for the benefit of its creditors; or takes any comparable action under any foreign laws relating to insolvency; 

  
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 (viii) a court of competent jurisdiction enters an order or decree under any Bankruptcy Law
that: 
 (1) is for relief against the Issuer, ARH or any Significant Subsidiary in an involuntary case; 

(2) appoints a Custodian of the Issuer, ARH or any Significant Subsidiary or for any substantial part of its property; or 

(3) orders the winding up or liquidation of the Issuer or any Significant Subsidiary; 

or any similar relief is granted under any foreign laws and the order or decree remains unstayed and in effect for 60 days; 

The foregoing shall constitute Event of Default whatever the reason for any such Event of Default and whether it is voluntary or involuntary or is
effected by operation of law or pursuant to any judgment, decree or order of any court or any order, rule or regulation of any administrative or governmental body. 
 The term “Bankruptcy Law” means Title 11, United States Code, or any similar Federal or state law for the relief of debtors. The term “Custodian” means any receiver, trustee, assignee,
liquidator, custodian or similar official under any Bankruptcy Law. 
 SECTION 6.2. Acceleration. If an Event of
Default (other than an Event of Default specified in Sections 6. 1(a)(vii) or (viii) above with respect to the Issuer) occurs and is continuing, the Trustee or the Holders of at least 25% in aggregate principal amount of the outstanding Notes
may direct the Trustee to declare the principal of, premium and accrued but unpaid interest on all the Notes to be due and payable. Upon such a declaration, such principal, premium, if any, and interest shall be due and payable immediately. In the
case of an Event of Default arising from Section 6. 1(a)(vii) or (viii) above with respect to the Issuer or any Guarantor that is a Significant Subsidiary, all outstanding Notes shall become due and payable immediately without further
action or notice on the part of the Trustee or the Holders. 
 SECTION 6.3. Other Remedies. If an Event of
Default occurs and is continuing, the Trustee may pursue any available remedy to collect the payment of principal of or interest on the Notes or to enforce the performance of any provision of the Notes, this Indenture (including sums owed to the
Trustee and its agents and counsel). 
 The Trustee may maintain a proceeding even if it does not possess any of the Notes or
does not produce any of them in the proceeding. A delay or omission by the Trustee or any Holder in exercising any right or remedy accruing upon an Event of Default shall not impair the right or remedy or constitute a waiver of or acquiescence in
the Event of Default. No remedy is exclusive of any other remedy. All available remedies are cumulative. 
 SECTION 6.4.
Waiver of Past Defaults. The Holders of a majority in principal amount of outstanding Notes (including without limitation, consents obtained in connection with a purchase of, or tender offer or exchange offer for, Notes) by written notice
to the Trustee may 

  
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waive an existing Default or Event of Default and its consequences (except a Default or Event of Default in the payment of the principal of, premium or Additional Interest, if any, or interest on
a Note) and rescind any acceleration with respect to the Notes and its consequences if (1) rescission would not conflict with any judgment or decree of a court of competent jurisdiction and (2) all existing Events of Default, other than
the nonpayment of the principal of, premium or interest on the Notes that have become due solely by such declaration of acceleration, have been cured or waived. 
 SECTION 6.5. Control by Majority. The Holders of a majority in principal amount of the then outstanding Notes may direct the time, method and place of conducting any proceeding for any
remedy available to the Trustee or of exercising any trust or power conferred on the Trustee. The Trustee, however, may refuse to follow any direction that conflicts with law or this Indenture or that the Trustee determines is unduly prejudicial to
the rights of any other Noteholders or that would involve the Trustee in personal liability unless such Holders have offered to the Trustee security and indemnity satisfactory to it against any loss, liability or expense. 

SECTION 6.6. Limitation on Suits. Subject to the provisions of this Indenture relating to the duties of the Trustee, in
case an Event of Default occurs and is continuing, the Trustee will be under no obligation to exercise any of the rights or powers under this Indenture at the request or direction of any Holders of Notes unless such Holders have offered to the
Trustee indemnity or security satisfactory to it against any loss, liability or expense. Except to enforce the right to receive payment of principal, premium, if any, or interest or Additional Interest, if any, when due, no Holder of a note may
pursue any remedy with respect to this Indenture or the Notes unless: 
 (i) such Holder has previously given the Trustee notice
that an Event of Default is continuing; 
 (ii) Holders of at least 25% in aggregate principal amount of the then outstanding
Notes have requested the Trustee to pursue the remedy; 
 (iii) such Holders have offered the Trustee security or indemnity
satisfactory to it against any loss, liability or expense; 
 (iv) the Trustee has not complied with such request within 60 days
after the receipt of the request and the offer of security or indemnity; and 
 (v) Holders of a majority in aggregate principal
amount of the then outstanding Notes have not given the Trustee a written direction inconsistent with such request within such 60-day period. 
 SECTION 6.7. Rights of Holders to Receive Payment. Notwithstanding any other provision of this Indenture, the right of any Holder to receive payment of principal of, premium (if any) or
interest on the Notes held by such Holder, on or after the respective due dates expressed in the Notes, or to bring suit for the enforcement of any such payment on or after such respective dates, shall not be impaired or affected without the consent
of such Holder. 

  
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 SECTION 6.8. Collection Suit by Trustee. If an Event of Default specified in
Section 6.1 (a)(i) or (ii) occurs and is continuing, the Trustee may recover judgment in its own name and as trustee of an express trust against the Issuer for the whole amount then due and owing (together with interest on any unpaid
interest to the extent lawful) and the amounts provided for in Section 7.6. 
 SECTION 6.9. Trustee May File Proofs
of Claim. The Trustee may file such proofs of claim and other papers or documents as may be necessary or advisable in order to have the claims of the Trustee (including any claim for the reasonable compensation, expenses, disbursements and
advances of the Trustee, its agents and counsel) and the Holders allowed in any judicial proceedings relative to the Issuer, its Subsidiaries or their respective creditors or properties and, unless prohibited by law or applicable regulations, may
vote on behalf of the Holders (pursuant to the written direction of holders of a majority in principal amount of the then outstanding Notes) in any election of a trustee in bankruptcy or other Person performing similar functions, and any Custodian
in any such judicial proceeding is hereby authorized by each Holder to make payments to the Trustee and, in the event that the Trustee shall consent to the making of such payments directly to the Holders, to pay to the Trustee any amount due it for
the reasonable compensation, expenses, disbursements and advances of the Trustee, its agents and its counsel, and any other amounts due the Trustee under Section 7.6. Nothing herein contained shall be deemed to authorize the Trustee to
authorize or consent to or accept or adopt on behalf of any Holder any plan or reorganization, arrangement, adjustment or composition affecting the Notes or the rights of any Holder thereof, or to authorize the Trustee to vote in respect of the
claim of any Holder in such proceeding. 
 SECTION 6.10. Priorities. The Trustee shall pay out any money or
property received by it, whether pursuant to the foreclosure or other remedial provisions or otherwise, in the following order: 

First: to the Trustee for amounts due to it under Section 7.6; 

Second: to Holders for amounts due and unpaid on the Notes for principal, premium, if any, and interest, ratably, without preference or
priority of any kind, according to the amounts due and payable on the Notes for principal, premium, if any, and interest, respectively; and 
 Third: to the Issuer or, to the extent the Trustee receives any amount for any Guarantor, to such Guarantor. 
 The Trustee may fix a record date and payment date for any payment to Holders pursuant to this Section. At least 15 days before such record date, the Issuer shall mail to each Holder and the Trustee a
notice that states the record date, the payment date and amount to be paid. 
 SECTION 6.11. Undertaking for
Costs. In any suit for the enforcement of any right or remedy under this Indenture or in any suit against the Trustee for any action taken or omitted by it as Trustee, a court in its discretion may require the filing by any party litigant in
the suit of an undertaking to pay the costs of the suit, and the court in its discretion may assess reasonable costs, including reasonable attorneys’ fees and expenses, against any party litigant in the suit, having due regard to the merits and
good faith of the claims or defenses made by the party litigant. This Section does not apply to a suit by the Trustee, a suit by a Holder pursuant to Section 6.7 or a suit by Holders of more than 10% in outstanding principal amount of the
Notes. 

  
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 ARTICLE VII 
 TRUSTEE 
 SECTION 7.1. Duties of Trustee. 

(a) If an Event of Default has occurred and is continuing, the Trustee shall exercise the rights and powers vested in it by this
Indenture and use the same degree of care and skill in its exercise as a prudent Person would exercise or use under the circumstances in the conduct of such Person’s own affairs; provided that if an Event of Default occurs and is
continuing, the Trustee shall not be under any obligation to exercise any of the rights or powers under this Indenture and the Notes at the request or direction of any of the Holders unless such Holders have offered the Trustee indemnity, security
or pre- funding satisfactory to the Trustee in its sole discretion, as applicable, against any loss, liability or expense it may incur. 
 (b) Except during the continuance of an Event of Default of which a responsible officer of the Trustee has actual knowledge, the Trustee: 

(i) undertakes to perform such duties and only such duties as are specifically set forth in this Indenture and no implied covenants or
obligations shall be read into this Indenture against the Trustee; and 
 (ii) in the absence of gross negligence or bad faith
on its part, each may conclusively rely, as to the truth of the statements and the correctness of the opinions expressed therein, upon certificates or opinions furnished to the Trustee under this Indenture and the Notes. However, in the case of any
such certificates or opinions which by any provisions hereof are specifically required to be furnished to the Trustee, the Trustee shall examine such certificates and opinions to determine whether or not they conform to the requirements of this
Indenture and the Notes (but need not confirm or investigate the accuracy of mathematical calculations or other facts stated therein). 
 (c) The Trustee shall not be relieved from liability for its own negligent action, its own negligent failure to act or its own willful misconduct, except that: 

(i) this Section 7.1(c) does not limit the effect of Section 7.1(b); 

(ii) the Trustee shall not be liable for any error of judgment made in good faith by a Trust Officer or Trust Officers unless it is
proved that the Trustee was negligent in ascertaining the pertinent facts; and 
 (iii) the Trustee shall not be liable with
respect to any action it takes or omits to take in good faith in accordance with a direction received by it pursuant to Section 6.5. 
 (d) The Trustee shall not be liable for interest on any money received by it except as the Trustee may agree in writing with the Issuer. 

  
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 (e) Money held in trust by the Trustee need not be segregated from other funds except to the
extent required by law. 
 (f) No provision of this Indenture, the Notes or the Guarantees, if any, shall require the Trustee to
expend or risk its own funds or otherwise incur any financial liability in the performance of any of its duties hereunder or thereunder or in the exercise of any of its rights or powers, if it shall have reasonable grounds to believe that repayment
of such funds or indemnity satisfactory to it against such risk or liability is not reasonably assured to it. 
 (g) Every
provision of this Indenture relating to the conduct or affecting the liability of or affording protection to the Trustee shall be subject to the provisions of this Section. 
 (h) The Trustee shall be under no obligation to exercise any of the rights or powers vested in it by this Indenture at the request or direction of any of the Holders unless such Holders shall have offered
to the Trustee security, prefunding or indemnity reasonably satisfactory to it against the costs, expenses (including reasonable attorneys’ fees and expenses) and liabilities that might be incurred by it in compliance with such request or
direction. 
 SECTION 7.2. Rights of Trustee. 

(a) The Trustee may conclusively rely and shall be protected in acting upon any resolution, certificate, statement, instrument, opinion,
notice, request, direction, consent, order, bond or any other paper or document believed by it to be genuine and to have been signed or presented by the proper Person or Persons. The Trustee need not investigate any fact or matter stated in the
document. 
 (b) Before the Trustee acts or refrains from acting, it may require an Officers’ Certificate or an Opinion of
Counsel. The Trustee shall not be liable for any action it takes or omits to take in good faith in reliance on an Officers’ Certificate or Opinion of Counsel. 
 (c) The Trustee may act through its attorneys, custodians, nominees and agents and shall not be responsible for the misconduct or negligence of or for the supervision of any agent, custodians, nominees or
attorney appointed with due care. 
 (d) The Trustee shall not be liable for any action it takes or omits to take in good faith
(in the case of the Trustee) which it believes to be authorized or within its rights or powers; provided, however, that the Trustee’s conduct does not constitute willful misconduct or negligence. 

(e) The Trustee may consult with counsel of its selection, and the advice or opinion of counsel with respect to legal matters relating to
this Indenture, the Notes and the Guarantees, if any, shall be full and complete authorization and protection from liability in respect to any action taken, omitted or suffered by it hereunder or under the Notes and the Guarantees, if any, in good
faith and in accordance with the advice or opinion of such counsel. 
 (f) The Trustee shall not be bound to make any
investigation into any statement, warranty or representation, or the facts or matters stated in any resolution, certificate, statement, instrument, opinion, notice, request, direction, consent, order, bond or other paper or document

  
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made or in connection with this Indenture; moreover, the Trustee shall not be bound to make any investigation into (i) the performance or observance of any of the covenants, agreements or
other terms or conditions set forth herein, (ii) the occurrence of any default, or the validity, enforceability, effectiveness or genuineness of this Indenture or any other agreement, instrument or document and (iii) the facts or matters
stated in any resolution, certificate, statement, instrument, opinion, report, notice, request, direction, consent, order, bond, debenture, note other evidence of indebtedness or other paper or document, but the Trustee, in its discretion, may make
such further inquiry or investigation into such facts or matters as it may see fit, and, if the Trustee shall determine to make such further inquiry or investigation, it shall be entitled to examine the books, records and premises of the Issuer,
personally or by agent or attorney and shall incur no liability or additional liability of any kind by reason of such inquiry or investigation. 
 (g) The Trustee shall not be deemed to have knowledge of any Default or Event of Default except any Default or Event of Default of which a Trust Officer shall have (x) received written notification
at the Corporate Trust Office of the Trustee and such notice references the Notes and this Indenture or (y) obtained “actual knowledge.” “Actual knowledge” shall mean the actual fact or statement of knowing by a Trust
Officer without independent investigation with respect thereto. 
 (h) In no event shall the Trustee be responsible or liable
for special, indirect, or consequential loss or damage of any kind whatsoever (including, but not limited to, loss of profit) irrespective of whether the Trustee has been advised of the likelihood of such loss or damage and regardless of the form of
action. 
 (i) The rights, privileges, protections, immunities and benefits given to the Trustee, including, without limitation,
its right to be indemnified, are extended to, and shall be enforceable by, the Trustee in each of its capacities hereunder and each agent, custodian and other Person employed to act hereunder. 

(j) The Trustee may request that the Issuer deliver a certificate setting forth the names of individuals and/or titles of officers
authorized at such time to take specified actions pursuant to this Indenture. 
 (k) The Trustee shall not have any duty to see
to any recording, filing, or depositing of this Indenture or any agreement referred to herein. 
 (l) The right of the Trustee
to perform any discretionary act enumerated in this Indenture shall not be construed as a duty. 
 (m) Each Holder, by its
acceptance of a Note hereunder, represents to the Trustee that it has, independently and without reliance upon the Trustee or any other Person, and based on such documents and information as it has deemed appropriate, made its own appraisal of and
investigation into the business, operations, property, financial and other condition and creditworthiness of the Issuer or any of its Subsidiaries. Each Holder also represents that each will, independently and without reliance upon the Trustee or
any other Person, and based on such documents and information as it shall deem appropriate at the time, continue to make its own 

  
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credit analysis, appraisals and decisions in taking or not taking action under this Indenture, and to make such investigation as it deems necessary to inform itself as to the business,
operations, property, financial and other condition and creditworthiness of the Issuer. Except for notices, reports and other documents expressly required to be furnished to the Holders by the Trustee hereunder, the Trustee shall not have any duty
or responsibility to provide any Holder with any credit or other information concerning the business, operations, property, financial and other condition or creditworthiness of the Issuer and any of its Subsidiaries which may come into the
possession of the Trustee or any of their officers, directors, employees, agents or attorneys-in-fact. 
 SECTION 7.3.
Individual Rights of Trustee. Subject to the TIA the Trustee in its individual or any other capacity may become the owner or pledgee of Notes and may otherwise deal with the Issuer, the Restricted Subsidiaries or their Affiliates with the
same rights it would have if it were not Trustee, respectively. Any Paying Agent, Registrar, co-registrar or co-paying agent may do the same with like rights. However, the Trustee must comply with Section 7.9. In addition, the Trustee shall be
permitted to engage in transactions with the Issuer; provided, however, that if the Trustee acquires any conflicting interest the Trustee must (i) eliminate such conflict within 90 days of acquiring such conflicting interest,
(ii) apply to the SEC for permission to continue acting as Trustee or (iii) resign. 
 SECTION 7.4.
Disclaimer. The Trustee shall not be responsible for and makes no representation as to the validity or adequacy of this Indenture, the Notes or the Guarantees, if any, it shall not be accountable for the Issuer’s use of the Notes or
the proceeds from the Notes, and it shall not be responsible for any statement of the Issuer in this Indenture or in any document issued in connection with the sale of the Notes or in the Notes other than the Trustee’s certificate of
authentication or for the use or application of any funds received by any Paying Agent other than the Trustee. 
 SECTION
7.5. Notice of Defaults. If a Default occurs and is continuing of which a Trust Officer shall have received written notification at the Corporate Trust Office of the Trustee or obtained actual knowledge of, the Trustee shall mail to each
Holder notice of the Default within 90 days after the Trustee obtains such notice or actual knowledge. Except in the case of a Default in payment of principal of, premium, if any, or interest on any Note, the Trustee may withhold the notice if and
so long as a committee of Trust Officers of the Trustee in good faith determines that withholding the notice is in the interests of Holders. 
 SECTION 7.6. Compensation and Indemnity. The Issuer shall pay to the Trustee from time to time such compensation for their services as the parties shall agree in writing from time to time.
The Trustee’s compensation shall not be limited by any law on compensation of a trustee of an express trust. The Issuer shall reimburse the Trustee upon request for all reasonable out-of-pocket expenses incurred or made by it, including, but
not limited to, costs of collection, costs of preparing and reviewing reports, certificates and other documents, costs of preparation and mailing of notices to Holders and reasonable costs of counsel, in addition to the compensation for its
services. Such expenses shall include the reasonable compensation and expenses, disbursements and advances of the Trustee’s agents, counsel, accountants and experts. The Issuer shall indemnify the Trustee or any predecessor Trustee in each of
its capacities hereunder (including Paying Agent, and Registrar), and each of their officers, directors, 

  
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employees, counsel and agents, against any and all loss, liability or expense (including, but not limited to, reasonable attorneys’ fees and expenses) incurred by it in connection with the
administration of this trust and the performance of their duties hereunder and under the Notes and the Guarantees, if any, including the costs and expenses of enforcing this Indenture (including this Section 7.6), the Notes and the Guarantees,
if any, and of defending itself against any claims (whether asserted by any Holder, the Issuer or otherwise). The Trustee shall notify the Issuer promptly of any claim for which it may seek indemnity. Failure by the Trustee to so notify the Issuer
shall not relieve the Issuer of its obligations hereunder. The Issuer shall defend the claim and the Trustee may have separate counsel and the Issuer shall pay the reasonable fees and expenses of such counsel. The Issuer need not reimburse any
expense or indemnify against any loss, liability or expense incurred by the Trustee as a result of its own willful misconduct, negligence or bad faith. 
 To secure the Issuer’s payment obligations in this Section, the Trustee shall have a lien prior to the Notes on all money or property held or collected by the Trustee other than money or property
held in trust to pay principal of and interest on particular Notes. The right of the Trustee to receive payment of any amounts due under this Section 7.6 shall not be subordinate to any other liability or indebtedness of the Issuer. 

The Issuer’s payment obligations pursuant to this Section and any lien arising hereunder shall survive the discharge of this
Indenture and the resignation or removal of the Trustee. When the Trustee incurs expenses after the occurrence of a Default specified in Section 6. 1(a)(vii) or (viii) with respect to the Issuer, the expenses are intended to constitute
expenses of administration under any Bankruptcy Law. 
 SECTION 7.7. Replacement of Trustee. The Trustee may
resign at any time by so notifying the Issuer. The Holders of a majority in principal amount of the Notes may remove the Trustee by so notifying the Issuer and the Trustee in writing and may appoint a successor Trustee. The Issuer shall remove the
Trustee if: 
 (i) the Trustee fails to comply with Section 7.9; 

(ii) the Trustee is adjudged bankrupt or insolvent; 
 (iii) a receiver or other public officer takes charge of the Trustee or its property; or 
 (iv) the Trustee otherwise becomes incapable of acting. 
 If the Trustee resigns
or is removed by the Issuer or by the Holders of a majority in principal amount of the Notes and such Holders do not reasonably promptly appoint a successor Trustee, or if a vacancy exists in the office of Trustee for any reason (the Trustee in such
event being referred to herein as the retiring Trustee), the Issuer shall promptly appoint a successor Trustee, as applicable. 

A successor Trustee shall deliver a written acceptance of its appointment to the retiring Trustee and to the Issuer. Thereupon the
resignation or removal of the retiring Trustee shall become effective, and the successor Trustee shall have all the rights, powers and duties of the 

  
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Trustee under this Indenture. The successor Trustee shall mail a notice of its succession to Holders. The retiring Trustee shall promptly transfer all property held by it as Trustee to the
successor Trustee, subject to the lien provided for in Section 7.6. All costs reasonably incurred in connection with any resignation or removal hereunder shall be borne by the Issuer. 

If a successor Trustee does not take office within 60 days after the retiring Trustee resigns or is removed, the retiring Trustee or the
Holders of at least 10% in principal amount of the Notes may petition, at the Issuer’s expense, any court of competent jurisdiction for the appointment of a successor Trustee. 

If the Trustee fails to comply with Section 7.9, unless the Trustee’s duty to resign is stayed, any Holder may petition any
court of competent jurisdiction for the removal of the Trustee and the appointment of a successor Trustee. 
 Notwithstanding
the replacement of the Trustee pursuant to this Section 7.7, the Issuer’s obligations under Section 7.6 shall continue for the benefit of the retiring Trustee. 
 SECTION 7.8. Successor Trustee by Merger. If the Trustee consolidates with, merges or converts into, or transfers all or substantially all its corporate trust business or assets to, another
corporation or banking association, the resulting, surviving or transferee corporation without any further act shall be the successor Trustee. 
 In case at the time such successor or successors by merger, conversion or consolidation to the Trustee shall succeed to the trusts created by this Indenture, any of the Notes shall have been authenticated
but not delivered, any such successor to the Trustee may adopt the certificate of authentication of any predecessor trustee, and deliver such Notes so authenticated; and in case at that time any of the Notes shall not have been authenticated, any
successor to the Trustee may authenticate such Notes either in the name of any predecessor hereunder or in the name of the successor to the Trustee; and in all such cases such certificates shall have the full force which it is anywhere in the Notes
or in this Indenture provided that the certificate of the Trustee shall have. 
 SECTION 7.9. Eligibility;
Disqualification. The Trustee shall have a combined capital and surplus of at least $50 million as set forth in its most recent filed annual report of condition. 
 This Indenture shall always have a Trustee who satisfies the requirements of TIA § 310(a)(1), (2) and (5). The Trustee is subject to TIA § 3 10(b). 

SECTION 7.10. Limitation on Duty of Trustee. The Trustee shall not have any duty to ascertain or inquire as to the
performance or observance of any of the terms of this Indenture, the Notes and any Guarantees by the Issuer, the Restricted Subsidiaries or any other Person. 
 SECTION 7.11. Preferential Collection of Claims Against the Issuer. The Trustee is subject to TIA § 311(a), excluding any creditor relationship listed in TIA § 311(b). A Trustee
who has resigned or been removed shall be subject to TIA § 311(a) to the extent indicated therein. 

  
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 SECTION 7.12. Reports by Trustee to Holders of the Notes. Within 60 days after
each March 1, beginning with March 1, 2012, the Trustee shall mail to the Holders of the Notes a brief report dated as of such reporting date that complies with TIA § 313(a) (but if no event described in TIA § 313(a) has occurred
within the twelve months preceding the reporting date, no report need be transmitted). The Trustee also shall comply with TIA § 313(b). The Trustee shall also transmit by mail all reports as required by TIA § 3 13(c). 

A copy of each report at the time of its mailing to the Holders of Notes shall be mailed to the Issuer and filed with the SEC and each
stock exchange on which any Notes are listed. The Issuer shall promptly notify the Trustee in writing when any Notes are listed on any stock exchange and of any delisting thereof. 

ARTICLE VIII 
 DISCHARGE OF INDENTURE; DEFEASANCE 
 SECTION 8.1. Discharge of
Liability on Notes; Defeasance. 
 (a) Satisfaction and Discharge. This Indenture will be discharged and will cease to
be of further effect as to all Notes issued thereunder, when: 
 (i) either: 

(1) all Notes that have been authenticated, except lost, stolen or destroyed Notes that have been replaced or paid and Notes for whose
payment money has been deposited in trust and thereafter repaid to the Issuer, have been delivered to the Trustee for cancellation; or 
 (2) all Notes that have not been delivered to the Trustee for cancellation have become due and payable by reason of the mailing of a notice of redemption or otherwise or will become due and payable within
one year and the Issuer or any Guarantor has irrevocably deposited or caused to be deposited with the Trustee as trust funds in trust solely for the benefit of the holders, cash in U.S. dollars, non-callable Government Securities, or a combination
of cash in U.S. dollars and non-callable Government Securities, in amounts as will be sufficient, without consideration of any reinvestment of interest, to pay and discharge the entire Indebtedness on the Notes not delivered to the Trustee for
cancellation for principal, premium and Additional Interest, if any, and accrued interest to the date of maturity or redemption; 
 (ii) no Default or Event of Default has occurred and is continuing on the date of the deposit (other than a Default or Event of Default resulting from the borrowing of funds to be applied to such deposit)
and the deposit will not result in a breach or violation of, or constitute a default under, any other instrument to which the Issuer or any Guarantor is a party or by which the Issuer or any Guarantor is bound; 

(iii) the Issuer or any Guarantor has paid or caused to be paid all sums payable by it under this Indenture including without limitation,
any accrued and unpaid fees, costs and expenses of the Trustee (and its agents and counsels); and 

  
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 (iv) the Issuer has delivered irrevocable instructions to the Trustee under this Indenture
to apply the deposited money toward the payment of the Notes at maturity or on the Redemption Date, as the case may be. 
 In
addition, the Issuer must deliver an Officers’ Certificate and an Opinion of Counsel to the Trustee each stating that all conditions precedent to satisfaction and discharge have been satisfied. 

Notwithstanding the satisfaction and discharge of this Indenture, if money has been deposited with the Trustee pursuant to sub-clause
(2) of clause (i) of this Section 8.1(a), the provisions of Sections 12.3 and 8.4 shall survive. In addition, nothing in this Section 8.1(a) shall be deemed to discharge any provisions of this Indenture, that, by their terms,
survive the satisfaction and discharge of this Indenture. 
 (b) Legal Defeasance. The Issuer may at any time, subject to
Section 8.2, elect to have all of its obligations discharged with respect to the outstanding Notes and all obligations of the Guarantors discharged with respect to their Guarantees (“Legal Defeasance”) except for: 

(i) the rights of Holders of outstanding Notes to receive payments in respect of the principal of, or interest or premium and Additional
Interest, if any, on, such Notes when such payments are due from the trust referred to below; 
 (ii) the Issuer’s
obligations with respect to the Notes concerning issuing temporary Notes, registration of Notes, mutilated, destroyed, lost or stolen Notes and the maintenance of an office or agency for payment and money for security payments held in trust;

 (iii) the rights, powers, trusts, duties and immunities of the Trustee, and the Issuer’s and the Guarantors’
obligations in connection therewith; and 
 (iv) this Article VIII. 
 Upon the Issuer exercising its Legal Defeasance option, payment of the Notes shall not be accelerated because of an Event of Default. The Issuer may exercise the Legal Defeasance option notwithstanding
its prior exercise of the Covenant Defeasance pursuant to Section 8.1(c). 
 (c) Covenant Defeasance. The Issuer may at its
option and at any time, subject to Section 8.2, elect to have the obligations of the Issuer and the Guarantors released (“Covenant Defeasance”) from Sections 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 3.11, 3.12, 3.16, 3.18, 3.19, 3.20,
3.21 and 4.1(a)(iv) and 5.2 of this Indenture and thereafter any omission to comply with those covenants will not constitute a Default or Event of Default with respect to the Notes. In the event Covenant Defeasance occurs, Section 6.1 (a)(iii)
(only with respect to Section 4.1 (a)(iv), and 5.2 only), Sections 6.1 (a)(vii) through (viii) (to the extent relating to a Significant Subsidiary) and Sections 6.1 (a)(v) and (vi), will no longer constitute an Event of Default with
respect to the Notes. 
 SECTION 8.2. Conditions to Defeasance. The Issuer may exercise its Legal
Defeasance option or its Covenant Defeasance option only if: 

  
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 (i) the Issuer must irrevocably deposit with the Trustee, in trust, for the benefit of the
holders of the Notes, cash in U.S. dollars, non-callable Government Securities, or a combination of cash in U.S. dollars and non-callable Government Securities, in amounts as will be sufficient (without consideration of any reinvestment of
interest), in the opinion of a nationally recognized investment bank, appraisal firm or firm of independent public accountants, to pay the principal of, or interest and premium and Additional Interest, if any, on, the outstanding Notes on the stated
date for payment thereof or on the applicable Redemption Date, as the case may be, and the Issuer must specify whether the Notes are being defeased to such stated date for payment or to a particular Redemption Date; 

(ii) in the case of Legal Defeasance, the Issuer must deliver to the Trustee an Opinion of Counsel confirming that (a) the Issuer
has received from, or there has been published by, the Internal Revenue Service a ruling or (b) since the Issue Date, there has been a change in the applicable federal income tax law, in either case to the effect that, and based thereon such
Opinion of Counsel will confirm that, the holders of the outstanding Notes will not recognize income, gain or loss for federal income tax purposes as a result of such Legal Defeasance and will be subject to federal income tax on the same amounts, in
the same manner and at the same times as would have been the case if such Legal Defeasance had not occurred; 
 (iii) in the
case of Covenant Defeasance, the Issuer must deliver to the Trustee an Opinion of Counsel confirming that the holders of the outstanding Notes will not recognize income, gain or loss for federal income tax purposes as a result of such Covenant
Defeasance and will be subject to federal income tax on the same amounts, in the same manner and at the same times as would have been the case if such Covenant Defeasance had not occurred; 

(iv) such Legal Defeasance or Covenant Defeasance will not result in a breach or violation of, or constitute a default under, any
material agreement (including, without limitation, the Credit Agreement) or instrument (other than this Indenture) to which the Issuer or any of its Subsidiaries is a party or by which the Issuer or any of its Subsidiaries is bound; 

(v) the Issuer must deliver to the Trustee an Officers’ Certificate stating that the deposit was not made by the Issuer with the
intent of preferring the holders of Notes over the other creditors of the Issuer with the intent of defeating, hindering, delaying or defrauding any creditors of the Issuer or others; and 

(vi) the Issuer must deliver to the Trustee an Officers’ Certificate and an Opinion of Counsel, each stating that all conditions
precedent relating to the Legal Defeasance or the Covenant Defeasance have been complied with. 
 Before or after a deposit, the
Issuer may make arrangements satisfactory to the Trustee for the redemption of Notes at a future date in accordance with Article V. 
 SECTION 8.3. Application of Trust Money. The Trustee shall hold in trust money or U.S. Government Obligations deposited with it pursuant to this Article VIII. It shall apply the
deposited money and the money from U.S. Government Obligations through the Paying Agent and in accordance with this Indenture to the payment of principal of and interest on the Notes. 

  
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 SECTION 8.4. Repayment to Issuer. Anything herein to the contrary
notwithstanding, the Trustee shall deliver or pay to the Issuer from time to time upon Company Order any money or U.S. Government Obligations held by it as provided in this Article VIII which, in the opinion of a nationally recognized firm of
independent public accountants expressed in a written certification thereof delivered to the Trustee, are in excess of the amount thereof which would then be required to be deposited to effect Legal Defeasance or Covenant Defeasance, as applicable,
provided that the Trustee shall not be required to liquidate any U.S. Government Obligations in order to comply with the provisions of this Section 8.4. 
 Subject to any applicable abandoned property law, the Trustee and the Paying Agent shall pay to the Issuer upon written request any money held by them for the payment of principal of or interest on the
Notes that remains unclaimed for two years, and, thereafter, Holders entitled to the money must look to the Issuer for payment as general creditors. 
 SECTION 8.5. Indemnity for U.S. Government Obligations. The Issuer shall pay and shall indemnify the Trustee against any tax, fee or other charge imposed on or assessed against
deposited U.S. Government Obligations or the principal and interest received on such U.S. Government Obligations. 
 SECTION
8.6. Reinstatement. If the Trustee or Paying Agent is unable to apply any money or U.S. Government Obligations in accordance with this Article VIII by reason of any legal proceeding or by reason of any order or judgment of any
court or governmental authority enjoining, restraining or otherwise prohibiting such application, the obligations of the Issuer and any Guarantor under this Indenture, the Notes and any Guarantees shall be revived and reinstated as though no deposit
had occurred pursuant to this Article VIII until such time as the Trustee or Paying Agent is permitted to apply all such money or U.S. Government Obligations in accordance with this Article VIII; provided, however, that, if the Issuer
or any Guarantors have made any payment of interest on or principal of any Notes because of the reinstatement of its obligations, the Issuer or any Guarantor, as the case may be, shall be subrogated to the rights of the Holders of such Notes to
receive such payment from the money or U.S. Government Obligations held by the Trustee or Paying Agent. 
 ARTICLE IX

 AMENDMENTS 
 SECTION 9.1. Without Consent of Holders. Notwithstanding Section 9.2 hereof, this Indenture, the Notes or any Guarantees may be amended by the Issuer, the Guarantors, if
any, and the Trustee, upon receipt of an Issuer order, without notice to or consent of any Holder: 
 (i) to cure any ambiguity,
defect or inconsistency; 
 (ii) to provide for uncertificated Notes in addition to or in place of certificated Notes;

 (iii) to provide for the assumption of the Issuer’s or a Guarantor’s obligations to holders of Notes and Guarantees
in the case of a merger or consolidation or sale of all or substantially all of the Issuer’s or such Guarantor’s assets, as applicable in accordance with the terms of this Indenture; 

  
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 (iv) to make any change that would provide any additional rights or benefits to the holders
of Notes or that does not adversely affect the legal rights under this Indenture of any such holder; 
 (v) to comply with
requirements of the SEC in order to effect or maintain the qualification of this Indenture under the TIA; 
 (vi) to conform the
text of this Indenture, the Guarantees or the Notes to any provision under the heading “Description of Notes” in the Offering Memorandum; 
 (vii) to allow any Guarantor to execute a supplemental indenture and/or a Guarantee with respect to the Notes; or 
 (viii) in the event that PIK Notes are issued in certificated form, to make appropriate amendments to this Indenture to reflect an appropriate minimum denomination of certificated PIK Notes and establish
minimum redemption amounts for certificated PIK Notes. 
 SECTION 9.2. With Consent of Holders. 

(a) This Indenture, the Notes or the Guarantees may be amended or supplemented with the consent of the holders of at least a majority in
aggregate principal amount of the Notes then outstanding (including, without limitation, consents obtained in connection with a purchase of, or tender offer or exchange offer for, Notes), and any existing Default or Event of Default or compliance
with any provision of this Indenture or the Notes or the Guarantees may be waived with the consent of the holders of a majority in aggregate principal amount of the then outstanding Notes (including, without limitation, consents obtained in
connection with a purchase of, or tender offer or exchange offer for, Notes). However, without the consent of each Holder of an outstanding Note affected, no amendment, supplement or waiver may (with respect to any Notes held by a non-consenting
Holder): 
 (i) reduce the principal amount of Notes whose holders must consent to an amendment, supplement or waiver;

 (ii) reduce the principal of or change the fixed maturity of any Note or alter the provisions with respect to the redemption
of the Notes pursuant to Section 5.1 or Section 5.2 (other than provisions relating to the notice period for consummating a redemption of the Notes); 
 (iii) reduce the rate of or change the time for payment of interest, including default interest, on any Note; 
 (iv) waive a Default or Event of Default in the payment of principal of, or interest or premium, or Additional Interest, if any, on, the Notes (except a rescission of acceleration of the Notes by the
holders of at least a majority in aggregate principal amount of the then outstanding Notes and a waiver of the payment default that resulted from such acceleration); 

  
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 (v) make any note payable in money other than that stated in the Notes; 

(vi) make any change in the provisions of this Indenture relating to waivers of past Defaults or the rights of holders of Notes to
receive payments of principal of, or interest or premium or Additional Interest, if any, on, the Notes; 
 (vii) make the Notes
subordinated in right of payment to any other obligations; 
 (viii) make any change in the preceding amendment and waiver
provisions; or 
 (ix) after the obligation to make an Asset Sale Offer, Intercompany Loan Refinancing Offer or Change of
Control Offer, as applicable, arises, amend, change or modify the obligations of the Issuer to make and consummate an Asset Sale Offer with respect to any Asset Sale in accordance with Section 3.7, obligations of the Issuer to make and
consummate an Intercompany Loan Refinancing Offer with respect to any Intercompany Loan Refinancing in accordance with Section 3.20 or obligation of the Issuer to make and consummate a Change of Control Offer in the event of a Change of Control
in accordance with Section 3.9 including, in each case, amending, changing or modifying any definition relating thereto. 

(b) It shall not be necessary for the consent of the Holders under this Section to approve the particular form of any proposed amendment,
but it shall be sufficient if such consent approves the substance thereof. 
 (c) After an amendment under this Indenture
becomes effective, the Issuer shall mail to the Holders a notice briefly describing such amendment. The failure to give such notice to all Holders of the Notes, or any defect therein, shall not impair or affect the validity of an amendment under
this Section 9.2. 
 SECTION 9.3. Effect of Consents and Waivers. A consent to an amendment or a
waiver by a Holder of a Note shall bind the Holder and every subsequent Holder of that Note or portion of the Note that evidences the same debt as the consenting Holder’s Note, even if notation of the consent or waiver is not made on the Note.
After an amendment or waiver becomes effective, it shall bind every Holder unless it makes a change described in clauses (i) through (x) of Section 9.2(a), in which case the amendment or waiver or other action shall bind each Holder
who has consented to it and every subsequent Holder that evidences the same debt as the consenting Holder’s Notes. An amendment or waiver made pursuant to Section 9.2 shall become effective upon receipt by the Trustee of the requisite
number of written consents. 
 The Issuer may, but shall not be obligated to, fix a record date for the purpose of determining
the Holders entitled to give their consent or take any other action described above or required or permitted to be taken pursuant to this Indenture. If a record date is fixed, then notwithstanding the immediately preceding paragraph, those Persons
who were Holders at such record date (or their duly designated proxies), and only those Persons, shall be entitled to give such consent or to take any such action, whether or not such Persons continue to be Holders after such record date.

 SECTION 9.4. Notation on or Exchange of Notes. If an amendment changes the terms of a Note, the Trustee
may require the Holder of the Note to deliver it to the Trustee. The 

  
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Trustee may place an appropriate notation on the Note regarding the changed terms and return it to the Holder. Alternatively, if the Issuer or the Trustee so determines, the Issuer in exchange
for the Note shall issue and the Trustee shall authenticate a new Note that reflects the changed terms. Failure to make the appropriate notation or to issue a new Note shall not affect the validity of such amendment. 

SECTION 9.5. Trustee To Sign Amendments. The Trustee shall sign any amendment, supplement or waiver authorized
pursuant to this Article IX if the amendment, supplement or waiver does not, in the sole determination of the Trustee, adversely affect the rights, duties, liabilities or immunities of the Trustee. If it does, the Trustee may but need not sign it.
In signing any amendment, supplement or waiver pursuant to this Article IX, the Trustee shall be entitled to receive, and (subject to Sections 7.1 and 7.2) shall be fully protected in relying upon, an Officers’ Certificate and an Opinion of
Counsel stating that such amendment, supplement or waiver is authorized or permitted by or complies with this Indenture, that all conditions precedent to such amendment required by this Indenture have been complied with and that such amendment,
supplement or waiver is the legal, valid and binding obligation of the Issuer, enforceable against the Issuer in accordance with its terms, subject to customary exceptions. Notwithstanding the foregoing, no Opinion of Counsel shall be required for
the Trustee to execute any amendment or supplement adding any Guarantors under this Indenture. 
 SECTION 9.6. Compliance
with Trust Indenture Act. Every amendment to this Indenture and the Notes shall be set forth in an amended or supplemental indenture that complies with the TIA as then in effect. 

ARTICLE X 

GUARANTEES 

SECTION 10.1. Guarantees. On the Issue Date, there shall be no Guarantor and no Restricted Subsidiary shall be
required to Guarantee the Notes unless otherwise required under Section 3.11 hereof. 
 (a) Subject to the provisions of
this Article X, each Guarantor hereby fully, unconditionally and irrevocably guarantees, as primary obligor and not merely as surety, jointly and severally with each other Guarantor, to each Holder of the Notes, to the extent lawful, and the Trustee
the full and punctual payment when due, whether at maturity, by acceleration, by redemption or otherwise, of the principal of, premium, if any, and interest on the Notes and all other obligations of the Issuer under this Indenture and the Notes
(including, without limitation, interest accruing after the filing of any petition in bankruptcy, or the commencement of any insolvency, reorganization or like proceeding, relating to the Issuer or any Guarantor whether or not a claim for
post-filing or post-petition interest is allowed in such proceeding and the obligations under Section 7.6) (all the foregoing being hereinafter collectively called the “Guarantor Obligations”). Each Guarantor agrees (to the extent
lawful) that the Guarantor Obligations may be extended or renewed, in whole or in part, without notice or further assent from it, and that it shall remain bound under this Article X notwithstanding any extension or renewal of any Guarantor
Obligation. 

  
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 (b) Each Guarantor waives (to the extent lawful) presentation to, demand of, payment from
and protest to the Issuer of any of the Guarantor Obligations and also waives (to the extent lawful) notice of protest for nonpayment. Each Guarantor waives (to the extent lawful) notice of any default under the Notes or the Guarantor Obligations.

 (c) Each Guarantor further agrees that its Guarantee herein constitutes a Guarantee of payment when due (and not a Guarantee
of collection) and waives any right to require that any resort be had by any Holder to any security held for payment of the Guarantor Obligations. 
 (d) Except as set forth in Section 10.2 and Article VIII, the obligations of each Guarantor hereunder shall not be subject to any reduction, limitation, impairment or termination for any reason
(other than payment of the Guarantor Obligations in full), including any claim of waiver, release, surrender, alteration or compromise, and shall not (to the extent lawful) be subject to any defense of setoff, counterclaim, recoupment or termination
whatsoever or by reason of the invalidity, illegality or unenforceability of the Guarantor Obligations or otherwise. Without limiting the generality of the foregoing, the obligations of each Guarantor herein shall not (to the extent lawful) be
discharged or impaired or otherwise affected by (a) the failure of any Holder to assert any claim or demand or to enforce any right or remedy against the Issuer or any other person under this Indenture, the Notes or any other agreement or
otherwise; (b) any extension or renewal of any thereof; (c) any rescission, waiver, amendment or modification of any of the terms or provisions of this Indenture, the Notes or any other agreement; (d) the release of any security held
by any Holder for the Guarantor Obligations or any of them; (e) the failure of any Holder to exercise any right or remedy against any other Guarantor; (f) any change in the ownership of the Issuer; (g) any default, failure or delay,
willful or otherwise, in the performance of the Guarantor Obligations; or (h) any other act or thing or omission or delay to do any other act or thing which may or might in any manner or to any extent vary the risk of any Guarantor or would
otherwise operate as a discharge of such Guarantor as a matter of law or equity. 
 (e) Each Guarantor agrees that its Guarantee
herein shall remain in full force and effect until payment in full of all the Guarantor Obligations or such Guarantor is released from its Guarantee in compliance with Section 4.1, Section 10.2 and Article VIII. Each Guarantor further
agrees that its Guarantee herein shall continue to be effective or be reinstated, as the case may be, if at any time payment, or any part thereof, of principal of, premium, if any, or interest on any of the Guarantor Obligations is rescinded or must
otherwise be restored by any Holder upon the bankruptcy or reorganization of the Issuer or otherwise. 
 (f) In furtherance of
the foregoing and not in limitation of any other right which any Holder has at law or in equity against any Guarantor by virtue hereof, upon the failure of the Issuer to pay any of the Guarantor Obligations when and as the same shall become due,
whether at maturity, by acceleration, by redemption or otherwise, each Guarantor hereby promises to and shall, upon receipt of written demand by the Trustee, forthwith pay, or cause to be paid, in cash, to the Trustee or the Trustee on behalf of the
Holders an amount equal to the sum of (i) the unpaid amount of such Guarantor Obligations then due and owing and (ii) accrued and unpaid interest on such Guarantor Obligations then due and owing (but only to the extent not prohibited by
law) (including interest accruing after the filing of any petition in bankruptcy or the commencement of any insolvency, reorganization or like proceeding relating to the Issuer or any Guarantor whether or not a claim for post-filing or post-petition
interest is allowed in such proceeding). 

  
 107

 (g) Each Guarantor further agrees that, as between such Guarantor, on the one hand, and the
Holders, on the other hand, (x) the maturity of the Guarantor Obligations guaranteed hereby may be accelerated as provided in this Indenture for the purposes of its Guarantee herein, notwithstanding any stay, injunction or other prohibition
preventing such acceleration in respect of the Guarantor Obligations guaranteed hereby and (y) in the event of any such declaration of acceleration of such Guarantor Obligations, such Guarantor Obligations (whether or not due and payable) shall
forthwith become due and payable by the Guarantor for the purposes of this Guarantee. 
 (h) Each Guarantor also agrees to pay
any and all reasonable costs and expenses (including reasonable attorneys’ fees) incurred by the Trustee or the Holders in enforcing any rights under this Section. 
 (i) Neither the Issuer nor the Guarantors shall be required to make a notation on the Notes to reflect any Guarantee or any release, termination or discharge thereof and any such notation shall not be a
condition to the validity of any Guarantee. 
 SECTION 10.2. Limitation on Liability; Termination, Release and
Discharge. 
 (a) Any term or provision of this Indenture to the contrary notwithstanding, the obligations of each
Subsidiary Guarantor hereunder shall be limited to the maximum amount as shall, after giving effect to all other contingent and fixed liabilities of such Subsidiary Guarantor and after giving effect to any collections from or payments made by or on
behalf of any other Subsidiary Guarantor in respect of the obligations of such other Subsidiary Guarantor under its Subsidiary Guarantee or pursuant to its contribution obligations under this Indenture, result in the obligations of such Subsidiary
Guarantor under its Subsidiary Guarantee not constituting a fraudulent conveyance or fraudulent transfer under federal or state law and not otherwise being void or voidable under any similar laws affecting the rights of creditors generally.

 (b) A Subsidiary Guarantee by a Subsidiary Guarantor shall be automatically and unconditionally released and discharged, and
each Subsidiary Guarantor and its obligations under the Subsidiary Guarantee and this Indenture shall be released and discharged: 
 in connection with any sale or other disposition of all or substantially all of the assets of that Guarantor (including by way of merger or consolidation) to a Person that is not (either before or after
giving effect to such transaction) the Issuer or a Guarantor, if the sale or other disposition does not violate the provisions of this Indenture; 
 (1) in connection with any sale or other disposition of the Capital Stock of that Guarantor to a Person that is not (either before or after giving effect to such transaction) the Issuer or a Guarantor
after which the Guarantor whose Capital Stock is sold or otherwise disposed of is no longer a Restricted Subsidiary, if the sale or other disposition does not violate the provisions of this Indenture; 

  
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 (2) if the Issuer designates any Restricted Subsidiary that is a Guarantor to be an
Unrestricted Subsidiary in accordance with the applicable provisions of this Indenture; 
 (3) upon payment in full, legal
defeasance, covenant defeasance or satisfaction and discharge of this Indenture pursuant to Section 8.1 and Section 8.2. 
 (4) the release or discharge of the Guarantee by such Restricted Subsidiary of Indebtedness of the Issuer which resulted in the obligation to Guarantee the Notes (other than by reason of payment under
such Guarantee). 
 (c) [Reserved]. 
 (d) In the case of this Section 10.2(b), the Issuer shall deliver to the Trustee an Officers’ Certificate and an Opinion of Counsel, each stating that all conditions precedent provided for in
this Indenture relating to such transaction have been complied with. 
 (e) The release of a Subsidiary Guarantor from its
Subsidiary Guarantee and its obligations under this Indenture in accordance with the provisions of this Section 10.2 shall not preclude the future applications of Section 3.11 to such Person. 

SECTION 10.3. Right of Contribution. Each Subsidiary Guarantor hereby agrees that to the extent that any such
Subsidiary Guarantor shall have paid more than its proportionate share of any payment made on the obligations under its Subsidiary Guarantee, such Subsidiary Guarantor shall be entitled to seek and receive contribution from and against the Issuer or
any other Subsidiary Guarantor who has not paid its proportionate share of such payment. The provisions of this Section 10.3 shall in no respect limit the obligations and liabilities of each Subsidiary Guarantor to the Trustee and the Holders
and each Subsidiary Guarantor shall remain liable to the Trustee and the Holders for the full amount guaranteed by such Subsidiary Guarantor hereunder. 
 SECTION 10.4. No Subrogation. Notwithstanding any payment or payments made by each Guarantor hereunder, no Guarantor shall be entitled to be subrogated to any of the rights of the
Trustee or any Holder against the Issuer or any other Guarantor or any collateral security or guarantee or right of offset held by the Trustee or any Holder for the payment of the Guarantor Obligations, nor shall any Guarantor seek or be entitled to
seek any contribution or reimbursement from the Issuer or any other Guarantor in respect of payments made by such Guarantor hereunder, until all amounts owing to the Trustee and the Holders by the Issuer on account of the Guarantor Obligations are
paid in full. If any amount shall be paid to any Guarantor on account of such subrogation rights at any time when all of the Guarantor Obligations shall not have been paid in full, such amount shall be held by such Guarantor in trust for the Trustee
and the Holders, segregated from other funds of such Guarantor, and shall, forthwith upon receipt by such Guarantor, be turned over to the Trustee in the exact form received by such Guarantor (duly indorsed by such Guarantor to the Trustee, if
required), to be applied against the Guarantor Obligations. 
 SECTION 10.5. Limitations on Merger. A
Guarantor may not sell or otherwise dispose of all or substantially all of its assets to, or consolidate with or merge with or into 

  
 109

 
(whether or not such Guarantor is the surviving Person) another Person, other than the Issuer or a Subsidiary Guarantor, unless: 

(1) the Person (if other than the Issuer or a Subsidiary Guarantor) acquiring the property in any such sale or disposition or the Person
(if other than the Issuer of a Subsidiary Guarantor) formed by or surviving any such consolidation or merger assumes all the obligations of that Guarantor under its Guarantee, this Indenture and the Registration Rights Agreement pursuant to a
supplemental indenture and other agreements to effectuate such assumption; or 
 (2) such transaction does not violate the
provisions of this Indenture and the Net Proceeds of such sale or other disposition are applied in accordance with Section 3.7; and 
 (3) immediately after such transaction, no Default or Event of Default exists. ARTICLE XI 
 ARTICLE XI 
 [RESERVED] 

ARTICLE XII 

MISCELLANEOUS 
 SECTION 12.1. Notices. Notices given by publication shall be deemed given on the first date on which publication is made, and notices given by first-class mail, postage prepaid, shall
be deemed given five calendar days after mailing. Any notice or communication shall be in writing and delivered in person, by facsimile or mailed by first-class mail addressed as follows: 

if to the Issuer or any Guarantor: 
 American Renal Holdings Company, Inc. 
 66 Cherry Hill Drive

 Beverly, MA 01915-1072 

Facsimile: (978) 232-4060 
 Attention: Michael Costa 
 if to the Trustee: 

Wilmington Trust FSB 
 50 South Sixth Street, Suite 1290 
 Minneapolis, MN 55402-1544

 Facsimile: (612) 217-5651 

Attention: American Renal Holdings Administrator 
 The Issuer or the Trustee by notice to the other may designate additional or different addresses for subsequent notices or communications. 

  
 110

 Any notice or communication mailed to a Holder shall be mailed to the Holder at the
Holder’s address as it appears on the registration books of the Registrar and shall be sufficiently given if so mailed within the time prescribed. Any notice or communication shall also be so mailed or delivered to any Person described in TIA
§ 313(c), to the extent required by the TIA. 
 Failure to mail a notice or communication to a Holder or any defect in it
shall not affect its sufficiency with respect to other Holders. If a notice or communication is mailed in the manner provided above, it is duly given, whether or not the addressee receives it. 

The Trustee agrees to accept and act upon instructions or directions pursuant to this Indenture sent by unsecured e-mail, facsimile
transmission or other similar unsecured electronic methods. If the party elects to give the Trustee e-mail or facsimile instructions (or instructions by a similar electronic method) and the Trustee in its discretion elects to act upon such
instructions, the Trustee’s understanding of such instructions shall be deemed controlling. The Trustee shall not be liable for any losses, costs or expenses arising directly or indirectly from the Trustee’s reliance upon and compliance
with such instructions notwithstanding such instructions conflict or are inconsistent with a subsequent written instruction. The party providing electronic instructions agrees to assume all risks arising out of the use of such electronic methods to
submit instructions and directions to the Trustee, including without limitation the risk of the Trustee acting on unauthorized instructions, and the risk or interception and misuse by third parties. 

SECTION 12.2. Certificate and Opinion as to Conditions Precedent. Upon any request or application by the Issuer to
the Trustee to take or refrain from taking any action under this Indenture (except in connection with the original issuance of Notes on the date hereof), the Issuer shall furnish to the Trustee: 

(i) an Officers’ Certificate in form reasonably satisfactory to the Trustee stating that, in the opinion of the signers, all
conditions precedent, if any, provided for in this Indenture relating to the proposed action have been complied with; 
 (ii) an
Opinion of Counsel in form reasonably satisfactory to the Trustee stating that, in the opinion of such counsel, all such conditions precedent have been complied with; and 
 (iii) if required by the TIA, an Independent Certificate from a firm of certified public accountants meeting the applicable requirements therein. 

SECTION 12.3. Statements Required in Certificate or Opinion. Each certificate or opinion with respect to compliance
with a covenant or condition provided for in this Indenture (other than a certificate provided pursuant to TIA § 3 14(a)(4)) shall comply with the provisions of TIA § 314(e) and also shall include: 

(i) a statement that the individual making such certificate or opinion has read such covenant or condition; 

(ii) a brief statement as to the nature and scope of the examination or investigation upon which the statements or opinions contained in
such certificate or opinion are based; 

  
 111

 (iii) a statement that, in the opinion of such individual, he has made such examination or
investigation as is necessary to enable him to express an informed opinion as to whether or not such covenant or condition has been complied with; and 
 (iv) a statement as to whether or not, in the opinion of such individual, such covenant or condition has been complied with. 
 In giving such Opinion of Counsel, counsel may rely as to factual matters on an Officers’ Certificate or on certificates of public officials. 

SECTION 12.4. When Notes Disregarded. In determining whether the Holders of the required principal amount of Notes have
concurred in any direction, waiver or consent, Notes owned by the Issuer, any Guarantor or by any Person directly or indirectly controlling or controlled by or under direct or indirect common control with the Issuer shall be disregarded and deemed
not to be outstanding, except that, for the purpose of determining whether the Trustee shall be protected in relying on any such direction, waiver or consent, only Notes which a Trust Officer of the Trustee knows are so owned shall be so
disregarded. Also, subject to the foregoing, only Notes outstanding at the time shall be considered in any such determination. Upon the reasonable request of the Trustee, the Issuer shall furnish to the Trustee promptly one or more Officer’s
Certificates listing and identifying all Notes, if any, known by the Issuer to be owned or held by or for the account of any of the above-described persons, and the Trustee shall be entitled to accept such Officer’s Certificate as conclusive
evidence of the facts therein set forth and of the fact that all Notes not listed therein are outstanding for the purpose of any such determination. 
 SECTION 12.5. Rules by Trustee, Paying Agent and Registrar. The Trustee may make reasonable rules for action by, or a meeting of, Holders. The Registrar and the Paying Agent may make
reasonable rules for their functions. 
 SECTION 12.6. Days Other than Business Days. If a payment date is not a
Business Day, payment shall be made on the next succeeding day that is a Business Day, and no interest shall accrue for the intervening period. If a regular Record Date is not a Business Day, the Record Date shall not be affected. 

SECTION 12.7. Governing Law. This Indenture, the Notes and the Guarantees shall be governed by, and construed in accordance
with, the laws of the State of New York. 
 SECTION 12.8. Waiver of Jury Trial. EACH OF THE ISSUER, THE SUBSIDIARY
GUARANTORS AND THE TRUSTEE HEREBY IRREVOCABLY WAIVES, TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW, ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY LEGAL PROCEEDING ARISING OUT OF OR RELATING TO THIS INDENTURE, THE NOTES OR THE TRANSACTIONS
CONTEMPLATED HEREBY. 
 SECTION 12.9. No Recourse Against Others. An incorporator, director, officer, employee,
stockholder or controlling person, as such, of the Issuer or any Guarantor shall not have any liability for any obligations of the Issuer or any Guarantor under the Notes, any Guarantees or this Indenture or for any claim based on, in respect of or
by reason of such obligations or their creation. By accepting a Note, each Holder shall waive and release all such liability. The waiver and release shall be part of the consideration for the issue of the Notes. 

  
 112

 SECTION 12.10. Successors. All agreements of the Issuer in this Indenture and
the Notes shall bind their respective successors. All agreements of the Trustee in this Indenture shall bind its successors. 

SECTION 12.11. Multiple Originals. The parties may sign any number of copies of this Indenture. Each signed copy shall be
an original, but all of them together represent the same agreement. One signed copy is enough to prove this Indenture. 

SECTION 12.12. Variable Provisions. The Issuer initially appoints the Trustee as Paying Agent and Registrar and custodian
with respect to any Global Notes. 
 SECTION 12.13. Table of Contents; Headings. The table of contents,
cross-reference sheet and headings of the Articles and Sections of this Indenture have been inserted for convenience of reference only, are not intended to be considered a part hereof and shall not modify or restrict any of the terms or provisions
hereof. 
 SECTION 12.14. [Reserved].Force Majeure. In no event shall the Trustee or be responsible or liable for
any failure or delay in the performance of its obligations hereunder arising out of or caused by, directly or indirectly, forces beyond its control, including, without limitation, strikes, work stoppages, accidents, acts of war or terrorism, civil
or military disturbances, nuclear or natural catastrophes or acts of God, and interruptions, loss or malfunctions of utilities, communications or computer (software and hardware) services; it being understood that the Trustee shall use reasonable
efforts which are consistent with accepted practices in the banking industry to resume performance as soon as practicable under the circumstances. 
 SECTION 12.15. USA Patriot Act. The parties hereto acknowledge that in accordance with Section 326 of the USA Patriot Act the Trustee and the Trust Officers, like all financial
institutions and in order to help fight the funding of terrorism and money laundering, are required to obtain, verify, and record information that identifies each person or legal entity that establishes a relationship or opens an account. The
parties to this agreement agree that they shall provide the Trustee and the Trust Officers with such information as they may request in order to satisfy the requirements of the USA Patriot Act. 

SECTION 12.16. Trust Indenture Act Controls. If any provision hereof limits, qualifies or conflicts with the duties imposed
by TIA § 318(c), the imposed duties shall control. 
 SECTION 12.17. Communication by Holders of Notes with Other
Holders of Notes. Holders of the Notes may communicate pursuant to TIA § 312(b) with other Holders of Notes with respect to their rights under this Indenture or the Notes. The Issuer, the Trustee, the Registrar and anyone else shall
have the protection of TIA § 312(c). 
 [Signature Pages Follow] 

  
 113

 IN WITNESS WHEREOF, the parties have caused this Indenture to be duly executed as of the
date first written above. 
  

			
	 AMERICAN RENAL HOLDINGS
 COMPANY, INC.
  

	By:	 	 /s/ Joseph A. Carlucci

	Name:	 	        Joseph A. Carlucci
	Title:	 	        Chief Executive Officer
	
	  
 WILMINGTON
TRUST FSB, as Trustee
  

	By:	 	 /s/ Jane Schweiger

	Name:	 	        Jane Schweiger
	Title:	 	        Vice President

 [Indenture Signature Page] 

 EXHIBIT A 

[FORM OF FACE OF NOTE] 
 Global Note Legend, if applicable 
 Private Placement Legend, if applicable

 Original Issue Discount Legend, if applicable 
 Temporary Regulation S Legend, if applicable 

  
 A-1

 No. [        ]    Principal Amount
$[            ], 
 as revised by the Schedule of Increases

 or Decreases in the Global Note attached hereto 
 CUSIP NO.     
 AMERICAN RENAL HOLDINGS COMPANY, INC.

 9.75%/10.50% Senior PIK Toggle Note due 2016 

American Renal Holdings Company, Inc., a Delaware corporation, promises to pay to
[                    ], or registered assigns, the initial principal amount set forth on the Schedule of Increases or Decreases in the Global
Note attached hereto, as revised by the Schedule of Increases or Decreases in the Global Note attached hereto, on March 1, 2016. 
 Interest Payment Dates: March 1 and September 1. 
 Record Dates:
February 15 and August 15. 
 Additional provisions of this Note are set forth on the other side of this Note.

  

			
	AMERICAN RENAL HOLDINGS

COMPANY, INC.

		
	By:	 	  

	Name:	 	  

	Title:	 	  

 TRUSTEE’S CERTIFICATE OF 
 AUTHENTICATION 
 WILMINGTON TRUST FSB 
 as Trustee, certifies that this is one of the Notes 
 referred to in the Indenture. 

 

			
	 By:
	 	  

		 	 Authorized
Signatory    Date:                    

  
 A-2

 [FORM OF REVERSE SIDE OF NOTE] 

9.75%/10.50% Senior PIK Toggle Note due 2016 
 Capitalized terms used and not not defined herein have the meanings specified in the Indenture. 
  

	1.	Interest 

 American Renal
Holdings Company, Inc., a Delaware corporation (such corporation, and its successors and assigns under the Indenture hereinafter referred to, being herein called the “Issuer”), promises to pay interest on the principal amount of this Note
at the rate per annum shown above. 
 The Issuer shall pay interest semiannually on March 1 and September 1 of each
year, with the first interest payment to be made on September 1, 2011.1 Interest on the Notes shall accrue from the most recent date to which interest has been paid on the Notes or, if no interest has been paid, from March 4, 2011.2 Interest will be payable, at the election of the Issuer (made by
delivering a notice to the Trustee not later than 10 business days prior to the beginning of each such interest period), (1) entirely in cash (“Cash Interest”), (2) by increasing the principal amount of the outstanding Notes or
by issuing additional PIK Notes (“PIK Interest”) or (3) 50% as Cash Interest and 50% as PIK Interest. Interest shall be calculated based on a 360-day year of 12 months of 30 days. The Issuer shall pay interest on overdue principal at
2% per annum in excess of the above rate and shall pay interest on overdue installments of interest at such higher rate to the extent lawful. 
 In the absence of an interest payment election made by the Issuer as set forth above, interest on the Notes shall be payable in the manner described in clause (2) of the preceding paragraph.
Notwithstanding anything to the contrary, the payment of accrued interest in connection with any redemption or purchase of the Notes, as described under paragraphs 6 and 7 below shall be made solely in cash. 

For interest payments on the Notes that the Issuer elects to pay as Cash Interest, it shall accrue at a rate equal to 9.75% per
annum. For interest payments on the Notes that the Company elects to pay as PIK Interest, it shall accrue on the Notes at a rate per annum equal to 10.50% per annum. At all times, PIK Interest on the Notes will be payable (x) with respect
to Notes represented by one or more global notes registered in the name of, or held by, The Depository Trust Company (“DTC”) or its nominee on the relevant record date, by increasing the principal amount of the outstanding global
note by an amount equal to the amount of PIK Interest for the applicable interest period (rounded down to the nearest whole dollar) as provided in writing by the Issuer to the Trustee and (y) with respect to Notes represented by certificated
notes, by issuing PIK Notes in certificated form in an aggregate principal amount equal to the amount of PIK Interest for the applicable interest period (rounded down to the nearest whole dollar), and the Trustee shall, upon receipt of an Issuer
order, authenticate and deliver such PIK Notes in certificated form for original issuance to the Holders on the relevant record date, as shown by the records of the register of Holders. Following an increase in the principal amount of the
outstanding global notes as a result of a PIK Interest Payment, the Notes shall bear interest on 
  

	1 	With respect to the Initial Notes. 

	2 	With respect to the Initial Notes. 

  
 A-3

 
such increased principal amount from and after the date of such PIK Interest Payment. Any PIK Notes issued in certificated form will be dated as of the applicable interest payment date and will
bear interest from and after such date. 
  

	2.	Method of Payment 

 By no
later than 10:00 a.m. (New York City time) on the date on which any principal of, premium, if any, or interest on any Note is due and payable, the Issuer shall irrevocably deposit with the Trustee or the Paying Agent money sufficient to pay such
principal, premium, if any, and/or interest (and if a PIK Note has been issued such amount shall increase) provided, however, that payment of interest may be made at the option of the Issuer by check mailed to the Person entitled
thereto as shown on the security register. The Issuer shall pay interest (except Defaulted Interest) to the Persons who are registered Holders of Notes at the close of business on the February 15 and August 15 next preceding the Interest
Payment Date unless Notes are cancelled, repurchased or redeemed after the record date and before the Interest Payment Date. Holders must surrender Notes to a Paying Agent to collect principal payments. The Issuer shall pay principal, premium, if
any, and interest in money of the United States that at the time of payment is legal tender for payment of public and private debts. Payments in respect of Notes represented by a Global Note (including principal, premium, if any, and interest) shall
be made by the transfer of immediately available funds to the accounts specified by the Depositary. The Issuer shall make all payments in respect of a Definitive Note (including principal, premium, if any, and interest) by mailing a check to the
registered address of each Holder thereof. 
 Subject to the issuance of PIK Notes as described herein, the Notes will be issued
only in fully registered form without coupons, in denominations of $2,000 and any integral multiple of $1,000 in excess thereof. PIK Payments will be made in PIK Note denominations of $1.00 and any integral multiple in excess of $1.00 thereof. No
service charge will be made for any registration of transfer, exchange or redemption of Notes, except in certain circumstances for any tax or other governmental charge that may be imposed in connection therewith. 

 

	3.	Paying Agent and Registrar 

Initially, Wilmington Trust FSB, duly organized and existing under the laws of the United States of America and having a corporate trust
office at 50 South Sixth Street, Suite 1290, Minneapolis, MN 55402-1544, Attention: American Renal Holdings Administrator (“Trustee”), shall act as Paying Agent and Registrar. The Issuer may appoint and change any Paying Agent, Registrar
or co- registrar without notice to any Holder. The Issuer or any of its domestically incorporated Subsidiaries may act as Paying Agent, Registrar or co-registrar. 
  

	4.	Indenture 

 The Issuer
issued the Notes under an Indenture dated as of March 4, 2011 (as it may be amended or supplemented from time to time in accordance with the terms thereof, the “Indenture”), between the Issuer and the Trustee. The terms of the Notes
include those stated in the Indenture. Capitalized terms used herein and not defined herein have the meanings ascribed thereto in the Indenture. The Notes are subject to all such terms, and Holders are referred to the Indenture and the Securities
Act for a statement of those terms. To the extent any provision of this Note conflicts with the express provisions of the Indenture, the provisions of the Indenture shall govern and be controlling. 

  
 A-4

 The Notes are general unsecured obligations of the Issuer. This Note is the 9.75%/10.50%
Senior PIK Toggle Notes due 2016 referred to in the Indenture. The Notes include (i) $135,000,000 aggregate principal amount of the Issuer’s 9.75%/10.50% Senior PIK Toggle Notes due 2016 issued under the Indenture on March 4, 2011
(herein called “Initial Notes”), (ii) pursuant to the Exchange Offer, Exchange Notes from time to time for issue only in exchange for a like principal amount of Initial Notes and (iii) if and when issued, additional 9.75%/10.50%
Senior PIK Toggle Notes due 2016 of the Issuer that may be issued from time to time under the Indenture subsequent to March 4, 2011 (herein called “Additional Notes”). The Indenture contains the terms and restrictions set forth in the
Indenture or made a part of the Indenture pursuant to the requirements of the TIA. The Indenture, among other things, imposes certain covenants with respect to the following matters: the Incurrence of Indebtedness by the Issuer and its Restricted
Subsidiaries, the payment of dividends and other distributions on the Capital Stock of the Issuer, the purchase or redemption of Capital Stock of the Issuer, the sale or transfer of assets and Capital Stock of Subsidiaries, the issuance or sale of
Capital Stock of Restricted Subsidiaries, the incurrence of certain Liens, future Guarantors, the business activities and investments of the Issuer and its Restricted Subsidiaries and transactions with Affiliates. In addition, the Indenture limits
the ability of the Issuer and its Restricted Subsidiaries to enter into agreements that restrict distributions and dividends from Subsidiaries. The Indenture also imposes requirements with respect to the provision of financial information. The
Indenture also contains certain exceptions to the foregoing, and this description is qualified in its entirety by reference to the Indenture. 
  

	5.	[Reserved] 

  

	6.	Optional Redemption 

 (a)
On or after March 1, 2013, the Issuer may, on one or more occasions, redeem all or any portion of the Notes, at the redemption prices (expressed as percentages of principal amount) set forth below plus accrued and unpaid interest and Additional
Interest, if any, on the Notes to be redeemed, to the applicable Redemption Date, if redeemed during the twelve-month period beginning on March 1 of the years indicated below, subject to the rights of Holders of Notes on the relevant record
date to receive interest on the relevant interest payment date: 
  

			
	Year	  	Percentage
	 2013
	  	105.000%
	 2014
	  	102.500%
	 2015 and thereafter
	  	100.000%

 (b) Before March 1, 2013, the Issuer may, on one or more occasions, redeem all or any portion of the
Notes, at a redemption price equal to 100% of the principal amount thereof plus the Applicable Premium as of, and accrued and unpaid interest and Additional Interest, if any, to, the date of redemption (a “Make-Whole Redemption Date”).

  
 A-5

 (c) Unless the Issuer defaults in the payment of the redemption price, interest and
Additional Interest will cease to accrue on the Notes or portions thereof called for redemption on the applicable Redemption Date. 
 (d) Any redemption pursuant to this paragraph 6 shall be made pursuant to the provisions of Article V of the Indenture. 
  

	7.	Mandatory Redemption Upon Certain Equity Issuances 

 (a) The Issuer will be required to redeem the maximum principal amount of Notes that is in minimum denominations of $2,000 and an integral multiple of $1,000 in excess thereof (or if a PIK Payment has
been made, in minimum denominations of $1.00 and any integral multiple of $1.00 in excess thereof) that may be redeemed out of any Qualified Equity Issuance Net Proceeds at a price in cash (A) in an amount equal to, prior to March 1, 2013,
105.00% of the principal amount thereof and (B) thereafter, in an amount equal to the redemption price applicable to such Notes on the date on which notice of such redemption is given as set forth in Section 5.1 of the Indenture, in each
case, plus accrued and unpaid interest and Additional Interest, if any, to the date fixed for the closing of such redemption, in accordance with the procedures set forth in the Indenture. Not later than 90 days following the receipt of the Qualified
Equity Issuance Net Proceeds from any Qualified Equity Issuance, the Issuer shall mail a notice of redemption to each Holder with a copy to the Trustee (such redemption, a “Qualified Equity Issuance Redemption”) stating: 

(i) that a Qualified Equity Issuance has occurred, the amount of Qualified Equity Issuance Net Proceeds received by the
Issuer, and that the Issuer will redeem such Holder’s Notes or a portion thereof, as discussed below, at a purchase price in cash in an amount equal to, as applicable, 105.00% of the principal amount or the redemption price applicable to such
Notes on the date on which the notice of such redemption is given as set forth in Section 5.1 of the Indenture, in each case, plus accrued and unpaid interest thereon and Additional Interest thereon, if any, to the date of redemption (subject
to the right of Holders of record on a record date to receive interest on the relevant interest payment date); 

(ii) the circumstances and relevant facts regarding such Qualified Equity Issuance, and the maximum principal amount of
Notes that may be redeemed by the Issuer in the Qualified Equity Issuance Redemption; and 
 (iii) the redemption
date (which shall be no earlier than 30 days nor later than 90 days from the date such notice is mailed). 
 (b) Notice of a
Qualified Equity Issuance Redemption may be delivered in advance of a Qualified Equity Issuance, conditional upon such Qualified Equity Issuance, if a definitive agreement is in place for the Qualified Equity Issuance at the time of delivery of the
notice of such Qualified Equity Issuance Redemption. 
 (c) Except as provided above in subparagraphs 7(a) and (b), the Issuer
is not required to make mandatory redemption or sinking fund payments with respect to the Notes. 

  
 A-6

	8.	Registration Rights Agreement 

 The Notes are entitled to the benefit of the Registration Rights
Agreement.]3 

 

	9.	Change of Control; Asset Sales 

 (a) If a Change of Control occurs, unless the Issuer has exercised its right to redeem all of the Notes under Section 5.1 of the Indenture, each Holder shall have the right to require the repurchase
all or any part (in integral multiples of $1,000 except that no Note may be tendered in part if the remaining principal amount would be less than $2,000 (or if a PIK Payment has been made, in minimum denominations of $1.00 and any integral multiple
of $1.00 in excess thereof in respect of PIK Notes)) of such Holder’s Notes at a purchase price in cash equal to 101% of the principal amount of the Notes plus accrued and unpaid interest, if any, to, but excluding, the date of purchase
(subject to the right of Holders of record on the relevant Record Date to receive interest due on the relevant Interest Payment Date) as provided in, and subject to the terms of, the Indenture. 

(b) In the event of an Asset Sale Offer or Intercompany Loan Refinancing that requires the purchase of Notes pursuant to
Section 3.7(d) or 3.20 of the Indenture, the Issuer shall be required to make an offer to all Holders to purchase Notes in accordance with Section 3.7(d), 3.20 and 5.8 of the Indenture at an offer price in cash in an amount equal to 100%
of the principal amount of the Notes, plus accrued and unpaid interest to, but excluding, the date of purchase (subject to the rights of Holders of record on any Record Date to receive payments of interest on the related Interest Payment Date).
Holders of Notes that are the subject of an offer to purchase shall receive an Asset Sale Offer or Intercompany Loan Refinancing Offer, as applicable, from the Issuer prior to any related purchase date and may elect to have such Note purchased
pursuant to such offer by completing the form entitled “Option of Holder To Elect Purchase” attached hereto, or transferring its interest in such Note by book-entry transfer, to the Issuer or a Paying Agent at the address specified in the
notice at least three Business Days before the Purchase Date. 
  

	10.	Denominations; Transfer; Exchange 

 The Notes are in registered form without coupons in denominations of principal amount of $2,000 and whole multiples of $1,000 in excess thereof (or if a PIK Payment has been made, in minimum denominations
of $1.00 and any integral multiple of $1.00 in excess thereof in respect of PIK Notes). A Holder may transfer or exchange Notes in accordance with the Indenture. The Registrar may require a Holder, among other things, to furnish appropriate
endorsements or transfer documents and to pay any taxes and fees required by law or permitted by the Indenture. The Registrar need not register the transfer of or exchange any Notes for a period beginning 15 Business Days before an Interest Payment
Date and ending on such Interest Payment Date. 
  

	11.	Persons Deemed Owners 

The registered Holder of this Note may be treated as the owner of it for all purposes. 

 

	3 	 To be included in Notes bearing the Private Placement Legend. 

  
 A-7

	12.	Unclaimed Money 

 If money
for the payment of the principal of or premium, if any, or interest remains unclaimed for two years, the Trustee or Paying Agent shall pay the money back to the Issuer at its request unless an abandoned property law designates another person. After
any such payment, Holders entitled to the money must look only to the Issuer and not to the Trustee for payment. 
  

	13.	Discharge and Defeasance 

Subject to certain conditions set forth in the Indenture, the Issuer at any time may terminate some or all of its obligations under the
Notes and the Indenture if the Issuer deposits with the Trustee money or U.S. Government Obligations for the payment of principal and interest on the Notes to redemption or maturity, as the case may be. 

 

	14.	Amendment, Waiver 

 The
Indenture and the Notes may be amended or waived as set forth in Article IX of the Indenture. 
  

	15.	Defaults and Remedies Events of Default shall be as set forth in Article VI of the Indenture 

If an Event of Default occurs and is continuing, the Trustee or Holders of at least 25% in aggregate principal amount of the outstanding
Notes then outstanding may declare all the Notes to be due and payable immediately. Certain events of bankruptcy or insolvency with respect to the Issuer are Events of Default which shall result in the Notes being due and payable immediately upon
the occurrence of such Events of Default. 
 Holders may not enforce the Indenture or the Notes except as provided in the
Indenture. The Trustee may refuse to enforce the Indenture or the Notes unless each receives indemnity or security reasonably satisfactory to the Trustee. Subject to certain limitations, Holders of a majority in principal amount of the Notes may
direct the Trustee in its exercise of any trust or power. The Trustee may withhold from Holders notice of any continuing Default or Event of Default (except a Default or Event of Default in payment of principal or interest) if it determines that
withholding notice is in their interest. 
  

	16.	Trustee Dealings with the Issuer 

 Subject to certain limitations set forth in the Indenture, the Trustee under the Indenture, in its individual or any other capacity, may become the owner or pledgee of Notes and may otherwise deal with
and collect obligations owed to it by the Issuer or its Affiliates and may otherwise deal with the Issuer or its Affiliates with the same rights it would have if it were not Trustee. 

 

	17.	No Recourse Against Others 

A director, officer, employee, incorporator, stockholder, member, partner or other holder of Equity Interests of the Issuer or any
Guarantor, as such, shall not have any liability for any obligations of the Issuer or any Guarantor under the Notes, the Indenture, any Guarantees or the Registration Rights Agreement or for any claim based on, in respect of, or by reason of, such
obligations or their creation. By accepting a Note, each Holder waives and releases all such liability. The waiver and release shall be part of the consideration for the issue of the Notes. 

  
 A-8

	18.	Authentication 

 This Note
shall not be valid until an authorized signatory of the Trustee (or an authenticating agent acting on its behalf) manually signs the certificate of authentication on the other side of this Note. 

 

	19.	Abbreviations 

 Customary
abbreviations may be used in the name of a Holder or an assignee, such as TEN COM (= tenants in common), TEN ENT (= tenants by the entirety), JT TEN (= joint tenants with rights of survivorship and not as tenants in common), CUST (= custodian) and
U/G/M/A (= Uniform Gift to Minors Act). 
  

	20.	CUSIP Numbers 

 Pursuant
to a recommendation promulgated by the Committee on Uniform Note Identification Procedures the Issuer has caused CUSIP numbers to be printed on the Notes. No representation is made as to the accuracy of such numbers as printed on the Notes and
reliance may be placed only on the other identification numbers placed thereon. 
  

	21.	Successor Entity 

 When a
successor entity assumes, in accordance with the Indenture, all the obligations of its predecessor under the Notes and the Indenture, and immediately before and thereafter no Default or Event of Default exists and all other conditions of the
Indenture are satisfied, the predecessor entity shall be released from those obligations. 
  

	22.	Governing Law 

 This Note
shall be governed by, and construed in accordance with, the laws of the State of New York. 
 The Issuer shall furnish to any
Holder upon written request and without charge to the Holder a copy of the Indenture which has in it the text of this Note in larger type. Requests may be made to: 
 American Renal Holdings Company, Inc. 
 66 Cherry Hill Drive 

Beverly, MA 01915-1072 
 Facsimile: (978) 232-4060 
 Attention: General Counsel 

  
 A-9

 ASSIGNMENT FORM 
 To assign this Note, fill in the form below: 
 I or we assign and transfer this Note to

  

	
	  
 (Print or type
assignee’s name, address and zip code)
  

	  
 (Insert
assignee’s soc. sec. or tax I.D. No.)

 and irrevocably appoint agent to transfer this Note on the books of the Issuer. The agent may substitute another to act
for him. 
  

			
	
Date:                       
                                         
                                    
	  	Your Signature:                       
                 
		
	 Signature
Guarantee:                                       
                                 
	  	
	                           
 (Signature must be guaranteed)	  	
	
	  
 Sign exactly as your name appears on the other side of this Note.

 The signature(s) should be guaranteed by an eligible guarantor institution (banks, stockbrokers, savings and loan
associations and credit unions with membership in an approved signature guarantee medallion program), pursuant to SEC Rule 17Ad-15. 

  
 A-10

 [TO BE ATTACHED TO GLOBAL NOTES] 

SCHEDULE OF INCREASES OR DECREASES IN GLOBAL NOTE 
 The initial principal amount of the Note shall be $[             ]. The following increases or decreases in this Global Note have been
made: 
  

													
	 Date of

Exchange
	  	Amount of
decrease in
Principal
Amount of this
Global Note	  	Amount of
increase in
Principal
Amount of this
Global Note	  	Principal
Amount of this
Global Note
following such
decrease or
increase	  	Signature of
authorized
signatory of
Trustee or
Notes
Custodian	  	PIK Increases	  	Other Increases
		  		  		  		  		  		  	

  
 A-11

 OPTION OF HOLDER TO ELECT PURCHASE 

If you want to elect to have this Note purchased by the Issuer pursuant to Section 3.7, 3.9 or 3.20 of the Indenture, check the box:

 ̈     ̈  
     ̈ 
 3.7    3.9    
3.20 
 If you want to elect to have only part of this Note purchased by the Issuer pursuant to Section 3.7,
3.9 or 3.20 of the Indenture, state the amount in principal amount (must be in denominations of $2,000 or integral multiples of $1,000 in excess thereof): $            

  

			
	
Date:                       
                 
	  	Your Signature:                          
              
		  	 (Sign exactly as your name appears on

the other side of the Note)

	
	 Signature
Guarantee:                                       
                                         

	                            
                    (Signature must be guaranteed)

 The signature(s) should be guaranteed by an eligible guarantor institution (banks, stockbrokers, savings and loan
associations and credit unions with membership in an approved signature guarantee medallion program), pursuant to SEC Rule 17Ad-15. 

  
 A-12

 EXHIBIT B 

FORM OF CERTIFICATE OF TRANSFER 
 American Renal Holdings Company, Inc 
 66 Cherry Hill Drive 

Beverly, MA 01915-1072 
 Facsimile:
(978) 232-4060 
 Attention: Michael Costa 
 Wilmington Trust FSB 
 50 South Sixth Street, Suite 1290 

Minneapolis, MN 55402-1544 
 Facsimile:
(612) 217-5651 
 Attention: American Renal Holdings Administrator 
 Re: 9.75%/10.50% Senior PIK Toggle Notes due 2016 
 Reference is hereby made to
the Indenture, dated as of March 4, 2011 (the “Indenture”), between American Renal Holdings Company, Inc., as Issuer (the “Issuer”) and Wilmington Trust FSB, as Trustee. Capitalized terms used but not defined
herein shall have the meanings given to them in the Indenture. 

                    (the
“Transferor”) owns and proposes to transfer the Note[s] or interest in such Note[s] specified in Annex A hereto, in the principal amount of $            in such
Note[s] or interests (the “Transfer”), to (the “Transferee”), as further specified in Annex A hereto. In connection with the Transfer, the Transferor hereby certifies that: 

[CHECK ALL THAT APPLY] 
  

	1.     ̈    	Check if Transferee will take delivery of a beneficial interest in the 144A GlobalNote or a Definitive Note pursuant to Rule 144A. The Transfer is being effected
pursuant to and in accordance with Rule 144A under the United States Securities Act of 1933, as amended (the “Securities Act”), and, accordingly, the Transferor hereby further certifies that the beneficial interest or Definitive
Note is being transferred to a Person that the Transferor reasonably believed and believes is purchasing the beneficial interest or Definitive Note for its own account, or for one or more accounts with respect to which such Person exercises sole
investment discretion, and such Person and each such account is a “qualified institutional buyer” within the meaning of Rule 144A in a transaction meeting the requirements of Rule 144A and such Transfer is in compliance with any applicable
blue sky securities laws of any state of the United States. Upon consummation of the proposed Transfer in accordance with the terms of the Indenture, the transferred beneficial interest or Definitive Note will be subject to the restrictions on
transfer enumerated in the Private Placement Legend printed on the 144A Global Note and/or the Definitive Note and in the Indenture and the Securities Act. 

 

	2.     ̈    	 Check if Transferee will take delivery of a beneficial interest in the Regulation S Global Note or a Definitive Note pursuant to Regulation S.
The Transfer is being 

  
 B-1

	 	
effected pursuant to and in accordance with Rule 903 or Rule 904 under the Securities Act and, accordingly, the Transferor hereby further certifies that (i) the Transfer is not being made to
a Person in the United States and (x) at the time the buy order was originated, the Transferee was outside the United States or such Transferor and any Person acting on its behalf reasonably believed and believes that the Transferee was outside
the United States or (y) the transaction was executed in, on or through the facilities of a designated offshore securities market and neither such Transferor nor any Person acting on its behalf knows that the transaction was prearranged with a
buyer in the United States, (ii) no directed selling efforts have been made in contravention of the requirements of Rule 903(b) or Rule 904(b) of Regulation S under the Securities Act, (iii) the transaction is not part of a plan or scheme
to evade the registration requirements of the Securities Act and (iv) if the proposed transfer is being made prior to the expiration of the Restricted Period, the transfer is not being made to a U.S. Person or for the account or benefit of a
U.S. Person (other than an Initial Purchaser). Upon consummation of the proposed transfer in accordance with the terms of the Indenture, the transferred beneficial interest or Definitive Note will be subject to the restrictions on Transfer
enumerated in the Private Placement Legend printed on the Regulation S Global Note and/or the Definitive Note and in the Indenture and the Securities Act. 

  

	3.     ̈    	Check and complete if Transferee will take delivery of a beneficial interest in an Unrestricted Global Note pursuant to any provision of the Securities Act other
than Rule 144A or Regulation S. The Transfer is being effected in compliance with the transfer restrictions applicable to beneficial interests in Restricted Global Notes and Restricted Definitive Notes and pursuant to and in accordance with the
Securities Act and any applicable blue sky securities laws of any state of the United States, and accordingly the Transferor hereby further certifies that (check one): 

 

	 	(a)     ̈    	such Transfer is being effected pursuant to and in accordance with Rule 144 under the Securities Act; 

or 
  

	 	(b)     ̈    	such Transfer is being effected to the Issuer or a subsidiary thereof; 

 or 
  

	 	(c)     ̈    	such Transfer is being effected pursuant to an effective registration statement under the Securities Act and in compliance with the prospectus delivery requirements of
the Securities Act. 

  

	4.	Check if Transferee will take delivery of a beneficial interest in an Unrestricted Global Note or of an Unrestricted Definitive Note. 

 

	 	(a)     ̈    	 Check if Transfer is pursuant to Rule 144. (i) The Transfer is being effected pursuant to and in accordance with Rule 144 under the
Securities Act and in compliance with the transfer restrictions contained in the Indenture and any applicable blue sky securities laws of any state of the United States and (ii) the restrictions on transfer contained in the

  
 B-2

	 	
Indenture and the Private Placement Legend are not required in order to maintain compliance with the Securities Act. Upon consummation of the proposed Transfer in accordance with the terms of the
Indenture, the transferred beneficial interest or Definitive Note will no longer be subject to the restrictions on transfer enumerated in the Private Placement Legend printed on the Restricted Global Notes, on Restricted Definitive Notes and in the
Indenture. 

  

	 	(b)     ̈    	Check if Transfer is pursuant to Regulation S. (i) The Transfer is being effected pursuant to and in accordance with Rule 903 or Rule 904 under the
Securities Act and in compliance with the transfer restrictions contained in the Indenture and any applicable blue sky securities laws of any state of the United States and (ii) the restrictions on transfer contained in the Indenture and the
Private Placement Legend are not required in order to maintain compliance with the Securities Act. Upon consummation of the proposed Transfer in accordance with the terms of the Indenture, the transferred beneficial interest or Definitive Note will
no longer be subject to the restrictions on transfer enumerated in the Private Placement Legend printed on the Restricted Global Notes, on Restricted Definitive Notes and in the Indenture. 

 

	 	(c)     ̈    	Check if Transfer is pursuant to other exemption. (i) The Transfer is being effected pursuant to and in compliance with an exemption from the registration
requirements of the Securities Act other than Rule 144, Rule 903 or Rule 904 and in compliance with the transfer restrictions contained in the Indenture and any applicable blue sky securities laws of any State of the United States and (ii) the
restrictions on transfer contained in the Indenture and the Private Placement Legend are not required in order to maintain compliance with the Securities Act. Upon consummation of the proposed Transfer in accordance with the terms of the Indenture,
the transferred beneficial interest or Definitive Note will not be subject to the restrictions on transfer enumerated in the Private Placement Legend printed on the Restricted Global Notes or Restricted Definitive Notes and in the Indenture.

 This certificate and the statements contained herein are made for your benefit and the benefit of the Issuer.

  

			
	  

	[Insert Name of Transferor]
		
	By:	 	  

	Name:	 	  

	Title:	 	  

Dated:                     

  
 B-3

 ANNEX A TO CERTIFICATE OF TRANSFER 1. 

 

	1.	The Transferor owns and proposes to transfer the following: 

 [CHECK ONE OF (a) OR (b)] 
 (a)     ̈    a beneficial interest in the: 

(i)    144A Global Note (CUSIP
[                     ]), or 
 (ii)    Regulation S Global Note (CUSIP [                     ]), or 

(b)     ̈    a Restricted Definitive Note.

  

	2.	After the Transfer the Transferee will hold: 

 [CHECK ONE] 

(a)     ̈    a beneficial interest in the:

                         
                   a beneficial interest in the: 
 (i)      144A Global Note (CUSIP [                     ]), or 

(ii)     Regulation S Global Note (CUSIP
[                     ]), or 
 (iii)    Unrestricted Global Note (CUSIP [                     ]), or 

(b)     ̈    a Restricted Definitive Note; or

 (c)     ̈    an Unrestricted
Definitive Note, in accordance with the terms of the Indenture. 

  
 B-4

 EXHIBIT C 

FORM OF CERTIFICATE OF EXCHANGE 
 American Renal Holdings Company, Inc. 
 66 Cherry Hill Drive 

Beverly, MA 01915-1072 
 Facsimile:
(978) 232-4060 
 Attention: Michael Costa 
 Wilmington Trust FSB 
 50 South Sixth Street, Suite 1290 

Minneapolis, MN 55402-1544 
 Facsimile:
(612) 217-5651 
 Attention: American Renal Holdings Administrator 
 Re:     9.75%/10.50% Senior PIK Toggle Notes due 2016 

(CUSIP
[                         ]) 
 Reference is hereby made to the Indenture, dated as of March 4, 2011 (the “Indenture”), among American Renal Holdings Company, Inc., as Issuer (the “Issuer”) and Wilmington Trust
FSB, as trustee. Capitalized terms used but not defined herein shall have the meanings given to them in the Indenture. 

                       
  (the “Owner”) owns and proposes to exchange the Note[s] or interest in such Note[s] specified herein, in the principal amount of $             in such Note[s] or interests
(the “Exchange”). In connection with the Exchange, the Owner hereby certifies that: 
 1. Exchange of Restricted
Definitive Notes or Beneficial Interests in a Restricted Global Note for Unrestricted Definitive Notes or Beneficial Interests in an Unrestricted Global Note. 
 (a)         ̈        Check if Exchange is from beneficial
interest in a Restricted Global Note to beneficial interest in an Unrestricted Global Note. In connection with the Exchange of the Owner’s beneficial interest in a Restricted Global Note for a beneficial interest in an Unrestricted Global
Note in an equal principal amount, the Owner hereby certifies (i) the beneficial interest is being acquired for the Owner’s own account without transfer, (ii) such Exchange has been effected in compliance with the transfer
restrictions applicable to the Global Notes and pursuant to and in accordance with the United States Securities Act of 1933, as amended (the “Securities Act”), (iii) the restrictions on transfer contained in the Indenture and the
Private Placement Legend are not required in order to maintain compliance with the Securities Act and (iv) the beneficial interest in an Unrestricted Global Note is being acquired in compliance with any applicable blue sky securities laws of
any state of the United States. 

(b)         ̈   
     Check if Exchange is from beneficial interest in a Restricted Global Note to Unrestricted Definitive Note. In connection with the Exchange of the Owner’s 

  
 C-1

 
beneficial interest in a Restricted Global Note for an Unrestricted Definitive Note, the Owner hereby certifies (i) the Definitive Note is being acquired for the Owner’s own account
without transfer, (ii) such Exchange has been effected in compliance with the transfer restrictions applicable to the Restricted Global Notes and pursuant to and in accordance with the Securities Act, (iii) the restrictions on transfer
contained in the Indenture and the Private Placement Legend are not required in order to maintain compliance with the Securities Act and (iv) the Definitive Note is being acquired in compliance with any applicable blue sky securities laws of
any state of the United States. 

(c)         ̈   
     Check if Exchange is from Restricted Definitive Note to beneficial interest in an Unrestricted Global Note. In connection with the Owner’s Exchange of a Restricted Definitive Note for a beneficial interest in an
Unrestricted Global Note, the Owner hereby certifies (i) the beneficial interest is being acquired for the Owner’s own account without transfer, (ii) such Exchange has been effected in compliance with the transfer restrictions
applicable to Restricted Definitive Notes and pursuant to and in accordance with the Securities Act, (iii) the restrictions on transfer contained in the Indenture and the Private Placement Legend are not required in order to maintain compliance
with the Securities Act and (iv) the beneficial interest is being acquired in compliance with any applicable blue sky securities laws of any state of the United States. 
 (d)         ̈        Check if Exchange is from Restricted
Definitive Note to Unrestricted Definitive Note. In connection with the Owner’s Exchange of a Restricted Definitive Note for an Unrestricted Definitive Note, the Owner hereby certifies (i) the Unrestricted Definitive Note is being
acquired for the Owner’s own account without transfer, (ii) such Exchange has been effected in compliance with the transfer restrictions applicable to Restricted Definitive Notes and pursuant to and in accordance with the Securities Act,
(iii) the restrictions on transfer contained in the Indenture and the Private Placement Legend are not required in order to maintain compliance with the Securities Act and (iv) the Unrestricted Definitive Note is being acquired in
compliance with any applicable blue sky securities laws of any state of the United States. 
 2. Exchange of Restricted
Definitive Notes or Beneficial Interests in Restricted Global Notes for Restricted Definitive Notes or Beneficial Interests in Restricted Global Notes. 
 (a)         ̈        Check if Exchange is from beneficial
interest in a Restricted Global Note to Restricted Definitive Note. In connection with the Exchange of the Owner’s beneficial interest in a Restricted Global Note for a Restricted Definitive Note with an equal principal amount, the Owner
hereby certifies that the Restricted Definitive Note is being acquired for the Owner’s own account without transfer. Upon consummation of the proposed Exchange in accordance with the terms of the Indenture, the Restricted Definitive Note issued
will continue to be subject to the restrictions on transfer enumerated in the Private Placement Legend printed on the Restricted Definitive Note and in the Indenture and the Securities Act. 

(b)         ̈   
     Check if Exchange is from Restricted Definitive Note to beneficial interest in a Restricted Global Note. In connection with the Exchange of the Owner’s Restricted Definitive Note for a beneficial interest in the
[CHECK ONE] _ 144A Global Note, _ Regulation S Global Note with an equal principal amount, the Owner hereby certifies (i) the 

  
 C-2

 
beneficial interest is being acquired for the Owner’s own account without transfer and (ii) such Exchange has been effected in compliance with the transfer restrictions applicable to
the Restricted Global Notes and pursuant to and in accordance with the Securities Act, and in compliance with any applicable blue sky securities laws of any state of the United States. Upon consummation of the proposed Exchange in accordance with
the terms of the Indenture, the beneficial interest issued will be subject to the restrictions on transfer enumerated in the Private Placement Legend printed on the relevant Restricted Global Note and in the Indenture and the Securities Act.

 This certificate and the statements contained herein are made for your benefit and the benefit of the Issuer. 

 

			
	  

[Insert Name of Transferor]

 

	 By:
	 	  

	 Name:
	 	  

	 Title:
	 	  

 Dated: 

  
 C-3

 EXHIBIT D 

[FORM OF GUARANTEE AGREEMENT] 
 Pursuant to the Indenture (the “Indenture”) dated as of March 4, 2011 between American Renal Holdings Company, Inc. (“Issuer”) and Wilmington Trust FSB, as trustee (the
“Trustee”), the Guarantor, subject to the provisions of Article X of the Indenture, hereby fully, unconditionally and irrevocably guarantees on a senior unsecured basis, ranking equally in right of payment with any senior Indebtedness of
the Issuer, as primary obligor and not merely as surety, jointly and severally with any other Guarantor, to each Holder of the Notes, to the extent lawful, and the Trustee the full and punctual payment when due, whether at maturity, by acceleration,
by redemption or otherwise, of the principal of, premium, if any, and interest on the Notes and all other obligations of the Issuer under the Indenture and the Notes (including without limitation interest accruing after the filing of any petition in
bankruptcy, or the commencement of any insolvency, reorganization or like proceeding, relating to the Issuer or any Guarantor whether or not a claim for post-filing or post-petition interest is allowed in such proceeding and the obligations under
Section 7.6 of the Indenture) (the “Guarantor Obligations”). The Guarantor agrees (to the extent lawful) that the Guarantor Obligations may be extended or renewed, in whole or in part, without notice or further assent from it, and
that it shall remain bound under this Guarantee Agreement notwithstanding any extension or renewal of any Guarantor Obligation. 

The Guarantor Obligations of the Guarantors to the Holders of the Notes pursuant to the Guarantee Agreement and the Indenture are
expressly set forth in Article X of the Indenture and reference is hereby made to the Indenture for the precise terms of the Guarantee Agreement. 
 The Guarantor also agrees to pay any and all reasonable costs and expenses (including reasonable attorneys’ fees) incurred by the Trustee or the Holders in enforcing any rights under this Guarantee
Agreement. 
  

			
	[Name of Guarantor]
		
	 By:
	 	  

	 Name:
	 	  

	 Title:
	 	  

  
 D-1Registraton Rights Agreement

 Exhibit 4.2 
 REGISTRATION RIGHTS AGREEMENT 
 by and between 

American Renal Holdings Company, Inc., 
 and 
 Merrill Lynch, Pierce, Fenner & Smith Incorporated

 Barclays Capital Inc. 
 as Representatives of the several Initial Purchasers 
 Dated as of
March 4, 2011 

  

 REGISTRATION RIGHTS AGREEMENT 

This Registration Rights Agreement (this “Agreement”) is made and entered into as of March 4, 2011, by and between
American Renal Holdings Company, Inc., a Delaware corporation (the “Company”) and Merrill Lynch, Pierce, Fenner & Smith Incorporated and Barclays Capital Inc., as Representatives of the several initial purchasers (collectively,
the “Initial Purchasers” named on Schedule A to the Purchase Agreement), each of whom has agreed to purchase the Company’s 9.75% / 10.50% Senior PIK Toggle Notes due 2016 (the “Initial Notes”) pursuant to the Purchase
Agreement (as defined below). 
 This Agreement is made pursuant to the Purchase Agreement, dated March 1, 2011 (the
“Purchase Agreement”), between the Company and the Initial Purchasers (i) for the benefit of the Initial Purchasers and (ii) for the benefit of the holders from time to time of the Initial Notes, including the Initial Purchasers.
In order to induce the Initial Purchasers to purchase the Initial Notes, the Company has agreed to provide the registration rights set forth in this Agreement. The execution and delivery of this Agreement is a condition to the obligations of the
Initial Purchasers set forth in Section 5(g) of the Purchase Agreement. 
 The parties hereby agree as follows: 

SECTION 1: Definitions. As used in this
Agreement, the following capitalized terms shall have the following meanings: 
 Additional Interest Payment Date: With
respect to the Initial Notes, each Interest Payment Date. 
 Broker-Dealer: Any broker or dealer registered under the
Exchange Act. 
 Business Day: Any day other than a Saturday, Sunday or U.S. federal holiday or a day on which banking
institutions or trust companies located in New York, New York are authorized or obligated to be closed. 
 Closing Date:
The date of this Agreement. 
 Commission: The Securities and Exchange Commission. 

Consummate: A registered Exchange Offer shall be deemed “Consummated” for purposes of this Agreement upon the occurrence
of (i) the filing and effectiveness under the Securities Act of the Exchange Offer Registration Statement relating to the Exchange Notes to be issued in the Exchange Offer, (ii) the maintenance of such Registration Statement continuously
effective and the keeping of the Exchange Offer open for a period not less than the minimum period required pursuant to Section 3(b) hereof, and (iii) the delivery by the Company to the Registrar under the Indenture of Exchange Notes in
the same aggregate principal amount as the aggregate principal amount of Initial Notes that were tendered by Holders thereof pursuant to the Exchange Offer. 
 Effectiveness Target Date: As defined in Section 5 hereof. 

  
 1 

 Exchange Act: The Securities Exchange Act of 1934, as amended. 

Exchange Offer: The registration by the Company under the Securities Act of the Exchange Notes pursuant to a Registration
Statement pursuant to which the Company offers the Holders of all outstanding Transfer Restricted Notes the opportunity to exchange all such outstanding Transfer Restricted Notes held by such Holders for Exchange Notes in an aggregate principal
amount equal to the aggregate principal amount of the Transfer Restricted Notes tendered in such exchange offer by such Holders. 
 Exchange Offer Registration Statement: The Registration Statement relating to the Exchange Offer, including the related Prospectus. 

Exchange Notes: The 9.75% / 10.50% Senior PIK Toggle Notes due 2016, of the same series under the Indenture as the Initial Notes,
to be issued to Holders in exchange for Transfer Restricted Notes pursuant to this Agreement. 
 FINRA: Financial
Industry Regulatory Authority. 
 Holders: As defined in Section 2(b) hereof. 

Indemnified Holder: As defined in Section 8(a) hereof. 

Indenture: The Indenture, dated as of March 4, 2011, by and among the Company and Wilmington Trust FSB, as trustee (the
“Trustee”), pursuant to which the Notes are to be issued, as such Indenture is amended or supplemented from time to time in accordance with the terms thereof. 
 Initial Purchasers: As defined in the preamble hereto. 
 Initial Notes:
As defined in the preamble hereto. 
 Initial Placement: The issuance and sale by the Company of the Initial Notes to
the Initial Purchasers pursuant to the Purchase Agreement. 
 Interest Payment Date: As defined in the Indenture and the
Notes. 
 Person: An individual, partnership, corporation, trust or unincorporated organization, or a government or
agency or political subdivision thereof. 
 Prospectus: The prospectus included in a Registration Statement, as amended
or supplemented by any prospectus supplement and by all other amendments thereto, including post- effective amendments, and all material incorporated by reference into such Prospectus. 

Registration Default: As defined in Section 5 hereof. 

Registration Statement: Any registration statement of the Company relating to (a) an offering of Exchange Notes pursuant to
an Exchange Offer or (b) the registration for resale of Transfer Restricted Notes pursuant to the Shelf Registration Statement, which is filed pursuant to 

  
 2 

 
the provisions of this Agreement, in each case, including the Prospectus included therein, all amendments and supplements thereto (including post-effective amendments) and all exhibits and
material incorporated by reference therein. 
 Securities Act: The Securities Act of 1933, as amended. 

Shelf Filing Deadline: As defined in Section 4(a) hereof. 

Shelf Registration Statement: As defined in Section 4(a) hereof. 

Transfer Restricted Notes: Each Initial Note, until the earliest to occur of (a) the date on which such Initial Note is
exchanged in the Exchange Offer for an Exchange Note entitled to be resold to the public by the Holder thereof without complying with the prospectus delivery requirements of the Securities Act, (b) the date on which such Initial Note has been
effectively registered under the Securities Act and disposed of in accordance with a Shelf Registration Statement and (c) the date on which such Initial Note is distributed to the public by a Broker-Dealer pursuant to the “Plan of
Distribution” contemplated by the Exchange Offer Registration Statement (including delivery of the Prospectus contained therein). 
 Trust Indenture Act: The Trust Indenture Act of 1939, as amended. 

Underwritten Registration or Underwritten Offering: A registration in which securities of the Company are sold to an underwriter
for reoffering to the public. 
 SECTION 2: Notes Subject to
this Agreement. 
 (a) Transfer Restricted Notes. The securities entitled
to the benefits of this Agreement are the Transfer Restricted Notes. 
 (b) Holders of Transfer Restricted Notes. A
Person is deemed to be a holder of Transfer Restricted Notes (each, a “Holder”) whenever such Person owns Transfer Restricted Notes. 
 SECTION 3: Registered Exchange Offer. 
 (a) Unless the Exchange Offer shall not be permissible under applicable law or Commission policy (after the procedures set forth in Section 6(a) hereof have been complied with), the Company shall
(i) cause to be filed with the Commission as soon as practicable after the Closing Date, but in no event later than 180 days after the Closing Date (or if such 180th day is not a Business Day, the next succeeding Business Day), a Registration
Statement under the Securities Act relating to the Exchange Notes and the Exchange Offer, (ii) use its reasonable best efforts to cause such Registration Statement to become effective at the earliest possible time, but in no event later than
210 days after the Closing Date (or if such 2 10th day is not a Business Day, the next succeeding Business Day), (iii) in connection with the foregoing, file (A) all pre- effective amendments to such Registration Statement as may be
necessary in order to cause such Registration Statement to become effective, (B) if applicable, a post-effective amendment to such Registration Statement pursuant to Rule 430A under the Securities Act and (C) cause all necessary filings in
connection with the registration and qualification of the Exchange Notes to 

  
 3 

 
be made under the state securities or blue sky laws of such jurisdictions as are necessary to permit Consummation of the Exchange Offer, and (iv) upon the effectiveness of such Registration
Statement, commence the Exchange Offer. The Exchange Offer shall be on the appropriate form permitting registration of the Exchange Notes to be offered in exchange for the Transfer Restricted Notes and to permit resales of Initial Notes held by
Broker-Dealers as contemplated by Section 3(c) hereof. 
 (b) The Company shall use its reasonable best efforts to cause
the Exchange Offer Registration Statement to be effective continuously and shall keep the Exchange Offer open for a period of not less than the minimum period required under applicable federal and state securities laws to Consummate the Exchange
Offer; provided, however, that in no event shall such period be less than 20 Business Days (or longer if required by applicable law) after the date notice of the Exchange Offer is mailed to the Holders. The Company shall cause the Exchange
Offer to comply with all applicable federal and state securities laws. No securities other than the Exchange Notes shall be included in the Exchange Offer Registration Statement. The Company shall use its reasonable best efforts to cause the
Exchange Offer to be Consummated on the earliest practicable date after the Exchange Offer Registration Statement has become effective, but in no event later than 240 days after the Closing Date (or if such 240th day is not a Business Day, the next
succeeding Business Day). 
 (c) The Company shall indicate in a “Plan of Distribution” section contained in the
Prospectus forming a part of the Exchange Offer Registration Statement that any Broker-Dealer who holds Initial Notes that are Transfer Restricted Notes and that were acquired for its own account as a result of market-making activities or other
trading activities (other than Transfer Restricted Notes acquired directly from the Company), may exchange such Initial Notes pursuant to the Exchange Offer; however, such Broker-Dealer may be deemed to be an “underwriter” within the
meaning of the Securities Act and must, therefore, deliver a prospectus meeting the requirements of the Securities Act in connection with any resales of the Exchange Notes received by such Broker-Dealer in the Exchange Offer, which prospectus
delivery requirement may be satisfied by the delivery by such Broker-Dealer of the Prospectus contained in the Exchange Offer Registration Statement. Such “Plan of Distribution” section shall also contain all other information with respect
to such resales by Broker-Dealers that the Commission may require in order to permit such resales pursuant thereto, but such “Plan of Distribution” shall not name any such Broker-Dealer or disclose the amount of Initial Securities held by
any such Broker-Dealer except to the extent required by the Commission as a result of a change in policy after the date of this Agreement. 
 The Company shall use its reasonable best efforts to keep the Exchange Offer Registration Statement continuously effective, supplemented and amended as required by the provisions of Section 6(c)
hereof to the extent necessary to ensure that it is available for resales of Initial Notes acquired by Broker-Dealers for their own accounts as a result of market-making activities or other trading activities, and to ensure that it conforms with the
requirements of this Agreement, the Securities Act and the policies, rules and regulations of the Commission as announced from time to time, for a period ending on the earlier of (i) 180 days from the date on which the Exchange Offer
Registration Statement is declared effective and (ii) the date on which a Broker-Dealer is no longer required to deliver a prospectus in connection with market-making or other trading activities. 

  
 4 

 The Company shall provide sufficient copies of the latest version of such Prospectus to
Broker-Dealers promptly upon request at any time during such 180-day (or shorter as provided in the foregoing sentence) period in order to facilitate such resales. 
 SECTION 4: Shelf Registration. 
 (a) Shelf
Registration. If (i) the Company is not required to file an Exchange Offer Registration Statement or to consummate the Exchange Offer because the Exchange Offer is not permitted by applicable law or Commission policy (after the procedures
set forth in Section 6(a) hereof have been complied with), (ii) for any reason the Exchange Offer is not Consummated within 240 days after the Closing Date (or if such 240th day is not a Business Day, the next succeeding Business Day), or
(iii) with respect to any Holder of Transfer Restricted Notes (A) such Holder is prohibited by applicable law or Commission policy from participating in the Exchange Offer, or (B) such Holder may not resell the Exchange Notes acquired
by it in the Exchange Offer to the public without delivering a prospectus and that the Prospectus contained in the Exchange Offer Registration Statement is not appropriate or available for such resales by such Holder, or (C) such Holder is a
Broker-Dealer and holds Initial Notes acquired directly from the Company or one of its affiliates, then, upon such Holder’s request, the Company shall 
 (x) use its reasonable best efforts to cause to be filed a shelf registration statement pursuant to Rule 415 under the Securities Act, which may be an amendment to the Exchange Offer Registration
Statement (in either event, the “Shelf Registration Statement”) as soon as practicable but in any event on or prior to 240 days after the Closing Date (or if such 240th day is not a Business Day, the next succeeding Business Day) (such
date being the “Shelf Filing Deadline”), which Shelf Registration Statement shall provide for resales of all Transfer Restricted Notes the Holders of which shall have provided the information required pursuant to Section 4(b) hereof;
and 
 (y) use its reasonable best efforts to cause such Shelf Registration Statement to be declared effective by
the Commission on or before the 30th day after the Shelf Filing Deadline (or if such 30th day is not a Business Day, the next succeeding Business Day). 
 The Company shall use its reasonable best efforts to keep such Shelf Registration Statement continuously effective, supplemented and amended as required by the provisions of Sections 6(b) and
(c) hereof to the extent necessary to ensure that it is available for resales of Initial Notes by the Holders of Transfer Restricted Notes entitled to the benefit of this Section 4(a), and to ensure that it conforms with the requirements
of this Agreement, the Securities Act and the policies, rules and regulations of the Commission as announced from time to time, for a period of at least two years following the effective date of such Shelf Registration Statement (or shorter period
that will terminate when all the Initial Securities covered by such Shelf Registration Statement have been sold pursuant to such Shelf Registration Statement). 
 (b) Provision by Holders of Certain Information in Connection with the Shelf Registration Statement. No Holder of Transfer Restricted Notes may include any of its Transfer Restricted Notes in any
Shelf Registration Statement pursuant to this Agreement unless and until such Holder furnishes to the Company in writing, within 20 Business Days after receipt of a 

  
 5 

 
request therefor, such information as the Company may reasonably request for use in connection with any Shelf Registration Statement or Prospectus or preliminary Prospectus included therein. Each
Holder as to which any Shelf Registration Statement is being effected agrees to furnish promptly to the Company all information required to be disclosed in order to make the information previously furnished to the Company by such Holder not
materially misleading. 
 SECTION 5: Additional
Interest. If (i) any of the Registration Statements required by this Agreement is not filed with the Commission on or prior to the
date specified for such filing in this Agreement, (ii) any of such Registration Statements has not been declared effective by the Commission on or prior to the date specified for such effectiveness in this Agreement (the “Effectiveness
Target Date”), (iii) the Exchange Offer has not been Consummated within 240 days after the Closing Date or (iv) any Registration Statement required by this Agreement is filed and declared effective but shall thereafter cease to be
effective or fail to be usable for its intended purpose without being succeeded immediately by a post-effective amendment to such Registration Statement that cures such failure and that is itself immediately declared effective (each such event
referred to in clauses (i) through (iv), a “Registration Default”), the Company hereby agrees that the interest rate borne by the Transfer Restricted Notes shall be increased by 0.25% per annum during the 180-day period
immediately following the occurrence of any Registration Default and shall increase by 0.25% per annum at the end of each subsequent 90-day period, but in no event shall such increase exceed 1.50% per annum. Following the cure of all
Registration Defaults relating to any particular Transfer Restricted Securities, the interest rate borne by the relevant Transfer Restricted Notes will be reduced to the original interest rate borne by such Transfer Restricted Notes; provided,
however, that, if after any such reduction in interest rate, a different Registration Default occurs, the interest rate borne by the relevant Transfer Restricted Notes shall again be increased pursuant to the foregoing provisions. 

All obligations of the Company set forth in the preceding paragraph that are outstanding with respect to any Transfer Restricted Note at
the time such security ceases to be a Transfer Restricted Note shall survive until such time as all such obligations with respect to such security shall have been satisfied in full. 

SECTION 6: Registration Procedures. 

(a) Exchange Offer Registration Statement. In connection with the Exchange Offer, the Company shall comply with all of the provisions of
Section 6(c) hereof, shall use its reasonable best efforts to effect such exchange to permit the sale of Transfer Restricted Notes being sold in accordance with the intended method or methods of distribution thereof, and shall comply with all
of the following provisions: 
 (i) If in the reasonable opinion of counsel to the Company there is a question as
to whether the Exchange Offer is permitted by applicable law, the Company hereby agrees to seek a no-action letter or other favorable decision from the Commission allowing the Company to Consummate an Exchange Offer for such Initial Notes. The
Company hereby agrees to pursue the issuance of such a decision to the Commission staff level but shall not be required to take commercially unreasonable action to effect a change of Commission policy. The Company hereby agrees, however, to
(A) participate 

  
 6 

 
in telephonic conferences with the Commission, (B) deliver to the Commission staff an analysis prepared by counsel to the Company setting forth the legal bases, if any, upon which such
counsel has concluded that such an Exchange Offer should be permitted and (C) diligently pursue a favorable resolution by the Commission staff of such submission. 

(ii) As a condition to its participation in the Exchange Offer pursuant to the terms of this Agreement, each Holder of
Transfer Restricted Securities shall furnish, upon the request of the Company, prior to the Consummation thereof, a written representation to the Company (which may be contained in the letter of transmittal contemplated by the Exchange Offer
Registration Statement) to the effect that (A) it is not an affiliate of the Company, (B) it is not engaged in, and does not intend to engage in, and has no arrangement or understanding with any Person to participate in, a distribution of
the Exchange Notes to be issued in the Exchange Offer and (C) it is acquiring the Exchange Notes in its ordinary course of business. In addition, all such Holders of Transfer Restricted Notes shall otherwise cooperate in the Company’s
preparations for the Exchange Offer. Each Holder hereby acknowledges and agrees that any Broker-Dealer and any such Holder using the Exchange Offer to participate in a distribution of the securities to be acquired in the Exchange Offer
(1) could not under Commission policy as in effect on the date of this Agreement rely on the position of the Commission enunciated in Morgan Stanley and Co., Inc. (available June 5, 1991) and Exxon Capital Holdings
Corporation (available May 13, 1988), as interpreted in the Commission’s letter to Shearman & Sterling dated July 2, 1993, and similar no-action letters (which may include any no-action letter obtained pursuant to clause
(i) above), and (2) must comply with the registration and prospectus delivery requirements of the Securities Act in connection with a secondary resale transaction and that such a secondary resale transaction should be covered by an
effective registration statement containing the selling security holder information required by Item 507 or 508, as applicable, of Regulation S-K if the resales are of Exchange Notes obtained by such Holder in exchange for Initial Notes
acquired by such Holder directly from the Company. 
 (b) Shelf Registration Statement. In connection with the Shelf
Registration Statement, the Company shall comply with all the provisions of Section 6(c) hereof and shall use its best efforts to effect such registration to permit the sale of the Transfer Restricted Notes being sold in accordance with the
intended method or methods of distribution thereof, and pursuant thereto the Company will as expeditiously as possible prepare and file with the Commission a Registration Statement relating to the registration on any appropriate form under the
Securities Act, which form shall be available for the sale of the Transfer Restricted Notes in accordance with the intended method or methods of distribution thereof. 
 (c) General Provisions. In connection with any Registration Statement and any Prospectus required by this Agreement to permit the sale or resale of Transfer Restricted Notes (including, without
limitation, any Registration Statement and the related Prospectus required to permit resales of Initial Securities by Broker-Dealers), the Company shall: 
 (i) use its reasonable best efforts to keep such Registration Statement continuously effective and provide all requisite financial statements for the period specified in Section 3 or 4 hereof, as
applicable; upon the occurrence of any event that 

  
 7 

 
would cause any such Registration Statement or the Prospectus contained therein (A) to contain a material misstatement or omission or (B) not to be effective and usable for resale of
Transfer Restricted Notes during the period required by this Agreement, the Company shall file promptly an appropriate amendment to such Registration Statement, in the case of clause (A), correcting any such misstatement or omission, and, in the
case of either clause (A) or (B), use its reasonable best efforts to cause such amendment to be declared effective and such Registration Statement and the related Prospectus to become usable for their intended purpose(s) as soon as practicable
thereafter; 
 (ii) prepare and file with the Commission such amendments and post-effective amendments to the
applicable Registration Statement as may be necessary to keep the Registration Statement effective for the applicable period set forth in Section 3 or 4 hereof, as applicable, or such shorter period as will terminate when all Transfer
Restricted Notes covered by such Registration Statement have been sold; cause the Prospectus to be supplemented by any required Prospectus supplement, and as so supplemented to be filed pursuant to Rule 424 under the Securities Act, and to comply
fully with the applicable provisions of Rules 424 and 430A under the Securities Act in a timely manner; and comply with the provisions of the Securities Act with respect to the disposition of all securities covered by such Registration Statement
during the applicable period in accordance with the intended method or methods of distribution by the sellers thereof set forth in such Registration Statement or supplement to the Prospectus; 

(iii) advise the underwriter(s), if any, and selling Holders promptly and, if requested by such Persons, to confirm such
advice in writing, (A) when the Prospectus or any Prospectus supplement or post-effective amendment has been filed, and, with respect to any Registration Statement or any post-effective amendment thereto, when the same has become effective,
(B) of any request by the Commission for amendments to the Registration Statement or amendments or supplements to the Prospectus or for additional information relating thereto, (C) of the issuance by the Commission of any stop order
suspending the effectiveness of the Registration Statement under the Securities Act or of the suspension by any state securities commission of the qualification of the Transfer Restricted Notes for offering or sale in any jurisdiction, or the
initiation of any proceeding for any of the preceding purposes, (D) of the existence of any fact or the happening of any event that makes any statement of a material fact made in the Registration Statement, the Prospectus, any amendment or
supplement thereto, or any document incorporated by reference therein untrue, or that requires the making of any additions to or changes in the Registration Statement or the Prospectus in order to make the statements therein not misleading. If at
any time the Commission shall issue any stop order suspending the effectiveness of the Registration Statement, or any state securities commission or other regulatory authority shall issue an order suspending the qualification or exemption from
qualification of the Transfer Restricted Notes under state securities or blue sky laws, the Company shall use its reasonable best efforts to obtain the withdrawal or lifting of such order at the earliest possible time; 

(iv) furnish without charge to each of the Initial Purchasers, each selling Holder named in any Registration Statement,
and each of the underwriter(s), if any, before filing with the Commission, copies of any Registration Statement or any 

  
 8 

 
Prospectus included therein or any amendments or supplements to any such Registration Statement or Prospectus (including all documents incorporated by reference after the initial filing of such
Registration Statement), which documents will be subject to the review and comment of such Holders and underwriter(s) in connection with such sale, if any, for a period of at least five Business Days, and the Company will not file any such
Registration Statement or Prospectus or any amendment or supplement to any such Registration Statement or Prospectus (including all such documents incorporated by reference) to which an Initial Purchaser of Transfer Restricted Notes covered by such
Registration Statement or the underwriter(s), if any, shall reasonably object in writing within five Business Days after the receipt thereof (such objection to be deemed timely made upon confirmation of telecopy transmission within such period). The
objection of an Initial Purchaser or underwriter, if any, shall be deemed to be reasonable if such Registration Statement, amendment, Prospectus or supplement, as applicable, as proposed to be filed, contains a material misstatement or omission;

 (v) promptly prior to the filing of any document that is to be incorporated by reference into a Registration
Statement or Prospectus, provide copies of such document to the Initial Purchasers, each selling Holder named in any Registration Statement, and to the underwriter(s), if any, make the Company’s representatives available for discussion of such
document and other customary due diligence matters, and include such information in such document prior to the filing thereof as such selling Holders or underwriter(s), if any, reasonably may request; 

(vi) make available at reasonable times for inspection by the Initial Purchasers, the managing underwriter(s), if any,
participating in any disposition pursuant to such Registration Statement and any attorney or accountant retained by such Initial Purchasers or any of the underwriter(s), all financial and other records, pertinent corporate documents and properties
of the Company and cause the Company’s officers, directors and employees to supply all information reasonably requested by any such Holder, underwriter, attorney or accountant in connection with such Registration Statement or any post-effective
amendment thereto subsequent to the filing thereof and prior to its effectiveness and to participate in meetings with investors to the extent reasonably requested by the managing underwriter(s), if any; 

(vii) if requested by any selling Holders or the underwriter(s), if any, promptly incorporate in any Registration
Statement or Prospectus, pursuant to a supplement or post-effective amendment if necessary, such information as such selling Holders and underwriter(s), if any, may reasonably request to have included therein, including, without limitation,
information relating to the “Plan of Distribution” of the Transfer Restricted Notes, information with respect to the principal amount of Transfer Restricted Notes being sold to such underwriter(s), the purchase price being paid therefor
and any other terms of the offering of the Transfer Restricted Notes to be sold in such offering; and make all required filings of such Prospectus supplement or post-effective amendment as soon as practicable after the Company is notified of the
matters to be incorporated in such Prospectus supplement or post-effective amendment; 

  
 9 

 (viii) cause the Transfer Restricted Notes covered by the Registration
Statement to be rated with the appropriate rating agencies, if so requested by the Holders of a majority in aggregate principal amount of Notes covered thereby or the underwriter(s), if any; 

(ix) furnish to each Initial Purchaser, each selling Holder and each of the underwriter(s), if any, without charge, at
least one copy of the Registration Statement, as first filed with the Commission, and of each amendment thereto, including financial statements and schedules, all documents incorporated by reference therein and all exhibits (including exhibits
incorporated therein by reference); 
 (x) deliver to each selling Holder and each of the underwriter(s), if any,
without charge, as many copies of the Prospectus (including each preliminary prospectus) and any amendment or supplement thereto as such Persons reasonably may request; the Company hereby consents to the use of the Prospectus and any amendment or
supplement thereto by each of the selling Holders and each of the underwriter(s), if any, in connection with the offering and the sale of the Transfer Restricted Notes covered by the Prospectus or any amendment or supplement thereto; 

(xi) enter into such agreements (including an underwriting agreement), and make such representations and warranties, and
take all such other actions in connection therewith in order to expedite or facilitate the disposition of the Transfer Restricted Notes pursuant to any Registration Statement contemplated by this Agreement, all to such extent as may be reasonably
requested by any Initial Purchaser or by any Holder of Transfer Restricted Notes or underwriter in connection with any sale or resale pursuant to any Registration Statement contemplated by this Agreement; and whether or not an underwriting agreement
is entered into and whether or not the registration is an Underwritten Registration, the Company shall: 
 (A)
furnish to each Initial Purchaser, each selling Holder and each underwriter, if any, in such substance and scope as they may request and as are customarily made by issuers to underwriter(s) in primary underwritten offerings, upon the date of the
Consummation of the Exchange Offer or, if applicable, the effectiveness of the Shelf Registration Statement: 

(1) a certificate, dated the date of Consummation of the Exchange Offer or the date of effectiveness of the Shelf
Registration Statement, as the case may be, signed by (y) the President or any Vice President and (z) a principal financial or accounting officer of the Company, confirming, as of the date thereof, the matters set forth in paragraphs (i),
(ii) and (iii) of Section 5(e) of the Purchase Agreement and such other matters as such parties may reasonably request; 
 (2) an opinion, dated the date of Consummation of the Exchange Offer or the date of effectiveness of the Shelf Registration Statement, as the case may be, of counsel for the Company, covering the matters
set forth in Section 5(c) of the Purchase Agreement and such other 

  
 10 

 
matter as such parties may reasonably request, and in any event including a statement to the effect that such counsel has participated in conferences with officers and other representatives of
the Company, representatives of the independent public accountants for the Company, representatives of the underwriter(s), if any, and counsel to the underwriter(s), if any, in connection with the preparation of such Registration Statement and the
related Prospectus and have considered the matters required to be stated therein and the statements contained therein, although such counsel has not independently verified the accuracy, completeness or fairness of such statements; and that such
counsel advises that, on the basis of the foregoing, no facts came to such counsel’s attention that caused such counsel to believe that the applicable Registration Statement, at the time such Registration Statement or any post-effective
amendment thereto became effective, and, in the case of the Exchange Offer Registration Statement, as of the date of Consummation, contained an untrue statement of a material fact or omitted to state a material fact required to be stated therein or
necessary to make the statements therein not misleading, or that the Prospectus contained in such Registration Statement as of its date and, in the case of the opinion dated the date of Consummation of the Exchange Offer, as of the date of
Consummation, contained an untrue statement of a material fact or omitted to state a material fact necessary in order to make the statements therein not misleading. Without limiting the foregoing, such counsel may state further that such counsel
assumes no responsibility for, and has not independently verified, the accuracy, completeness or fairness of the financial statements, notes and schedules and other financial data included in any Registration Statement contemplated by this Agreement
or the related Prospectus; and 
 (3) a customary comfort letter, dated the date of effectiveness of the Shelf
Registration Statement, from the Company’s independent accountants, in the customary form and covering matters of the type customarily requested to be covered in comfort letters by underwriter(s) in connection with primary underwritten
offerings, and covering or affirming the matters set forth in the comfort letters delivered pursuant to Section 5(a) of the Purchase Agreement, without exception; 

(B) set forth in full or incorporate by reference in the underwriting agreement, if any, the indemnification provisions
and procedures of Section 8 hereof with respect to all parties to be indemnified pursuant to said Section; and 
 (C) deliver such other documents and certificates as may be reasonably requested by such parties to evidence compliance with Section 6(c)(xi)(A) hereof and with any customary conditions contained in
the underwriting agreement or other agreement entered into by the Company pursuant to this Section 6(c)(xi), if any. 

  
 11 

 If at any time the representations and warranties of the Company contemplated in
Section 6(c)(xi)(A)(1) hereof cease to be true and correct, the Company shall so advise the Initial Purchasers and the underwriter(s), if any, and each selling Holder promptly and, if requested by such Persons, shall confirm such advice in
writing; 
 (xii) prior to any public offering of Transfer Restricted Notes, cooperate with the selling Holders,
the underwriter(s), if any, and their respective counsel in connection with the registration and qualification of the Transfer Restricted Notes under the state securities or blue sky laws of such jurisdictions as the selling Holders or
underwriter(s), if any, may request and do any and all other acts or things necessary or advisable to enable the disposition in such jurisdictions of the Transfer Restricted Notes covered by the Shelf Registration Statement; provided,
however, that the Company shall not be required to register or qualify as a foreign corporation where it is not then so qualified or to take any action that would subject it to the service of process in suits or to taxation, other than as to
matters and transactions relating to the Registration Statement, in any jurisdiction where it is not then so subject; 
 (xiii) shall issue, upon the request of any Holder of Initial Notes covered by the Shelf Registration Statement, Exchange Securities having an aggregate principal amount equal to the aggregate principal
amount of Initial Securities surrendered to the Company by such Holder in exchange therefor or being sold by such Holder; such Exchange Notes to be registered in the name of such Holder or in the name of the purchaser(s) of such Securities, as the
case may be; in return, the Initial Notes held by such Holder shall be surrendered to the Company for cancellation; 
 (xiv) cooperate with the selling Holders and the underwriter(s), if any, to facilitate the timely preparation and delivery of certificates representing Transfer Restricted Notes to be sold and not bearing
any restrictive legends; and enable such Transfer Restricted Notes to be in such denominations and registered in such names as the Holders or the underwriter(s), if any, may request at least two Business Days prior to any sale of Transfer Restricted
Notes made by such Holders or underwriter(s); 
 (xv) use its best efforts to cause the Transfer Restricted Notes
covered by the Registration Statement to be registered with or approved by such other governmental agencies or authorities as may be necessary to enable the seller or sellers thereof or the underwriter(s), if any, to consummate the disposition of
such Transfer Restricted Notes, subject to the proviso contained in Section 6(c)(xii) hereof; 
 (xvi) if
any fact or event contemplated by Section 6(c)(iii)(D) hereof shall exist or have occurred, prepare a supplement or post-effective amendment to the Registration Statement or related Prospectus or any document incorporated therein by reference
or file any other required document so that, as thereafter delivered to the purchasers of Transfer Restricted Notes, the Prospectus will not contain an untrue statement of a material fact or omit to state any material fact necessary in order to make
the statements therein not misleading; 

  
 12 

 (xvii) provide a CUSIP number for all Notes not later than the effective
date of the Registration Statement covering such Notes and provide the Trustee under the Indenture with printed certificates for such Notes which are in a form eligible for deposit with the Depository Trust Company and take all other action
necessary to ensure that all such Notes are eligible for deposit with the Depository Trust Company; 
 (xviii)
cooperate and assist in any filings required to be made with FINRA and in the performance of any due diligence investigation by any underwriter (including any “qualified independent underwriter”) that is required to be retained in
accordance with the rules and regulations of FINRA; 
 (xix) otherwise use its best efforts to comply with all
applicable rules and regulations of the Commission, and make generally available to its security holders, as soon as practicable, a consolidated earnings statement meeting the requirements of Rule 158 (which need not be audited) for the twelve-month
period (A) commencing at the end of any fiscal quarter in which Transfer Restricted Notes are sold to underwriter(s) in a firm commitment or best efforts Underwritten Offering or (B) if not sold to underwriter(s) in such an offering,
beginning with the first month of the Company’s first fiscal quarter commencing after the effective date of the Registration Statement; 
 (xx) cause the Indenture to be qualified under the Trust Indenture Act not later than the effective date of the first Registration Statement required by this Agreement, and, in connection therewith,
cooperate with the Trustee and the Holders of Notes to effect such changes to the Indenture as may be required for such Indenture to be so qualified in accordance with the terms of the Trust Indenture Act; and to execute and use its best efforts to
cause the Trustee to execute, all documents that may be required to effect such changes and all other forms and documents required to be filed with the Commission to enable such Indenture to be so qualified in a timely manner; 

(xxi) cause all Notes covered by the Registration Statement to be listed on each securities exchange or automated
quotation system on which similar securities issued by the Company are then listed if requested by the Holders of a majority in aggregate principal amount of Initial Notes or the managing underwriter(s), if any; and 

(xxii) provide promptly to each Holder upon request each document filed with the Commission pursuant to the requirements
of Section 13 and Section 15 of the Exchange Act. 
 Each Holder agrees by acquisition of a Transfer Restricted Note
that, upon receipt of any notice from the Company of the existence of any fact of the kind described in Section 6(c)(iii)(D) hereof, such Holder will forthwith discontinue disposition of Transfer Restricted Notes pursuant to the applicable
Registration Statement until such Holder’s receipt of the copies of the supplemented or amended Prospectus contemplated by Section 6(c)(xvi) hereof, or until it is advised in writing (the “Advice”) by the Company that the use of
the Prospectus may be resumed, and has received copies of any additional or supplemental filings that are incorporated by reference in the Prospectus. If so directed by the Company, each Holder will deliver to the Company (at the Company’s
expense) all copies, other than permanent file copies then in such 

  
 13 

 
Holder’s possession, of the Prospectus covering such Transfer Restricted Notes that was current at the time of receipt of such notice. In the event the Company shall give any such notice,
the time period regarding the effectiveness of such Registration Statement set forth in Section 3 or 4 hereof, as applicable, shall be extended by the number of days during the period from and including the date of the giving of such notice
pursuant to Section 6(c)(iii)(D) hereof to and including the date when each selling Holder covered by such Registration Statement shall have received the copies of the supplemented or amended Prospectus contemplated by Section 6(c)(xvi)
hereof or shall have received the Advice; provided, however, that no such extension shall be taken into account in determining whether Additional Interest is due pursuant to Section 5 hereof or the amount of such Additional Interest, it
being agreed that the Company’s option to suspend use of a Registration Statement pursuant to this paragraph shall be treated as a Registration Default for purposes of Section 5 hereof. 

SECTION 7: Registration Expenses. 

(a) All expenses incident to the Company’s performance of or compliance with this Agreement will be borne by the Company, regardless
of whether a Registration Statement becomes effective, including, without limitation: (i) all registration and filing fees and expenses (including filings made by any Initial Purchaser or Holder with FINRA (and, if applicable, the fees and
expenses of any “qualified independent underwriter” and its counsel that may be required by the rules and regulations of FINRA)); (ii) all fees and expenses of compliance with federal securities and state securities or blue sky laws;
(iii) all expenses of printing (including printing certificates for the Exchange Securities to be issued in the Exchange Offer and printing of Prospectuses), messenger and delivery services and telephone; (iv) all fees and disbursements of
counsel for the Company and, subject to Section 7(b) hereof, the Holders of Transfer Restricted Notes; (v) all application and filing fees in connection with listing the Exchange Notes on a securities exchange or automated quotation system
pursuant to the requirements thereof; and (vi) all fees and disbursements of independent certified public accountants of the Company (including the expenses of any special audit and comfort letters required by or incident to such performance).

 The Company will, in any event, bear its internal expenses (including, without limitation, all salaries and expenses of its
officers and employees performing legal or accounting duties), the expenses of any annual audit and the fees and expenses of any Person, including special experts, retained by the Company. 

(b) In connection with any Registration Statement required by this Agreement (including, without limitation, the Exchange Offer
Registration Statement and the Shelf Registration Statement), the Company will reimburse the Initial Purchasers and the Holders of Transfer Restricted Notes being tendered in the Exchange Offer and/or resold pursuant to the “Plan of
Distribution” contained in the Exchange Offer Registration Statement or registered pursuant to the Shelf Registration Statement, as applicable, for the reasonable fees and disbursements of not more than one counsel, who shall be Cahill
Gordon & Reindel LLP or such other counsel as may be chosen by the Holders of a majority in principal amount of the Transfer Restricted Notes for whose benefit such Registration Statement is being prepared. 

  
 14 

 SECTION 8: Indemnification. 

(a) The Company agrees to indemnify and hold harmless (i) each Holder and (ii) each Person, if any, who controls (within the
meaning of Section 15 of the Securities Act or Section 20 of the Exchange Act) any Holder (any of the Persons referred to in this clause (ii) being hereinafter referred to as a “controlling person”) and (iii) the
respective officers, directors, partners, employees, representatives and agents of any Holder or any controlling person (any Person referred to in clause (i), (ii) or (iii) may hereinafter be referred to as an “Indemnified
Holder”), to the fullest extent lawful, from and against any and all losses, claims, damages, liabilities, judgments, actions and expenses (including, without limitation, and as incurred, reimbursement of all reasonable costs of investigating,
preparing, pursuing, settling, compromising, paying or defending any claim or action, or any investigation or proceeding by any governmental agency or body, commenced or threatened, including the reasonable fees and expenses of counsel to any
Indemnified Holder), joint or several, directly or indirectly caused by, related to, based upon, arising out of or in connection with any untrue statement or alleged untrue statement of a material fact contained in any Registration Statement or
Prospectus (or any amendment or supplement thereto), or any omission or alleged omission to state therein a material fact required to be stated therein or necessary to make the statements therein not misleading, except insofar as such losses,
claims, damages, liabilities or expenses are caused by an untrue statement or omission or alleged untrue statement or omission that is made in reliance upon and in conformity with information relating to any of the Holders furnished in writing to
the Company by any of the Holders expressly for use therein. This indemnity agreement shall be in addition to any liability which the Company may otherwise have. 
 In case any action or proceeding (including any governmental or regulatory investigation or proceeding) shall be brought or asserted against any of the Indemnified Holders with respect to which indemnity
may be sought against the Company, such Indemnified Holder (or the Indemnified Holder controlled by such controlling person) shall promptly notify the Company in writing; provided, however, that the failure to give such notice shall not
relieve any of the Company of its obligations pursuant to this Agreement. Such Indemnified Holder shall have the right to employ its own counsel in any such action and the fees and expenses of such counsel shall be paid, as incurred, by the Company
(regardless of whether it is ultimately determined that an Indemnified Holder is not entitled to indemnification hereunder). The Company shall not, in connection with any one such action or proceeding or separate but substantially similar or related
actions or proceedings in the same jurisdiction arising out of the same general allegations or circumstances, be liable for the reasonable fees and expenses of more than one separate firm of attorneys (in addition to any local counsel) at any time
for such Indemnified Holders, which firm shall be designated by the Holders. The Company shall be liable for any settlement of any such action or proceeding effected with the Company’s prior written consent, which consent shall not be withheld
unreasonably, and the Company agrees to indemnify and hold harmless any Indemnified Holder from and against any loss, claim, damage, liability or expense by reason of any settlement of any action effected with the written consent of the Company. The
Company shall not, without the prior written consent of each Indemnified Holder, settle or compromise or consent to the entry of judgment in or otherwise seek to terminate any pending or threatened action, claim, litigation or proceeding in respect
of which indemnification or contribution may be sought hereunder (whether or not any Indemnified Holder is a party thereto), unless such settlement, compromise, consent or termination includes an unconditional release of each Indemnified Holder from
all liability arising out of such action, claim, litigation or proceeding. 

  
 15 

 (b) Each Holder of Transfer Restricted Notes agrees, severally and not jointly, to indemnify
and hold harmless the Company and the directors and officers of the Company who sign a Registration Statement, and any Person controlling (within the meaning of Section 15 of the Securities Act or Section 20 of the Exchange Act) the
Company, and the officers, directors, partners, employees, representatives and agents of each such Person, to the same extent as the foregoing indemnity from the Company to each of the Indemnified Holders, but only with respect to claims and actions
based on information relating to such Holder furnished in writing by such Holder expressly for use in any Registration Statement. In case any action or proceeding shall be brought against the Company or its directors or officers or any such
controlling person in respect of which indemnity may be sought against a Holder of Transfer Restricted Notes, such Holder shall have the rights and duties given the Company, and the Company, its directors and officers and such controlling person
shall have the rights and duties given to each Holder by the preceding paragraph. 
 (c) If the indemnification provided for in
this Section 8 is unavailable to an indemnified party under Section 8(a) or (b) hereof (other than by reason of exceptions provided in those Sections) in respect of any losses, claims, damages, liabilities, judgments, actions or
expenses referred to therein, then each applicable indemnifying party, in lieu of indemnifying such indemnified party, shall contribute to the amount paid or payable by such indemnified party as a result of such losses, claims, damages, liabilities
or expenses in such proportion as is appropriate to reflect the relative benefits received by the Company, on the one hand, and the Holders, on the other hand, from the Initial Placement (which in the case of the Company shall be deemed to be equal
to the total gross proceeds to the Company from the Initial Placement), the amount of Additional Interest which did not become payable as a result of the filing of the Registration Statement resulting in such losses, claims, damages, liabilities,
judgments actions or expenses, and such Registration Statement, or if such allocation is not permitted by applicable law, the relative fault of the Company, on the one hand, and the Holders, on the other hand, in connection with the statements or
omissions which resulted in such losses, claims, damages, liabilities or expenses, as well as any other relevant equitable considerations. The relative fault of the Company on the one hand and of the Indemnified Holder on the other shall be
determined by reference to, among other things, whether the untrue or alleged untrue statement of a material fact or the omission or alleged omission to state a material fact relates to information supplied by the Company, on the one hand, or the
Indemnified Holders, on the other hand, and the parties’ relative intent, knowledge, access to information and opportunity to correct or prevent such statement or omission. The amount paid or payable by a party as a result of the losses,
claims, damages, liabilities and expenses referred to above shall be deemed to include, subject to the limitations set forth in the second paragraph of Section 8(a) hereof, any legal or other fees or expenses reasonably incurred by such party
in connection with investigating or defending any action or claim. 
 The Company and each Holder of Transfer Restricted Notes
agree that it would not be just and equitable if contribution pursuant to this Section 8(c) were determined by pro rata allocation (even if the Holders were treated as one entity for such purpose) or by any other method of allocation which does
not take account of the equitable considerations referred to in the immediately preceding paragraph. The amount paid or payable by an indemnified party as a result of the losses, claims, damages, liabilities or expenses referred to in the
immediately preceding paragraph shall be deemed to include, subject to the limitations set forth above, any 

  
 16 

 
legal or other expenses reasonably incurred by such indemnified party in connection with investigating or defending any such action or claim. Notwithstanding the provisions of this
Section 8, none of the Holders (and its related Indemnified Holders) shall be required to contribute, in the aggregate, any amount in excess of the amount by which the total discount received by such Holder with respect to the Initial Notes
exceeds the amount of any damages which such Holder has otherwise been required to pay by reason of such untrue or alleged untrue statement or omission or alleged omission. No Person guilty of fraudulent misrepresentation (within the meaning of
Section 11(f) of the Securities Act) shall be entitled to contribution from any Person who was not guilty of such fraudulent misrepresentation. The Holders’ obligations to contribute pursuant to this Section 8(c) are several in
proportion to the respective principal amount of Initial Notes held by each of the Holders hereunder and not joint. 

SECTION 9: Rule 144A and Rule 144. The Company hereby agrees with each
Holder, for so long as any Transfer Restricted Notes remain outstanding and (a) during any period in which the Company is not subject to Section 13 or 15(d) of the Exchange Act, to make available to any Holder or beneficial owner of
Transfer Restricted Notes in connection with any sale thereof and any prospective purchaser of such Transfer Restricted Notes from such Holder or beneficial owner, the information required by Rule 144A(d)(4) under the Securities Act in order to
permit resales of such Transfer Restricted Securities pursuant to Rule 144A under the Securities Act, and (b) during any period in which the Company is subject to Section 13 or 15(d) of the Exchange Act, to make all filings required
thereby in a timely manner in order to permit resales of such Transfer Restricted Notes pursuant to Rule 144. 
 SECTION
10: Participation in Underwritten Registrations. No Holder may participate in any Underwritten Registration hereunder unless such Holder (a) agrees to sell such Holder’s Transfer
Restricted Notes on the basis provided in any underwriting arrangements approved by the Persons entitled hereunder to approve such arrangements and (b) completes and executes all reasonable questionnaires, powers of attorney, indemnities,
underwriting agreements, lock-up letters and other documents required under the terms of such underwriting arrangements. 

SECTION 11: Selection of Underwriters. The Holders of Transfer Restricted
Notes covered by the Shelf Registration Statement who desire to do so may sell such Transfer Restricted Notes in an Underwritten Offering. In any such Underwritten Offering, the investment banker(s) and managing underwriter(s) that will administer
such offering will be selected by the Holders of a majority in aggregate principal amount of the Transfer Restricted Notes included in such offering; provided, however, that such investment banker(s) and managing underwriter(s) must be
reasonably satisfactory to the Company. 
 SECTION 12: Miscellaneous. 

(a) Remedies. The Company hereby agrees that monetary damages would not be adequate compensation for any loss incurred by reason
of a breach by it of the provisions of this Agreement and hereby agree to waive the defense in any action for specific performance that a remedy at law would be adequate. 

  
 17 

 (b) No Inconsistent Agreements. The Company will not on or after the date of this
Agreement enter into any agreement with respect to its securities that is inconsistent with the rights granted to the Holders in this Agreement or otherwise conflicts with the provisions hereof. The Company has not previously entered into any
agreement granting any registration rights with respect to its securities to any Person. The rights granted to the Holders hereunder do not in any way conflict with and are not inconsistent with the rights granted to the holders of the Company’
s securities under any agreement in effect on the date hereof. 
 (c) Adjustments Affecting the Notes. The Company will
not take any action, or permit any change to occur, with respect to the Notes that would materially and adversely affect the ability of the Holders to Consummate any Exchange Offer. 

(d) Amendments and Waivers. The provisions of this Agreement may not be amended, modified or supplemented, and waivers or consents
to or departures from the provisions hereof may not be given unless the Company has (i) in the case of Section 5 hereof and this Section 12(d)(i), obtained the written consent of Holders of all outstanding Transfer Restricted Notes
and (ii) in the case of all other provisions hereof, obtained the written consent of Holders of a majority of the outstanding principal amount of Transfer Restricted Notes (excluding any Transfer Restricted Notes held by the Company or its
Affiliates). Notwithstanding the foregoing, a waiver or consent to departure from the provisions hereof that relates exclusively to the rights of Holders whose securities are being tendered pursuant to the Exchange Offer and that does not affect
directly or indirectly the rights of other Holders whose securities are not being tendered pursuant to such Exchange Offer may be given by the Holders of a majority of the outstanding principal amount of Transfer Restricted Notes being tendered or
registered; provided, however, that, with respect to any matter that directly or indirectly affects the rights of any Initial Purchaser hereunder, the Company shall obtain the written consent of each such Initial Purchaser with respect to
which such amendment, qualification, supplement, waiver, consent or departure is to be effective. 
 (e) Notices. All
notices and other communications provided for or permitted hereunder shall be made in writing by hand-delivery, first-class mail (registered or certified, return receipt requested), telex, telecopier, or air courier guaranteeing overnight delivery:

 (i) if to a Holder, at the address set forth on the records of the Registrar under the Indenture, with a copy
to the Registrar under the Indenture; and 
 (ii) if to the Company: 

American Renal Holdings Company, Inc. 
 66 Cherry Hill Drive 
 Beverly, MA 01915-1072 

Facsimile: (978) 232-4060 
 Attention: Michael Costa 

  
 18 

 With copies to: 
 Centerbridge Partners LP 
 375 Park Avenue, 12th Floor 

New York, NY 10152 
 Telecopier No.: (212) 672-5001 
 Attention: Jared S. Hendricks 

Simpson Thacher & Bartlett LLP 
 425 Lexington Avenue 
 New York, NY 10017 

Telecopier No.: (212) 455-2502 
 Attention: Stephan J. Feder 
 All such notices and communications shall be deemed
to have been duly given: at the time delivered by hand, if personally delivered; five Business Days after being deposited in the mail, postage prepaid, if mailed; when answered back, if telexed; when receipt acknowledged, if telecopied; and on the
next Business Day, if timely delivered to an air courier guaranteeing overnight delivery. 
 Copies of all such notices, demands
or other communications shall be concurrently delivered by the Person giving the same to the Trustee at the address specified in the Indenture. 
 (f) Successors and Assigns. This Agreement shall inure to the benefit of and be binding upon the successors and assigns of each of the parties, including, without limitation, and without the need
for an express assignment, subsequent Holders of Transfer Restricted Notes; provided, however, that this Agreement shall not inure to the benefit of or be binding upon a successor or assign of a Holder unless and to the extent such successor
or assign acquired Transfer Restricted Notes from such Holder. 
 (g) Counterparts. This Agreement may be executed in any
number of counterparts and by the parties hereto in separate counterparts, each of which when so executed shall be deemed to be an original and all of which taken together shall constitute one and the same agreement. 

(h) Headings. The headings in this Agreement are for convenience of reference only and shall not limit or otherwise affect the
meaning hereof. 
 (i) Governing Law. THIS AGREEMENT SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF
THE STATE OF NEW YORK, WITHOUT REGARD TO THE CONFLICTS OF LAW RULES THEREOF. 
 (j) Severability. In the event that any
one or more of the provisions contained herein, or the application thereof in any circumstance, is held invalid, illegal or unenforceable, the validity, legality and enforceability of any such provision in every other respect and of the remaining
provisions contained herein shall not be affected or impaired thereby. 

  
 19 

 (k) Entire Agreement. This Agreement is intended by the parties as a final expression
of their agreement and intended to be a complete and exclusive statement of the agreement and understanding of the parties hereto in respect of the subject matter contained herein. There are no restrictions, promises, warranties or undertakings,
other than those set forth or referred to herein with respect to the registration rights granted by the Company with respect to the Transfer Restricted Notes. This Agreement supersedes all prior agreements and understandings between the parties with
respect to such subject matter. 

  
 20 

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

			
	 AMERICAN RENAL HOLDINGS
 COMPANY, INC.

		
	 By:
	 	  

		 	 Name: Joseph A. Carlucci

		 	 Title: Chief Executive Officer

 [Registration Rights Agreement Signature Page] 

 The foregoing Registration Rights Agreement is hereby confirmed and accepted as of the date
first above written: 
 MERRILL LYNCH, PIERCE, FENNER & SMITH INCORPORATED 

			
		
	BY:	 	
                    
                            ”

		 	 Name: Mark Stephanz

		 	 Title: Managing Director

 [Registration Rights Agreement Signature Page] 

			
	BARCLAYS CAPITAL INC.
		
	 By:
	 	  

		 	 Name: John Skrobe

		 	 Title: Managing Director

 [Registration Rights Agreement Signature Page]

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