Document:

EX-4.43

 Exhibit 4.43 
  

 
 ADHERENCE DEED FOR THE SHARE PLEDGE POLICY OF CEMEX ESPAÑA, S.A. GRANTED BY THE ENTITIES “THE BANK OF NEW YORK MELLON”
and “CEMEX ESPAÑA, S.A.” NUMBER ONE THOUSAND FOUR HUNDRED EIGHTY THREE In Madrid, at my office on the sixteenth day of March of two thousand sixteen. Before me, ANTONIO PÉREZ-COCA CRESPO, Notary Public of Madrid and its Bar
Association, 
APPEAR: MRS. ANA MARÍA ARIAS SOMALO, of legal age, of Spanish nationality, domiciled for these purposes at calle José Abascal, number
45, 28010 Madrid; with National Identification Card number 000410487-Y. 
MR. JUAN PELEGRÍ Y GIRÓN, of legal age, domiciled for these purposes at calle
Hernández de Tejada, number 1, 28027 Madrid; with National Identification Card number 01489996-X. ACTING: The first, in the name and representation of THE BANK OF NEW YORK MELLON (hereinafter, the “Bank”), entity constituted in
accordance with the laws of 

 

 
 the State of New York (United States of America), with its corporate domicile at 225 Wall Street, New York, N.Y. 10286, United States of
America, which in turn acts in representation and to the benefit of the holders of Senior Secured Notes for an added principal maximum amount of ONE BILLION (1.000.000.000) dollars, at an interest rate of 7.750%, with maturity in two thousand
twenty-six, notwithstanding the cases of early repayment that have been foreseen, issued under the bond issuance agreement (Indenture) governed by the laws of the State of New York (United States of America), signed on March 16, 2016 by, among
others, CEMEX, S.A.B. de C.V. a corporation constituted under the laws of Mexico, as issuer, and THE BANK OF NEW YORK MELLON, as Trustee (hereinafter, together with its subsequent modifications or novations, the “Bonds Issuance”).

She makes use of the power of attorney in effect, as affirmed, in her favor, conferred through the document granted before the Notary Public of New York,
Mr. Christopher J. Traina, on the sixteenth day of March of two thousand sixteen, a photocopy of which has been shown to me and the original, duly stamped according to the La Hague Convention of October 5, 1961, I will attach hereto,
by means of written substantiation, when it is submitted to me. 

 

 
 The second party, in name and representation of the company “CEMEX ESPAÑA, S.A.”, (formerly Compañía
Valenciana de Cementos Portland, S.A.), and with its corporate domicile in Madrid, calle Hernández de Tejada, number 1, whose purpose is to act as a holding company. 
With CNAE Code Number 6420 “Activities of the Holding Company”. 
It was constituted
for an indefinite duration in the document authorized by the Notary Public at the time in Valencia, Mr. Juan Bautista Roch Contelles, on April 30, 1917, adapted to current legislation through the document authorized by the Notary Public of
Valencia, Mr. Antonio Soto Bisquert on July 13, 1990; with said constitution REGISTERED in the Commercial Registry of Valencia, under volume 122, book 28 of companies, section 3 of corporations, page 354, registry 1. The adaptation is
registered in the aforementioned Registry, under volume 2854, book 10, general section, page V2533, registry 165. The bylaws of the company were also amended through another public document authorized by the Notary Public of Madrid, Mr. Antonio
Francés y de Mateo on August 12, 1993, with number 6796 of his notarial records, under record 200. 

 

 
 The above indicated current domicile was moved, through document authorized by the Notary Public of Valencia, Mr. Antonio Soto
Bisquert, on June 29, 1995, with number 1489 of his notarial records, and registered in the Commercial Registry of Madrid, under volume 9743 and 9744, section 8, of the Book of Companies, folio 1 and 166, page number M-156542, records 1 and 2.

Its name was changed to its current name through the agreement taken by the General Shareholders Meeting of the Company, in its meeting held on the twenty-fourth
of June of two thousand and two, recorded as a document of public record, before me on the same day, under number 662 of my records, registry number 122. 
Its Tax
Identification number is: A-46.004.214 and CNAE Code Number 6420 “Holding Companies”. 
The party appearing represents that the identifying data of the
Company and, especially, its social purpose and domicile, has not changed with respect to those reported. 
Its Tax Identification number is: A-46.004.214.

He makes use of the powers in effect, as affirmed, in his power, conferred by agreement taken by the Administrative Board of the Company, at its meeting held on
the twenty-fourth of 

 

 
 February of two thousand sixteen, recorded as a document of public record, before me, on the twenty-fourth of February of two thousand
sixteen, recorded as a document of public record, before Mr. José Luis López de Garayo y Gallardo, Notary of Madrid, on my absence, on the fifteenth day of March of two thousand sixteen, under number 964 of my records, as
accredited to me with an authorized copy of said document which I have before me. 
For the purposes established in article 98 of Law 24/2001 and in accordance with
the Resolution of the General Directorate for Registries and Notary Affairs of April 12, 2002, I certify that, in my opinion, I consider that the representative powers accredited are sufficient for the execution of this document under the terms
indicated below. 
BENEFICIAL OWNERSHIP.- I, the Notary Public, expressly confirm that I have complied with the obligation of identifying the beneficial owner as
imposed by Law 10/2010 of April 28, the result of which is recorded in a document authorized before me, on the eleventh of November of two thousand and ten, under number 2387 of my records, which has been modified since then as attested by the
representative of the Company. 

 

 
 The parties appearing before me have, in my opinion, as they appear, the legal capacity and legitimate interest necessary to grant this
ADHERENCE DEED FOR THE SHARE PLEDGE POLICY OF CEMEX ESPAÑA, S.A. and, for such purpose, in their capacity and for all applicable legal purposes, 
THEY HEREBY
DECLARE 
I. That, by virtue of the policy agreement granted before me on November 8, 2012, registered with number 3530 in Section A of the Registry Book
(hereinafter the “Pledge Policy”), CEMEX, S.A.B. de C.V. and New Sunward Holding B.V. constituted certain real pledge rights (hereinafter the “Pledges”) over the shares of the company CEMEX España, S.A. in its name.

II. That, in accordance with the Creditors Relation Agreement (as this is defined in the Pledge Policy), the creditors of the CEMEX group, in virtue of the
issuance of bonds such as the Bonds Issuance will have the consideration of Additional Notes Creditors and, therefore, of Secured Parties according to the terms established in the Creditors Relation Agreement and in the Pledge Policy, and may obtain
the benefit of the Pledges through their adhesion to the Pledge Policy according to the provisions of Clause 16 of the same. 

 

 
 III. That, in accordance with the provisions of Clause 16 of the Pledge Policy, the Secured Parties in whose benefit the Relationship
Manager acted, among which include the Bank, as trustee of the holders of bonds of the Bonds Issuance, may adhere to the Pledge Policy and ratify the content of the same, accepting the Pledges constituted in their favor as guarantee of the
corresponding Secured Obligations, through appearance before Mr. Monjo, the substituting Notary Public. 
Said adhesions will be carried out through the
granting of the corresponding adhesion deed or policy, all without the need for a new consent from the pledgors, for having provided said consent previously in the Creditor Relation Agreement and in the Pledge Policy itself. 
IV. That the Bank expressly declares that the adhesion referred to in the Stipulations of this Document is formalized as a mere instrument of execution of the rights attributed to
the Bank in the Pledge Policy, from which it is derived, so that the payment obligations resulting from the 

 

 
 Bonds Issuance are guaranteed with a real first ranking pledge right over the Shares (as defined in the Pledge Policy), concurrent with
the remaining Pledges. 
V. That by virtue of the foregoing, the Bank wishes to grant this Adhesion Deed (hereinafter the “Deed”) in accordance with the
following 
STIPULATIONS 
ONE.- ADHESION TO THE PLEDGE POLICY. 
The Bank, through this Deed, adheres to, ratifies and approves the Pledge Policy to the fullest extent, the entire content of which it declares to know, therefore giving such
granting full value and legal efficacy and accepting that the payment obligations resulting from the Bonds Issuance are guaranteed with a real first ranking pledge right over the Shares (as defined in the Pledge Policy), concurrent with the
remaining Pledges. 
The Bank REQUIRES from me, the Notary Public, to NOTIFY this adhesion to WILMINGTON TRUST (LONDON) LIMITED, domiciled for these purposes on the
Third Floor, 1 King’s Arms Yard, London, United Kingdom, EC2R 7AF (attention Sajada Afzal), in her capacity as Relationship Manager and I, the Notary Public, accept said requirement. 

 

 
 CEMEX España, S.A., appears herein for the purposes of acknowledging itself as notified of this adhesion. 
TWO.- APPLICABLE LAW AND JURISDICTION. 
2.1 This Deed is subject to Spanish common law.

2.2 The Parties submit themselves expressly to the jurisdiction and competence of the Courts and Tribunals of Madrid for all matters that may result from the
validity, interpretation, fulfillment and execution of this Deed. 
HANDLING OF DATA.- The appearing parties accept the incorporation of their data and the copy of
identification documents in the files of the Notary Public in order to carry out the functions inherent to the notarial activity and for the communication of data established in the Public Administration Law and, as applicable, for the Notary Public
who follows the current one. They may exercise their rights to access, rectify, cancel and oppose at the authorizing Notary’s office. 
It is thus stated and
executed. 
And I, the Notary Public, ATTEST: 
a.- To have identified the
appearing parties through their identification documents, indicated in the appearance clause, which have been shown to me. 

 

 
 b.- That the appearing parties, in my opinion, have the capacity and legal standing for the granting hereof. 
c.- That the granting hereof by the appearing parties is legal, duly informed and made willingly. 
d.- That I have read this public instrument to the grantors thereof, having previously advised them of their right to read it for themselves, which they have done, and they have
stated that they have been duly made aware of the entire content of the same, and they provide their consent, all in accordance with article 193 of the Notarial Regulations. 
e.- That this public instrument is executed in six notarized pages, series CR numbers: 9729761 and the following five numbers in correlated order and I, the Notary Public, attest.-
The signatures of the appearing parties follow.- Signed ANTONIO PÉREZ-COCA CRESPO. Signed. Notary Seal. 
CERTIFICATE.- To record that I, ANTONIO
PÉREZ-COCA CRESPO, on the twenty-first day of March of two thousand sixteen, left filed at the Post Office Branch, located at office 2825494, E.O MINISTRY OF PUBLIC ADMINISTRATIONS, as a Certificate and notification of receipt, the
non-certified copy of this deed, and that the official in charge of the service has given to me the receipt which bears the sending number RF074346004ES. 

 

 
 All of which I attest and that this certificate is issued after the deed on which it is based, on this sheet of notarized paper, of the
CR series, number 9729766. In Madrid on the twenty-first day of March of two thousand sixteen.- Signed. ANTONIO PÉREZ-COCA CRESPO. Signed. Notary Seal.

CERTIFICATE.- I, ANTONIO PÉREZ-COCA CRESPO, Notary Public of Madrid and its Bar Association, issue this certificate to record that on today’s date, the
twenty-fifth day of March of two thousand sixteen, I have received a copy of the power of attorney in English and Spanish, languages that I, the Notary, knows, specially granted to formalize the public deed by Mrs. Catherine F. Donohue, as
Vice-president and Mrs. Sonia Chaliha, as General Director of the entity THE BANK OF NEW YORK MELLON, before the Notary Public of New York, Mr. Christopher J. Traina, on the fifth day of March of two thousand sixteen, duly legalized
with the La Hague apostille, and I, the Notary Public, consider that the representative of the entity has 

 

 
 sufficient powers to formalize the deed which is the object hereof. I leave a copy of said power incorporated hereto, forming an
integral part of the same. 
And with nothing further to record, I issue this document over this sole sheet of notarized paper and I, the Notary Public, attest. The
signatures of the appearing parties follow. Signed. ANTONIO PÉREZ-COCA CRESPO. Signed. Notary Seal. 
ATTACHED DOCUMENTS FOLLOW 

 

 
 (Convention de La Haye du 5 Octobre 1961) 
1.
Country: United States of America 
This public document 
2. has been signed by
Milton A. Tingling 
3. acting in the capacity of County Clerk 
4. bears the
seal/stamp of the county of New York 
Certified 
5. at New York City, New York
6. the 16th day of March 2016 
7. by Special Deputy Secretary of State, State of New York 
8. No. NYC-551266 
9. Seal/Stamp 10. Signature 
Apostille (REV: 09/25/12) 
Whitney A. Clark 
Special Deputy Secretary of State 

 

 
 POWER OF ATTORNEY 
Ms. Catherine F. Donohue and Ms.
Sonia Chaliha acting in the name and on behalf ofThe Bank of New York Mellon (a corporation duly organized and existing under the laws of the State of New York, with corporate domicile at 225 Liberty Street, New York, N.Y. 10286, U.S.A., and with an
I.R.S. employer ideotification number 13-5160382) (the “Grantor”), grant a special power of attorney, as broad and sufficient as is required by law, in favour of (i) Ms. Ana :Maria Arias Semalo, of legal age, of Spanish nationality,
domiciled for these purposes in Madrid, calle Jose Abascal cS, and bearer of Spanish identification card number 000410487-Y, in force, (ii) Ms. Marta Garcia L6pez, of legal age, domiciled at Calle Jose Abaseal 45, Madrid, of Spanish nationality and
bearer of Spanish identification card number 02634855K, in force and (iii) Ms. Paloma Julieta Alvarez-Urfa Berres, of legal age, of Spanish Nationality, with business address in Calle Jose Abascal 45, Madrid (Spain) and holder of national
identification card number 9.427,338-Y, currently in force (hereinafter, any of them, indistinctly. an II Attorney” and jointly the “Attorneys”), so that any of them may, acting jointly and severally, in the name and on behalf of the
Grantor, acting on behalf and for the benefit of the holders of the US$ 1,000,000,000 7.750% Senior Secured Noles Due 2026 (the 11 Notes”) referred to below (the “Noteholders”) and issued by virtue of an indenture entered into by,
among others, CEMEX SAB. DE C.V. as issuer (the “Issuer”), CEMEX Mexico, S.A. de C.V., Cemex Concretos S.A. de C.V., Empreses Tolteca de Mexico S.A. de C.v., 
PODER ESPECIAL Dfia Catherine F. Donohue y Dfia. Sonia Chaliha, actuando en nombrey representacion de The Bank of New York Mellon (una sociedad debidamente constiruida can arreglo
a Ins leyes del estado de Nueva York. con domicilio en 225 Liberty Street, New York, N.Y. 10286, (U.SA) y con mimero de IRS. 13-5160382) (el “Poderdanle”), confiere poder especial, tan amplio y bastante como en derecho sea menester, en
favor de (i) DR. Ana Marla Arias Somalo, mayor de edad, de nacionalidad espanola, con domicilio profesional en Madrid, calle Jose Abascal 45, titular de DNI 1 numerc 000410487-Y en vigor, (ii) D • Marta Garda Lopez, mayor de edad, con domicilio
en la calle Jose Abaseal 45, Madrid, de nacionalidad espaiiola, titular del DN! numero 02634855K en vigor y (iii) D’ Paloma Julieta Alvarcz..Uria Berres, mayor de edad, de nacionalidad espanola, con domicilio profesional en Calle Jose
Abasca145, Madrid (Espana) y titular de docutnentc nacional de identidad numerc 9.427.338-Y en vigor (en 10 sueesivo, uno cualquiera de ellos, indistintamente, un “Apoderado’ y, conjuntamente, los “Apcderados”), para que uno
cualquiera de ellos pueda, actuando indistinta y solidariamente, en nombre y representaci6n del Poderdante, que a su vez aetna en representecion y beneficio de los tenedores de Bonos Senior Garantizados at tipo de interes del 7.750% con fecha de
vencimiento en 2026 y denominados en d6lares estadounidenses (US$],000.000,000 7.750%Senior Secured Notes Due 2026) (los “Bonos”) a los que se haee referencia mas adelame (los “Bonistas”) y que han sido emitidos en virtud del
contrato de emision de bonos suscritoel 16 de marzo de 2016 par CEMEX S,A.B. DE C.V. como emisor (el “Emisor”), CEMEX Mexico, SA de C.V., Cemex Concretes S.A. de C.V., Emprcsas Tolteca de 

 

 
 New Sunward Holding B.V., Cemex Espana, S.A., Cemex Asia B.V., Cemex Corp.• CEMEX Finance LLC, Cemex Egyptian Investments B.V,
Cemex Egyptian Investments II B.V.• Cemex France Gesticn (S.A.S.), Cemex Research Group AG. Cemex Shipping B.V. and Cemex UK as guarantors (the “Note Guarantors”) and the Grantor. as trustee and paying agent, dated as of March 16,
2016 (hereinafter, as amended from time to time, the “Indenture”). carry out any of the following acts. in the terms and conditions that the Attorney may deem appropriate: 1. Negotiate, execute, accept, amend, extend, accede or ratify one
or several pledge agreements (the “Share Pledges”) over all or part of the shares taccioness of the Spanish company CEl\1EX Espana, S.A. (Tax Identification Number A46004214, registered with the Commercial Registry of Madrid, in volume
9,743 and 9,744, sheet I to 166. section 8, page no. M-156542), whereby one or more share pledges are created to secure inter alia the full and punctual performance of all or part of the obligations assumed by the Issuer and each of the Note
Guarantors in favour of, among others, the relevant Noteholders, as well as other secured obligations assumed by the Issuer and its subsidiaries. 2. Execute or ratify the abovementioned documents. in a public or private document and appear before a
Spanish Notary Public to grant the notarial deeds (p6/izas) or public deeds (escrtturas publicas) of the abovementioned documents and. in particular (without limitation), appear before a Spanish notary public (Notario) to notarize or raise to the
status of public document (elevar a documento publico) the Share Pledges. the Indenture and any other agreements, documents, notices or letters related thereto.

Mexico S.A. de C.V., New Sunward Holding B.V., Cemex Espana. S.A., Cemex Asia B.V., Cemex Corp.• CEMEX Finance LLC, Cemex Egyptian Investments B.V. Cemex
Egyptian Investments II B. V., Cemex France Gestion (S.A.S.), Cemex Research Group AG. Cemex Shipping B.V. y Cemex UK. como garantes (los “Garantes “) y el Otorgante como trustee y agente de pages (en adelante, segun sea modifieado en cada
memento, el “Contrato de Emisi6n de Bonos”). realizar cualesquiera de las siguientes actuaciones, en los terminos y condiciones que el Apoderado erea apropiados: 1. Negcciar, celebrar, firmar, ejecutar, ratifiear, aceptar, modificar,
extender, adherirse y otorgar en los terrninos y condiciones que el Apoderado crea convenientes [a constitucion de una 0 varias prendas (las “Prendas sabre las Acetones”) sabre todas 0 parte de las acciones de la sociedad espaiiola CEMEX
Espaiia, S.A. (C.LF. uumero A46004214 e inscrita en el Registro Mercantil de Madrid, en e1 Torno 9.743, folio 9.744, hoja 1 y 166. secci6n 8, pagina M-156542), mediante las cuales se constituyan una 0 varias prendas sabre acciones para garantizar el
completo y puntual cumplimiento de todas 0 parte de las obligacioues asumidas por el Emisor y cada uno de los Garantes de los Bonos en favor de, entre otros, los respectivos Bonistas, al igual que otras obligaciones garantizadas asumidas por el
Bmisor y sus filiales. 2. Firmar 0 ratiflcar los anteriores documentos y contratos en documento privado 0 publico. comparecer ante notario espezot para intervenga en paliza 0 eleve a publico los mencionados documentos, y, en especial (sin
lirnitacion), comparecer ante Notaric para elevar a documento publico las Prendas sobre las Acciones, el Contrato de Emisi6n de Bonos y cualquiera otros contratos, documentos 0 cart as relacionados 0 prevlstos en los citados contratos zero(0)
documentos. 

 

 
 3. Carry out whichever other actions, declarations, agreements, letters or execute whichever other public or private document the
Attorney deems desirable or necessary for the validity of the documents previously mentioned, as well as (in particular without limitation) to accept the extension of the Share Pledges to any other shares of CEMEX Espana, S.A. that the pledgers that
created the Share Pledges may hold from time to time, and to acknowledge the creation of any pledges or any other security agreement granted in accordance with the preceding paragraph. 4. Carry out whichever other actions, declarations, agreements,
letters or execute whichever other public or private document the Attorney deems desirable or necessary to maintain and protect the Share Pledges or any other security interest related to the documents referred to in the preceding paragraphs. 5. To
appear before the Spanish administrative authorities and execute, in the name and on behalf of the Grantor, the necessary documents for obtaining the Spanish tax identification by filing the necessary tax forms. 6. To appear before any Spanish
administrative authorities and, in particular, but not limited to, the Foreign Investments’ Registry of the Ministry of Finance and the Bank of Spain executing, delivering and filing, in the name and on behalf of the Grantor, any document,
statement, payment, application or official forms (including those of a tax nature) that may be necessary or advisable in connection with the execution or compliance with the Indenture and the Share Pledges. 7. As a result of the authority granted
in the preceding paragraphs, to agree on the terms and conditions the Attorney deems appropriate 3. Realizar cualesquiera otros aetas 0 declaraclones, y firmar contratos, cartes, u otorgar cualesquiera otros documentos pablicos 0 privados que el
Aporlerado considere necesarios 0 convenientes para la validez de los documentos a los que se ha hecho referencia anteriormente y, en. particular {aunque sin limitacion), para aceptar la extensi6n de las Prendas sobre las Acetones a cualesquiera
otras acciones de CEMEX Espana, S,A. de las que sean titulares en cada momenta los pignorantes que constituyeron las Prendas sobre las Acoiones, y para tomar conocimiento de Ia constituci6n 0 extension de cuantas prendas U otros derechos de garantia
se otorguen de acuerdo COD los apartados anteriores, 4. Realizar cualesquiera orros actos a declaraciones, y firmar contratos, cartas, u otorgar cualesquiera otros documentos publicos 0 privados que el Apcderado considere necesarios 0 convenientes
para conservar y proteger la validez de las Prendas sabre las Acciones 0 cualesquiera otros derechos de garantia se otorguen de acuerdo con los apartados anteriores. 5. Comparecer ante las autoridades administrativas espaiiolas y firmar, en nombre
del Poderdante, cuantos documentos sean neceserios para la obtenci6n de identificacion fiscal presentando los modelos fiscales que sean neeesarios. 6. Comparecer ante cuantas autoridades administrativas espaiiclas y, en particular, pero sin
limitacion ante, el Registro de Inversiones Exterlores del Ministerio de Economia y el Banco de Espana, otorgando, comunicando y cumplimentando, en nombre y representaci6n del Poderdante, cuantos docurnentos, declaraciones, pagos, solicitudes, 0
impresos oficiales (incluidos los de fndole fiscal) que resulten necesarios 0 convenientes para la celebration 0 cumplimiento las Prendas sobre las Acciones y el Contrato de Emisi6n de Bonos. 7. En el ejercicio de la autoridad conferida en los
parrafos precedentes, fijar los terminos y condiciones que considere apropiados y emitir 

 

 
 and to issue and receive any binding declarations. 8. Grant deeds of formalization, acknowledgement, ratification, confirmation,
modification or amendment of any of the agreements, and/or public deeds referred to above. 9. To request the issue of copies of any of the aforementioned public documents. IO.All the powers granted herein can be exercised by the Attorney, even if
this would result in the self-contracting (awocontratacions or multi-representation (multirepresentaci6n) or conflict of interest (conjlicto de imeres) figures. The deed and text of the present power of attorney will be interpreted exclusively
according to the English Language translation. This power of attorney is effective for ninety (90) days from the date hereof or the earlier of (i) revocation by the Grantor, (ii) the Attorney shall no longer be retained on behalf of the Grantor or
an affiliate of the Grantor; or (iii) the expiration or the ninety (90) days from the date of execution. The authority granted to the Attorney by this Power of Attorney is not transferable to any other party or entity. The relationship of the
Grantor and the Attorney under this Power of Attorney is intended by the parties to be that of an independent contractor and not that of a joint venture, partner, or agent. This Power of Attorney shall be governed by, and construed in accordance
with, the laws of the State of New York without regard to its conflicts oflaw principles. The Grantor hereby undertakes to confirm and ratify, if so requested by the Attorney, each and every actions taken by the Attorney in y recibir todo tipo de
declaraciones de voluntad y manifestaciones. 8. Otorgar escrituras 0 polizas de fonnalizaci6n, reconocimienro, ratificacion, confirmacion, modificaci6n 0 rectificaci6n de cualquiera de los contratos, escrituras 0 p6lizas referidos anterionnente. 9.
Solicitar copias de las citadas p6lizas 0 escrituras. 10.La totalidad de las facuItades incluidas en este poder podran ser ejercitadas por el Apoderado aun cuando en el ejercicio de las mismas incunieran en las figuras de autocontraracion,
multirepresentaci6n 0 conflicto de interes. La minuta y redacei6n del presente pcder sera, en todo case, interpretado conforme a la dicci6n y sentido del texto que se incluye en lengua ingles. El presente poder sera efectivo por noventa (90) dias
desde esta fecha 0 basta la primera fecha en producirse algunc de los siguientes supuestos: (i) revocaci6n del poder por el Poderdante, (ii) que el Apoderado no continue siendo empleado par el Poderdante 0 una de sus filiales; 0 (iii) expiracion del
plazo de noventa (90) dias desde la fecha de otorgamiento del poder. Las facultades otorgadas par la Poderdante a traves de este poder no son transferibles a ninguna ctra parte a entidad. La relacion entre el Poderdante y el Apoderado bajo este
Poder, pretendida por las partes, es la propia de un contratista independiente y no de un miembro de unajoint venture, socio 0 agente. Este poder se regira y sera interprctado de conformidad con las leyes del Estado de Nueva York, con exclusion de
sus principios sabre contlicto de reyes. ŁL1 Poderdante se compromete a continnar y ratlficar, si es requerido para ello por el Apoderado, todas y carla una de las actuaciones 

 

 
 accordance with the terms of this power of attorney.

In New York, on March 16,2016. reaIizadas par el Apoderado de confonnidad con los termlnos de este poder. EnNueva York,e1 16 demarzo de 2016. The Bank of New York
MeDon 
By: Ms. Catherine F. Donohue Vice President! Viee Presidente 
By: Ms.
Sonia Chaliha Managing Directorl Gerente General 
NOTARIAL CERTIFICATE 
I,
Notary Public ofNew York hereby certify that: I. The Bank of New York Mellon is a corporation duly organized and existing under the laws of the State of New York, with corporate domicile at 225 Liberty Street” New York, N,Y. 10286, U,SA, with
an I.R.S. employer identification number of 13-5160382, and with the required capacity to grant this Power of Attorney. n. This Power of Attorney has been validly executed by Ms. Catherine F_Donohue and Ms. Sonia Chaliha who have the required
authority to grant this Power of Attorney in the name and on behalf ofThe Bank of New York Mellon. Ill. The above is the true hand-written signature of Ms. Catherine F. Donohue and Ms. Sonia Chaliha. IV. That the Grantor has the necessary authority
to act in the name and on behalf of the Noteholders. 
CERTIFICADO NOTARIAL 
Yo,
Notario de Nueva York, por la presente certifieo que: J. The Bank of New York Mellon es una sociedad existente y validamenteconstituida de acuerdo can las leyes del estado de Nueva York, con domicilio social en 225 Liberty Street, New York, N,Y.
10286, (U.S.A.), con mimero I.R.S. 13-5160382 Y coo, la eapacidad necesaria para otorgar este poder. II. El presente poder ha sido validamente emitido por Dna. Catherine F. Donohue y Dna. Sonia Chaliha quienes tiene capacidad legal para otorgar
dicho poder en nombre y representaci6n de The Bank of New York Mellon. III. La anterior firma es la firma manuscrita nutentica de DBa. Catherine F, Donohue y Diia.Sonia Chaliha. IV. El Poderdante tiene autoridad necesaria para aetuar en nombre y
representacicn de los Bonistas. 

 

 
 State of.New York ss: No. 194523 
County of New
York 
I, Mllton AdairTingling, Clerk oftheCounty 01 New York, and Clerk oftheSupreme Court in and forsaid 
county, thesame being a court 01 record having a Seal, DO HEREBY CERTIFY THAT 
CHRISTOPHER J
TRAINA 
whose name issubscribed totheannexed original instrument has been commissioned and qualified as a NOTARY PUBLiC , : : : , : . and hasfiled his/her original
signature inthisoffioe andthathe/she was atthetime 01 laking such . prool oracknowledgment oroath duly authorized bythelaviS of the Slate 01 New York tolake the same: thathe/she isWell acquainted wtth the handwriting 01 such pUblic offioer
orhascompared . the signature ontheoertificateol proctoracknowledgment or oath’with the original signature filed inhislheroffioe bysuch public oOOr andhe/she believes thatthesignaMe onthe original instrument 
.isgenuine: 
INWITNESS WHEREOF, I have hereunto setmyhand and myofficial seal·this 16th
day 01 March, 2016 
County Clerk, New york country 

 

 
 V. The acts and transactions effected by the Attorney appointed in this Power of Attorney in the name and onbehalf of The Bank. of New
York Mellon, within the scope of such Power of Attorney, will be acts or transactions validly effected by The Bank of New York. Mellon. Executed beforeme, onMarch 16,2016. V. Los aetos realizados y negocios celebrados por el Apoderado designado
enesre poder en nombre y representacion de The Bank of 
New York Mellon, dentro del ambito del presente poder, seran actos 0 negocios validamente realizados a
ce1ebrados par The Bank ofNew York Mellon. Firmadoante mi, e116demarzo de2016. 
STATE OF NEW YORK ) COUNTY OF NEW YORK ) On the 16 day of March in the year 2016
before me, the undersigned, a notary public in and for said State, personally appeared Catherine F. Donohue, a Vice Presidentand Sonia Chaliha, a Managing Director, personally known to me or proved to me on the basis of satisfactory evidence to be
the individuals whose names are subscribed to within that instrument and acknowledged to me that they executed the same within theircapacities, and that by their signature on the instrument, the corporation executed e instrument. 
CHRISTOPHER J. TRAINA NOTARY PUBLIC·STATE OF NEW YORI{ No,OlTR6297825 Qualified in Queens County Cerllfled in New York County My Commission Expires March 03, 2018

 

 
 EXACT FIRST COPY OF ITS ORIGINAL where it is recorded. For the appearing parties, as they appear, I issue it in twelve stamped pages in
paper that is only for notarial documents, CT series, numbers 3628885 and the following eleven in descending sequential order, which I sign and stamped in MADRID, as of the Thirty-first day of March two thousand and sixteen. ATTEST. 
Bases: 903.832.248.73 
Numbers: 2, 4, 7 
Rights: 90.602.87Meritor, Inc.
2135 West Maple Road
Troy, Michigan 48084-7121
      USA
800-535-5560
      Tel
  
meritor.com

	April 21,
      2016

Ivor J.
Evans
[redacted]

Mr. Evans:

Subject: Mutually Agreed Upon Transition Agreement

This letter agreement (this "Agreement")
confirms your acceptance of a transition package from Meritor, Inc (“Meritor” or
the “Company”). Both parties expressly agree that your acceptance of this
agreement is completely voluntary. You and the Company have agreed to enter into
this Agreement pursuant to the following terms and conditions and
consideration:

	     	1.	     	Transition Date from Active
      Employment to Board Member. Your last
      day of work in the office with the Company is April 21, 2016. Your last
      day of active employment with the Company will be April 30, 2016, your
      "Transition Date". Post Transition Date, you will become a non-independent
      director of the Company’s Board of Directors, whereby you will compensated
      with a prorated board approved retainer fee, committee meeting fees and
      equity-based award for your service on an annual basis for the rest of
      your term.
	 
	 	2.	 	Vacation Pay. You will receive any unpaid salary and any accrued but
      unused vacation through your Transition Date in the form of a lump sum
      within 30 days of your Transition Date, or such earlier date as may be
      required by law. These amounts are savings plan eligible under the
      Company's tax-qualified savings plan ("Company Savings
Plan").
	 
		3.		Incentive Compensation
      Plan. Given that your last day of
      active employment will be April 30, 2016 you will be eligible to receive a
      pro-rated incentive compensation plan (ICP) payment for fiscal year 2016
      based on time worked through your Transition Date. Such payment will be
      subject to the applicable formula, in accordance with ICP metrics. Any
      final award determination is subject to approval by the Compensation &
      Management Development Committee of the Company's Board of Directors. If
      an ICP award is approved, your ICP award payment for fiscal year 2016 will
      be paid in a single lump sum payment in December 2016.
	 	 	 	 
	 	4.	 	Equity
      Awards. You have received equity grant(s). You will be eligible to
      retain your equity grants as
follows:

	-	Hiring Incentive Award of Non-qualified Stock
      Options:
 

	○	Any
      vested options shall be exercisable until September 11,
      2018
 
	○	Unvested options can vest until September 30, 2016 so long as
      remaining performance hurdles are achieved. Failure to achieve the
      remaining performance hurdles will result in forfeiture of any of the
      unvested stock options.
 

	-	FY2014-FY2016 LTIP award will vest on December 1, 2016 pending
      Board of Directors approval, based upon applicable
      formulae
 
	-	FY2015-FY2017 LTIP award will be forfeited based on plan
      provisions since your Transition Date is prior to the December 1, 2017
      vesting date.

Ivor J. Evans
April 21, 2016
Page 2
of 7 

	-	FY2016-FY2018 LTIP award will be forfeited based on plan
      provisions since your Transition Date is prior to the December 1, 2018 vesting
      date.

		5.		Financial Planning/Car
      Allowance. Your Company-provided
      financial planning benefits and car allowance will cease as of April 30,
      2016.
		 
		6.		Disability
      Coverage. Your coverage under the
      Company's short and long term disability plans will cease as of April 30,
      2016.
		 
		7.		Company Tax-Qualified Savings
      Plan. You will cease to be an active
      participant in the Company Savings Plan as of April 30, 2016. You are 100%
      vested in your savings plan deferrals and related company matching
      contributions under such plan. Benefits under the Company Savings Plan
      will be paid in accordance with the terms of such plan.
		 
				Based on your age and years of
      service with the Company, you are 100% vested in the pension contribution
      portion of your Company Savings Plan account.
		 
				You will be able to request a
      Company Savings Plan distribution after your Transition Date. Please
      contact T. Rowe Price for information about your Meritor Savings Plan and
      Pension Contribution accounts at (800) 922-9945.
		 
		8.		Company Supplemental Pension,
      Supplemental Savings and Deferred Compensation Plans. Any benefits to which you are entitled under the
      Company's supplemental pension, supplemental savings and deferred
      compensation plans will be payable in accordance with the terms of such
      plans, including the six month wait for key employees. Please contact Mike
      Lei for more information.
		 
	     	9.	     	Company Health
      Plans. If you are currently enrolled in
      the Company's group medical, dental and/or vision plans and are making the
      payroll deductions associated therewith, coverage will remain in force
      through April 30, 2016. After April 30, 2016, you will be entitled to
      continue your group medical, dental and vision coverage at your own
      expense for a period of up to 18 months through COBRA. Information as to
      the cost of such coverage will be supplied to you approximately two weeks
      following your Transition Date. Notwithstanding the foregoing, if you
      become employed and covered by a health insurance plan of a new employer,
      you must immediately notify the Company’s Vice President of Human
      Resources. Your coverage under the Company’s health plans will cease as of
      the date you become covered under such other employer’s health
    plan.
		 
		10.		Other Company Welfare
      Benefits. Your coverage under the
      Company's life and accidental death and dismemberment (AD&D) plans
      will remain in force through April 30, 2016. Such life Insurance coverage
      may be converted to an individual policy within 31 days after termination
      of such coverage by contacting MetLife at (888) 622-6616.
		 
				Your enrollment in any voluntary
      benefits, including Supplemental Life and/or supplemental AD&D for you
      and/or your dependents, Critical Illness Insurance and/or MetLaw, and the
      payroll deductions associated therewith, will continue through April 30,
      2016. MetLife will contact you by mail following that date with regard to
      your ability to convert the coverage to an individual policy.
		 
		11.		Medicare
      Reporting. By signing this Agreement,
      you acknowledge that you have carefully reviewed Attachment A regarding
      Medicare Reporting and you have fully and accurately completed Attachment
      A regarding potential Medicare eligibility. You also agree to waive and
      release any private cause of action for damages pursuant to 42 U.S.C.
      1395. The parties have not shifted responsibility for medical treatment to
      Medicare in contravention of 42 U.S.C. 1395 and further acknowledge that
      any action or decision by the Centers for Medicare & Medicaid Services
      or Medicare regarding your eligibility or entitlement to Medicare or
      Medicare payments will not affect the finality of this Agreement or render
      the release of claims void or ineffective. The parties made every effort
      to adequately protect Medicare’s interest and incorporate such into the
      settlement terms, and to comply with both federal and state law. You agree
      you will indemnify, defend and hold the Company harmless from any Medicare
      conditional payments and right to payment, known or unknown, and all
      claims or liens related thereto.

Ivor J. Evans
April 21, 2016
Page 3
of 7 

		12.		Withholdings. All payments and benefits under this Agreement are
      subject to any and all applicable tax and other withholdings.
		 
	     	13.	     	Company
      Property. You will deliver promptly to
      the Company (and not keep in your possession or deliver to any other
      person or entity) any and all property belonging to the Company or any of
      its subsidiaries or divisions that is in your possession or under your
      control, including without limitation, credit cards, other electronic
      equipment, records, data, notes, reports, correspondence, financial
      information, customer files and information and other documents or
      information (including any and all copies of such Company
    property).
		 
		14.		Release of
      Claims. You will not have the right to
      assert that the Company or any Company Released Party unlawfully
      terminated your employment or violated any of your rights in connection
      with your employment.
		 
				You affirm that you have not
      filed, and agree, to the maximum extent permitted by law, not to initiate
      or cause to be initiated on your behalf, any complaint, charge, claim or
      proceeding against the Company Released Parties before any federal, state
      or local agency, court or other body relating to your employment, the
      cessation thereof or any other matters covered by the terms described
      above, and agree not to voluntarily participate in such a proceeding.
      Further, you hereby waive your right to, and agree, to the maximum extent
      permitted by law, not to, seek, receive, collect, or benefit from any
      monetary or other compensatory settlement, award, judgment, or other
      resolution (including a resolution that would otherwise provide for
      reinstatement to employment) of any complaint, charge, or claim that any
      agency or other body pursues against any of the Company Released Parties,
      whether pursued solely on your behalf or on behalf of a greater class of
      individuals.
		 
				Nothing in this Agreement shall
      preclude or prevent you from filing a claim with the Equal Employment
      Opportunity Commission that challenges the validity of the release in this
      paragraph 14 solely with respect to your waiver of any Losses that may
      arise under the ADEA.
		 
		15.		
      The Company agrees on behalf of its
      subsidiaries and divisions and its and their respective current and former
      officers, directors, employees, agents, owners, affiliates, successors and
      assigns (the "Company Parties") to release, acquit and forever discharge
      you, your heirs, executors, administrators and assigns, of and from any
      and all manner of actions and causes of action, suits, debts, damages,
      dues, accounts, bonds, covenants, contracts, agreements, judgments,
      charges, claims, rights and demands whatsoever, whether known or unknown
      ("Losses"), which the Company Parties ever had, now have or may hereafter
      have, against you or any of them arising out of or by reason of any cause,
      claim, controversy, matter or thing whatsoever, including but not limited
      to any and all claims arising in the ordinary course and scope of your
      employment with the Company and its predecessors, excepting any act found
      to be criminal by a court of competent jurisdiction from the beginning of
      the world to the date hereof, including without limitation, any and all
      matters relating to your employment by the Company and its predecessors
      and the cessation thereof, any and all matters relating to your
      compensation and benefits by or from the Company and its predecessors and
      any and all matters arising under any federal, state or local statute,
      rule, regulation or principle of contract law or common
  law.

Ivor J. Evans
April 21,
2016
Page 4 of 7 

				
      The Company understands that as a result of the
      prior paragraph, the Company will not have the right to assert that you
      unlawfully terminated your employment or violated any of the Company’s
      rights in connection with your employment.

		 
				The Company affirms that it has
      not filed, and agrees not to initiate or cause to be initiated on its
      behalf, any complaint, charge, claim or proceeding against you before any
      federal, state or local agency, court or other body relating to matters
      released in this paragraph 15, and agrees not to voluntarily participate
      in such a proceeding.
		 
				The Company agrees to indemnify
      you and to provide you legal counsel in any litigation, administrative
      proceeding or investigation relating to your employment with the Company
      in which you are originally named as a defendant. Notwithstanding the
      foregoing, the Company shall have no obligation to indemnify you for any
      act found to be criminal or outside the scope of your employment, by a
      court of competent jurisdiction.
		 
	     	16.	     	Confidentiality. The Company and
      you agree that the terms and conditions of this Agreement are confidential
      and that neither party will disclose the terms of this Agreement to any
      third parties, other than (i) disclosure by you to your spouse, (ii)
      disclosure by the Company or you to its or your respective attorneys,
      auditors, financial advisors and accountants, (iii) as may be required by
      law (including securities laws) or (iv) as may be necessary to enforce
      this Agreement. Without limiting the generality of the foregoing, you
      acknowledge that the Company may, to the extent required by applicable
      law, describe or incorporate the terms of this Agreement in, and/or file
      or incorporate this Agreement as an exhibit to, one or more filings with
      the Securities and Exchange Commission.
		 
		17.		Termination. Either party shall have the right to terminate this
      Agreement at any time if the other party breaches any of the obligations
      stated herein under this Agreement after that party has received written
      notice of the claimed breach and has failed to cure the breach within
      fifteen (15) days of receipt of notice.
		 
		18.		Advice of Counsel/Voluntary
      Consideration. You acknowledge that you
      have been advised to consult with an attorney prior to signing this
      Agreement. You also acknowledge, understand and agree that this Agreement
      is voluntarily entered into by you in consideration of the undertakings by
      the Company as set forth herein and is consistent in all respects with the
      discussions by the Company personnel with you relating to your
      separation.
		 
		19.		Proprietary
      Information. You agree that you will
      not disclose, nor will you use any Meritor proprietary information at any
      time, including after you leave employment with the Company. Proprietary
      information is any sensitive information owned by the Company and which
      gives or potentially gives the Company certain competitive advantages and
      is not widely known to the public. Proprietary information can include
      secret formulas, processes, and methods used in production. It can also
      include the Company’s business and marketing plans, salary structure,
      customer lists, contracts, and details of its computer systems. Special
      knowledge and skills that an employee has learned on the job are
      considered to be the Company’s proprietary information.
	 	 
		20.		Release Period and Effective
      Date. This Agreement may be revoked
      within seven (7) days from the date it is signed by you by notifying
      counsel for Meritor, Richard Rose, Interim General Counsel Meritor, Inc.,
      2135 W. Maple Road, Troy, Michigan 48084, in writing. Any such revocation
      will be effective upon receipt by Mr. Rose. This Agreement will become
      effective and irrevocable upon expiration of the seven (7) day revocation
      period.
		 
		21.		Arbitration. In the event there is a dispute regarding this
      Agreement or your employment with the Company, you and the Company agree
      that, except where injunctive relief is being sought by either party to
      enforce this Agreement, any such dispute will be resolved solely and
      exclusively by binding arbitration, by and under the rules of the American
      Arbitration Association, in accordance with the Company’s “Mutual
      Agreement to Arbitrate Claims” and the Company’s “Standards of Business
      Conduct and Conflict of Interest Certificate” that you have signed
      previously. A judgment of any circuit court may be rendered upon the award
      made pursuant to this Agreement and shall be valid, enforceable and
      irrevocable save upon such grounds as exist at law or in equity for the
      rescission or revocation of any contract. Any controversy involving the
      construction or application of any terms, covenants or conditions of this
      Agreement, or any claims arising out of any alleged breach of this
      Agreement, will be submitted to and resolved by final and binding
      arbitration in Oakland County, Michigan (conducted pursuant to the
      aforementioned American Arbitration
Association).

Ivor J. Evans
April 21,
2016
Page 5 of 7 

	     	22.	     	Severability. If any provision
      or portion of this Agreement shall for any reason be held invalid or
      unenforceable such invalidity or unenforceability shall not affect any
      other provision hereof and the remaining provisions or portions of this
      Agreement shall remain in full force and effect, and shall be interpreted
      to best reflect the intent of the parties.
		 
		23.		Section
      409A.
		 
				(a)	     	The payments and benefits under
      this Agreement are intended to comply with or be exempt from the
      requirements of Section 409A. To the extent that any payment or benefit
      under this Agreement is subject to the requirements of Section 409A, then,
      with respect to such payment or benefit, this Agreement will be
      interpreted to the maximum extent permitted by law in a manner to comply
      with the requirements of Section 409A.
		 
				(b)		Notwithstanding any other
      provision of this Agreement, payments or benefits under this Agreement
      that are subject to the requirements of Section 409A may only be provided
      upon an event and in a manner that complies with Section 409A, and any
      such payment or benefit that is to be made upon or as a result of a
      termination of employment shall only be made if such termination of
      employment constitutes a "separation from service" (as defined under
      Section 409A).
		 
				(c)		Notwithstanding any other
      provision of this Agreement, payments or benefits under this Agreement
      that are subject to the requirements of Section 409A that are provided as
      a result of a separation from service during the six (6) month period
      immediately following your separation from service will not be provided
      during that six (6) month period immediately following your separation
      from service. Such payments and benefits shall instead be provided during
      the first payroll cycle immediately following the expiration of such
      six-month period.
		 
				(d)		All reimbursements and in-kind
      benefits provided under this Agreement will be made or provided in
      accordance with the requirements of Section 409A to the extent that such
      reimbursements and in-kind benefits are subject to Section 409A,
      including, where applicable, the requirements that (i) any reimbursement
      is for expenses incurred during your employment with the Company and any
      in-kind benefit is provided during your employment with the Company
      (unless a different time period is stated elsewhere in this Agreement),
      (ii) the amount of expenses eligible for reimbursement or in-kind benefits
      to be provided during a calendar year will not affect the amount of
      expenses eligible for reimbursement or in-kind benefits to be provided in
      any other calendar year, (iii) any reimbursement will be made on or before
      the last day of the calendar year following the calendar year in which the
      expense is incurred, and (iv) the right to the reimbursement or in-kind
      benefit is not subject to liquidation or exchange for cash or any other
      benefit.
		 
	 	 	 	(e)	 	Notwithstanding the foregoing,
      the Company makes no representation to you about the effect of Section
      409A on the provisions of this Agreement.

Ivor J. Evans
April 21,
2016
Page 6 of 7 

	     	24.	     	Final
      Agreement. This Agreement is a complete
      and final agreement between you and the Company and its successors and
      supersedes all other offers, agreements, and negotiations. Notwithstanding
      the foregoing, the Invention Assignment and Arbitration Agreements remain
      in full force and effect except as modified by this
  Agreement.

Sincerely, 

 

William R. Newlin 
Lead Director of the Board of Directors of Meritor, Inc.

	/s/ William R. Newlin	 
	cc: 	J. Craig
		T. Heffron
		R. Rose

	
      Accepted and Agreed by:
	
	/s/
      Ivor J. Evans	
	Ivor J. Evans	 
	 	 
	4/21/16	
	Date	

Ivor J. Evans
April 21, 2016
Page 7
of 7 

ATTACHMENT A - MEDICARE ELIGIBILITY
AND REPORTING 

Medicare Eligible and a Medicare
Beneficiary: A person may be Medicare
eligible if he/she: (1) is 65 years of age or older; (2) is suffering from end
stage renal failure and meets certain additional conditions, (3) is suffering
from amyotrophic lateral sclerosis, (4) has received Social Security benefits
for twenty-four (24) months or longer. A person currently receiving Medicare
benefits is a Medicare Beneficiary.

I confirm the following:

☐   I am Medicare
eligible or a Medicare Beneficiary. I
confirm that I am either Medicare eligible (or will be Medicare eligible within
thirty (30) months), or I am currently a beneficiary of Medicare
benefits. 

☐   I am not
Medicare eligible and do not reasonably expect to be Medicare eligible within
thirty (30) months, nor am I currently
a beneficiary of Medicare benefits.
I further confirm that I have not applied for
Social Security benefits, nor have I been denied Social Security benefits for
which I am appealing the denial.

If you have selected “Yes, I am
Medicare eligible or a Medicare Beneficiary,” please read the following
provisions carefully:

I confirm that I have not made any claim
for illness or injury against the Released Parties, nor am I aware of any facts
supporting any claim, under which the Released Parties could be liable for
medical expenses incurred by me before or after signing this Agreement. I
confirm that I am not aware of any medical expenses which Medicare has paid on
my behalf for which the Company is or could be liable now or in the future. I am
not aware of any Medicare conditional payments that have been made on my behalf
in connection with my transition of employment from the Company, and I agree if
requested to use my best efforts to obtain a letter from Medicare to this
effect. I agree and affirm that, to the best of my knowledge, no liens by any
governmental entity exists, including but not limited to, any lien for Medicare
conditional payments.

I will assume responsibility for Medicare
conditional payments, including but not limited to, subrogation claims, liens,
or other rights to payment, relating to medical treatment that may be asserted
by a health care provider, insurer, governmental entity, employer or other
person or entity. I will indemnify, defend and hold the Company harmless from
any and all damages (including multiple damages), claims and rights to payment,
including any attorneys’ fees, brought by any person or entity against the
Company to recover any conditional or other Medicare payments made to
me.

I confirm and acknowledge that the
above statements by me are true. Further, I confirm that the above definitions
are provided for my assistance, however, it is my sole responsibility to
accurately evaluate my Medicare eligibility and/or beneficiary status and
disclose that status to the Company. If I am Medicare eligible or a Medicare
Beneficiary, I have carefully read and agree to the above provisions.

	Signature: 	 	          	Date:

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