Document:

Exhibit 10.1

 

SECURITIES
PURCHASE AGREEMENT

 

This
SECURITIES PURCHASE AGREEMENT (the “Agreement”), dated as of [      ], by and between Jerrick Media Holdings,
Inc., a Nevada corporation, with headquarters located at 202 S. Dean Street, Englewood, NJ 07631 (the “Company”),
and [      ], a [Jurisdiction] [type of entity], with its address at ___________________________ (the “Buyer”).

 

WHEREAS:

 

A.       The
Company and the Buyer are executing and delivering this Agreement in reliance upon the exemption from securities registration
afforded by the rules and regulations as promulgated by the United States Securities and Exchange Commission (the “SEC”)
under the Securities Act of 1933, as amended (the “1933 Act”).

 

B.       Buyer
desires to purchase and the Company desires to issue and sell, upon the terms and conditions set forth in this Agreement: (i)
an 8.5% redeemable Debenture of the Company, in the form attached hereto as Exhibit A, in the aggregate principal amount of $[_________]
(together with any Debenture(s) issued in replacement thereof or as a dividend thereon or otherwise with respect thereto in accordance
with the terms thereof, the “Debenture”), convertible into shares of common stock of the Company (the “Conversion
Shares”); and (ii) a five-year warrant, in the form attached hereto as Exhibit B, to purchase up to [_________] shares of
the Company’s common stock at an exercise price of $0.20 per share (the “Warrant”, and the shares of common
stock issuable upon exercise of the Warrant, the “Warrant Shares”), upon the terms and subject to the limitations
and conditions set forth in such Debenture. The Debenture shall have an original issue discount of approximately 10% such that
the purchase price of the Debenture shall be $[_________].

 

C.       The
Buyer wishes to purchase, upon the terms and conditions stated in this Agreement, such principal amount of Debenture as is set
forth immediately below its name on the signature pages hereto; and

 

NOW
THEREFORE, the Company and the Buyer severally (and not jointly) hereby agree as follows:

 

1.       Purchase
and Sale of Debenture.

 

a.       Purchase
of Debenture and Warrant. On each of the Closing Dates (as defined below), the Company shall issue and sell to the Buyer and
the Buyer agrees to purchase from the Company such principal amount of Debenture and Warrant as is set forth immediately below
the Buyer’s name on the signature pages hereto.

 

 

Company
Initials

 

     

     

    

 

b.       Form
of Payment. On the Closing Date (as defined below), (i) the Buyer shall pay the purchase price for the Debenture and Warrant
to be issued and sold to it at the Closing (as defined below) (the “Purchase Price”) by wire transfer of immediately
available funds to the Company, in accordance with the Company’s written wiring instructions, against delivery of the Debenture
and the Warrant in the principal amount equal to the Purchase Price as is set forth immediately below the Buyer’s name on
the signature pages hereto, and (ii) the Company shall deliver such duly executed Debenture on behalf of the Company, to the Buyer,
against delivery of such Purchase Price.

 

c.       Closing
Date. The date and time of the first issuance and sale of the Debenture and Warrant pursuant to this Agreement (the
“Closing Date”) shall be on or about [     ], or such other mutually agreed upon time. The closing of the
transactions contemplated by this Agreement (the “Closing”) shall occur on the Closing Date at such location as
may be agreed to by the parties.

 

2.      
Buyer’s Representations and Warranties.The Buyer represents and warrants to the Company that:

 

a.       Investment
Purpose. As of the date hereof, the Buyer is purchasing the Debenture Conversion Shares, Warrant and Warrant Shares (collectively,
the “Securities”) for its own account and not with a present view towards the public sale or distribution thereof,
except pursuant to sales registered or exempted from registration under the 1933 Act and has no direct or indirect arrangement
or understandings with any other person or entity to distribute or regarding the distribution of such Securities; provided,
however, that by making the representations herein, the Buyer does not agree to hold any of the Securities for any minimum
or other specific term and reserves the right to dispose of the Securities at any time in accordance with or pursuant to a registration
statement or an exemption under the 1933 Act.

 

b.       Accredited
Investor Status. The Buyer is an “accredited investor” as that term is defined in Rule 501(a) of Regulation D
(an “Accredited Investor”). The Buyer is experienced in investments and business matters, has made investments of
a speculative nature and has purchased securities of United States publicly-owned companies in private placements in the past
and, with its representatives, has such knowledge and experience in financial, tax and other business matters as to enable the
Buyer to utilize the information made available by the Company to evaluate the merits and risks of, and to make an informed investment
decision with respect to, the proposed purchase, which the Buyer hereby agrees represents a speculative investment. The Buyer
has the authority and is duly and legally qualified to purchase and own the Securities. The Buyer is able to bear the risk of
such investment for an indefinite period and to afford a complete loss thereof.

 

c.       Reliance
on Exemptions. The Buyer understands that the Securities are being offered and sold to it in reliance upon specific
exemptions from the registration requirements of United States federal and state securities laws and that the Company is
relying upon the truth and accuracy of, and the Buyer’s compliance with, the representations, warranties, agreements,
acknowledgments and understandings of the Buyer set forth herein in order to determine the availability of such exemptions
and the eligibility of the Buyer to acquire the Securities.

 

    2

     

    

 

d.       Information.
The Buyer and its advisors, if any, have been, and for so long as the Debenture remain outstanding will continue to be, furnished
with all materials relating to the business, finances and operations of the Company and materials relating to the offer and sale
of the Securities which have been requested by the Buyer or its advisors. The Buyer and its advisors, if any, have been, and for
so long as the Debenture remain outstanding will continue to be, afforded the opportunity to ask questions of the Company. Notwithstanding
the foregoing, the Company has not disclosed to the Buyer any material nonpublic information and will not disclose such information
unless such information is disclosed to the public prior to or promptly following such disclosure to the Buyer. Neither such inquiries
nor any other due diligence investigation conducted by Buyer or any of its advisors or representatives shall modify, amend or
affect Buyer’s right to rely on the Company’s representations and warranties contained in Section 3 below. The Buyer
understands that its investment in the Securities involves a significant degree of risk. The Buyer is not aware of any facts that
may constitute a breach of any of the Company's representations and warranties made herein.

 

e.       Governmental
Review. The Buyer understands that no United States federal or state agency or any other government or governmental agency
has passed upon or made any recommendation or endorsement of the Securities.

 

f.       Transfer
or Re-sale. The Buyer understands that (i) the sale or re-sale of the Securities has not been and is not being
registered under the 1933 Act or any applicable state securities laws, and the Securities may not be transferred unless (a)
the Securities are sold pursuant to an effective registration statement under the 1933 Act, (b) the Buyer shall have
delivered to the Company, at the cost of the Buyer, an opinion of counsel that shall be in form, substance and scope
customary for opinions of counsel in comparable transactions to the effect that the Securities to be sold or transferred may
be sold or transferred pursuant to an exemption from such registration, which opinion shall be accepted by the Company, (c)
the Securities are sold or transferred to an “affiliate” (as defined in Rule 144 promulgated under the 1933 Act
(or a successor rule) (“Rule 144”) of the Buyer who agrees to sell or otherwise transfer the Securities only in
accordance with this Section 2(f) and who is an Accredited Investor, (d) the Securities are sold pursuant to Rule 144, or (e)
the Securities are sold pursuant to Regulation S under the 1933 Act (or a successor rule) (“Regulation S”), and
the Buyer shall have delivered to the Company, at the cost of the Buyer, an opinion of counsel that shall be in form,
substance and scope customary for opinions of counsel in corporate transactions, which opinion shall be accepted by the
Company; (ii) any sale of such Securities made in reliance on Rule 144 may be made only in accordance with the terms of said
Rule and further, if said Rule is not applicable, any re-sale of such Securities under circumstances in which the seller (or
the person through whom the sale is made) may be deemed to be an underwriter (as that term is defined in the 1933 Act) may
require compliance with some other exemption under the 1933 Act or the rules and regulations of the SEC thereunder; and (iii)
neither the Company nor any other person is under any obligation to register such Securities under the 1933 Act or any state
securities laws or to comply with the terms and conditions of any exemption thereunder (in each case). Notwithstanding
the foregoing or anything else contained herein to the contrary, the Securities may be pledged as collateral in connection
with a bona fide margin account or other lending arrangement.

 

    3

     

    

 

g.       Legends.
The Buyer understands that the Debenture and, until such time as the Conversion Shares have been registered under the 1933 Act
may be sold pursuant to Rule 144 or Regulation S without any restriction as to the number of securities as of a particular date
that can then be immediately sold, the Conversion Shares may bear a restrictive legend in substantially the following form (and
a stop-transfer order may be placed against transfer of the certificates for such Securities):

 

“NEITHER
THE ISSUANCE AND SALE OF THE SECURITIES REPRESENTED BY THIS CERTIFICATE NOR THE SECURITIES INTO WHICH THESE SECURITIES ARE EXERCISABLE
HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE STATE SECURITIES LAWS. THE SECURITIES MAY NOT
BE OFFERED FOR SALE, SOLD, TRANSFERRED OR ASSIGNED (I) IN THE ABSENCE OF (A) AN EFFECTIVE REGISTRATION STATEMENT FOR THE SECURITIES
UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR (B) AN OPINION OF COUNSEL (WHICH COUNSEL SHALL BE SELECTED BY THE HOLDER), IN
A GENERALLY ACCEPTABLE FORM, THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT OR (II) UNLESS SOLD PURSUANT TO RULE 144 OR RULE
144A UNDER SAID ACT. NOTWITHSTANDING THE FOREGOING, THE SECURITIES MAY BE PLEDGED IN CONNECTION WITH A BONA FIDE MARGIN ACCOUNT
OR OTHER LOAN OR FINANCING ARRANGEMENT SECURED BY THE SECURITIES.”

 

The
legend set forth above shall be removed and the Company shall issue a certificate without such legend to the holder of any Security
upon which it is stamped, if, unless otherwise required by applicable state securities laws, (a) such Security is registered for
sale under an effective registration statement filed under the 1933 Act or otherwise may be sold pursuant to Rule 144 or Regulation
S without any restriction as to the number of securities as of a particular date that can then be immediately sold, or (b) such
holder provides the Company with an opinion of counsel, in form, substance and scope customary for opinions of counsel in comparable
transactions, to the effect that a public sale or transfer of such Security may be made without registration under the 1933 Act,
which opinion shall be accepted by the Company so that the sale or transfer is effected. The Buyer agrees to sell all Securities,
including those represented by a certificate(s) from which the legend has been removed, in compliance with applicable prospectus
delivery requirements, if any. In the event that the Company does not accept the opinion of counsel provided by the Buyer with
respect to the transfer of Securities pursuant to an exemption from registration, such as Rule 144 or Regulation S, within 2 business
days, it will be considered an Event of Default under the Debenture.

 

h.       
Authorization and Power. Buyer has the requisite power and authority to enter into and perform this Agreement and to advance
the Purchase Price and accept the Debenture.

 

    4

     

    

 

The
execution, delivery and performance of this Agreement by the Buyer, and the consummation by the Buyer of the transactions contemplated
hereby, have been duly authorized by all necessary action, and no further consent or authorization of Buyer is required. This
Agreement has been duly authorized, executed and delivered by the Buyer and constitutes, or shall constitute, when executed and
delivered, a valid and binding obligation of the Buyer, enforceable against Buyer in accordance with the terms hereof.

 

i.       No
Market Manipulation. Buyer has not taken, and will not take, any action to cause manipulation of the price of the Common Stock.

 

j.       Residency.
The Buyer is a resident of the jurisdiction set forth immediately below the Buyer’s name on the signature pages hereto.

 

3.       Representations
and Warranties of the Company. The Company represents and warrants to the Buyer that:

 

a.       Organization
and Qualification. The Company and each of its subsidiaries, if any, is a corporation duly organized, validly existing and
in good standing under the laws of the jurisdiction in which it is incorporated, with full power and authority (corporate and
other) to own, lease, use and operate its properties and to carry on its business as and where now owned, leased, used, operated
and conducted.

 

b.       Authorization;
Enforcement. (i) The Company has all requisite corporate power and authority to enter into and perform this Agreement, the
Debenture and to consummate the transactions contemplated hereby and thereby and to issue the Securities, in accordance with the
terms hereof and thereof, (ii) the execution and delivery of this Agreement, the Debenture by the Company and the consummation
by it of the transactions contemplated hereby and thereby (including without limitation, the issuance of the Debenture and the
issuance and reservation for issuance of the Conversion Shares issuable upon conversion or exercise thereof) have been duly authorized
by the Company’s Board of Directors and no further consent or authorization of the Company, its Board of Directors, or its
shareholders is required, (iii) this Agreement has been duly executed and delivered by the Company by its authorized representative,
and such authorized representative is the true and official representative with authority to sign this Agreement and the other
documents executed in connection herewith and bind the Company accordingly, and (iv) this Agreement constitutes, and upon execution
and delivery by the Company of the Debenture, each of such instruments will constitute, a legal, valid and binding obligation
of the Company enforceable against the Company in accordance with its terms.

 

c.       Issuance
of Shares. The Conversion Shares are duly authorized and reserved for issuance and, upon conversion of the Debenture in
accordance with its respective terms, will be validly issued, fully paid and non-assessable, and free from all taxes, liens,
claims and encumbrances with respect to the issue thereof and shall not be subject to preemptive rights or other similar
rights of shareholders of the Company and will not impose personal liability upon the holder thereof.

 

    5

     

    

 

d.       Acknowledgment
of Dilution. The Company understands and acknowledges the potentially dilutive effect to the Common Stock upon the issuance
of the Conversion Shares upon conversion of the Debenture. The Company further acknowledges that its obligation to issue Conversion
Shares upon conversion of the Debenture in accordance with this Agreement, the Debenture is absolute and unconditional regardless
of the dilutive effect that such issuance may have on the ownership interests of other shareholders of the Company.

 

e.       No
Conflicts. The execution, delivery and performance of this Agreement, the Debenture by the Company and the consummation by
the Company of the transactions contemplated hereby and thereby (including, without limitation, the issuance and reservation for
issuance of the Conversion Shares) will not (i) conflict with or result in a violation of any provision of the Certificate of
Incorporation or By-laws, or (ii) violate or conflict with, or result in a breach of any provision of, or constitute a default
(or an event which with notice or lapse of time or both could become a default) under, or give to others any rights of termination,
amendment, acceleration or cancellation of, any agreement, indenture, patent, patent license or instrument to which the Company
or any of its Subsidiaries is a party, or (iii) result in a violation of any law, rule, regulation, order, judgment or decree
(including federal and state securities laws and regulations and regulations of any self-regulatory organizations to which the
Company or its securities are subject) applicable to the Company or any of its Subsidiaries or by which any property or asset
of the Company or any of its Subsidiaries is bound or affected (except for such conflicts, defaults, terminations, amendments,
accelerations, cancellations and violations as would not, individually or in the aggregate, have a Material Adverse Effect). All
consents, authorizations, orders, filings and registrations which the Company is required to obtain pursuant to the preceding
sentence have been obtained or effected on or prior to the date hereof. The Company is not in violation of the listing requirements
of the OTC Markets Exchange (the “OTC MARKETS”) and does not reasonably anticipate that the Common Stock will be delisted
by the OTC MARKETS in the foreseeable future, nor are the Company’s securities “chilled” by FINRA. The Company
and its Subsidiaries are unaware of any facts or circumstances which might give rise to any of the foregoing.

 

f.       Absence
of Litigation. Except as disclosed in the Company’s public filings or as disclosed on the Schedules hereto, there is
no action, suit, claim, proceeding, inquiry or investigation before or by any court, public board, government agency, self-regulatory
organization or body pending or, to the knowledge of the Company or any of its subsidiaries, threatened against or affecting the
Company or any of its subsidiaries, or their officers or directors in their capacity as such, that could have a material adverse
effect. Schedule 3(f) contains a complete list and summary description of any pending or, to the knowledge of the Company, threatened
proceeding against or affecting the Company or any of its subsidiaries, without regard to whether it would have a material adverse
effect. The Company and its subsidiaries are unaware of any facts or circumstances which might give rise to any of the foregoing.

 

    6

     

    

 

g.        Acknowledgment
Regarding Buyer’ Purchase of Securities. The Company acknowledges and agrees that the Buyer is acting solely in the
capacity of arm’s length purchasers with respect to this Agreement and the transactions contemplated hereby. The
Company further acknowledges that the Buyer is not acting as a financial advisor or fiduciary of the Company (or in any
similar capacity) with respect to this Agreement and the transactions contemplated hereby and any statement made by the Buyer
or any of its respective representatives or agents in connection with this Agreement and the transactions contemplated hereby
is not advice or a recommendation and is merely incidental to the Buyer’ purchase of the Securities. The Company
further represents to the Buyer that the Company’s decision to enter into this Agreement has been based solely on the
independent evaluation of the Company and its representatives.

 

h.       No
Integrated Offering. Neither the Company, nor any of its affiliates, nor any person acting on its or their behalf, has directly
or indirectly made any offers or sales in any security or solicited any offers to buy any security under circumstances that would
require registration under the 1933 Act of the issuance of the Securities to the Buyer. The issuance of the Securities to the
Buyer will not be integrated with any other issuance of the Company’s securities (past, current or future) for purposes
of any shareholder approval provisions applicable to the Company or its securities.

 

i.       Title
to Property. The Company and its subsidiaries have good and marketable title in fee simple to all real property and good and
marketable title to all personal property owned by them which is material to the business of the Company and its subsidiaries,
in each case free and clear of all liens, encumbrances and defects except such as are described in Schedule 3(i) or such as would
not have a material adverse effect. Any real property and facilities held under lease by the Company and its subsidiaries are
held by them under valid, subsisting and enforceable leases with such exceptions as would not have a material adverse effect.

 

j.       Bad
Actor. No officer or director of the Company would be disqualified under Rule 506(d) of the Securities Act as amended on the
basis of being a "bad actor" as that term is established in the September 19, 2013 Small Entity Compliance Guide published
by the Securities and Exchange Commission.

 

k.       Breach
of Representations and Warranties by the Company. If the Company breaches any of the representations or warranties set forth
in this Section 3, and in addition to any other remedies available to the Buyer pursuant to this Agreement, it will be considered
an Event of default under the Debenture.

 

 4.       COVENANTS.

 

a.       Expenses.
At the Closing, the Company shall reimburse Buyer in the amount of $[_________] for expenses incurred by them in connection with
the negotiation, preparation, execution, delivery and performance of this Agreement and the other agreements to be executed in
connection herewith (“Documents”), and such amount shall be withheld by the Buyer from the purchase price of the Debenture.

 

    7

     

    

 

b.       Listing.
The Company shall promptly secure the listing of the Conversion Shares upon each national securities exchange or automated quotation
system, if any, upon which shares of Common Stock are then listed (subject to official notice of issuance) and, so long as the
Buyer owns any of the Securities, shall maintain, so long as any other shares of Common Stock shall be so listed, such listing
of all Conversion Shares from time to time issuable upon conversion of the Debenture. The Company will obtain and, so long as
the Buyer owns any of the Securities, maintain the listing and trading of its Common Stock on the OTC MARKETS or any equivalent
replacement exchange, the Nasdaq National Market (“Nasdaq”), the Nasdaq SmallCap Market (“Nasdaq SmallCap”),
the New York Stock Exchange (“NYSE”), or the American Stock Exchange (“AMEX”) and will comply in all respects
with the Company’s reporting, filing and other obligations under the bylaws or rules of the Financial Industry Regulatory
Authority (“FINRA”) and such exchanges, as applicable. The Company shall promptly provide to the Buyer copies of any
notices it receives from the OTC MARKETS and any other exchanges or quotation systems on which the Common Stock is then listed
regarding the continued eligibility of the Common Stock for listing on such exchanges and quotation systems.

 

c.       Corporate
Existence. So long as the Buyer beneficially owns any Debenture, the Company shall maintain its corporate existence and shall
not sell all or substantially all of the Company’s assets, except in the event of a merger or consolidation or sale of all
or substantially all of the Company’s assets, where the surviving or successor entity in such transaction (i) assumes the
Company’s obligations hereunder and under the agreements and instruments entered into in connection herewith and (ii) is
a publicly traded corporation whose Common Stock is listed for trading on the OTC MARKETS, Nasdaq, Nasdaq SmallCap, NYSE or AMEX.

 

d.       No
Integration. The Company shall not make any offers or sales of any security (other than the Securities) under circumstances
that would require registration of the Securities being offered or sold hereunder under the 1933 Act or cause the offering of
the Securities to be integrated with any other offering of securities by the Company for the purpose of any stockholder approval
provision applicable to the Company or its securities.

 

e.       Restricted
Shares. The Company shall issue 110,000 restricted shares of Common Stock to the Buyer and/or Buyer’s general partner
([_________]) as additional consideration for the purchase of the Debenture. The Company will use its best efforts to have the
shares registered.

 

f.       Warrants.
The Company shall issue the Buyer a five (5) year warrant to purchase 350,000 shares of Common Stock at an exercise price
of $0.20 per share.

 

    8

     

    

 

g.       PiggyBack
Rights. While the Debenture is outstanding, the Company will not effect a registration statement without including the shares
issuable upon conversion of the Debenture and warrants issued to the Buyer.

 

h.       Breach
of Covenants. If the Company breaches any of the covenants set forth in this Section 4, and in addition to any other remedies
available to the Buyer pursuant to this Agreement, it will be considered an event of default under the Debenture.

 

5.
      Governing Law; Miscellaneous.

 

a.       Governing
Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Nevada without regard to
principles of conflicts of laws. Any action brought by either party against the other concerning the transactions contemplated
by this Agreement shall be brought only in the state courts of Miami-Dade County, Florida in the federal courts located in Miami-Dade
County, Florida. The parties to this Agreement hereby irrevocably waive any objection to jurisdiction and venue of any action
instituted hereunder and shall not assert any defense based on lack of jurisdiction or venue or based upon forum non conveniens.
The Company and Buyer waive trial by jury. The prevailing party shall be entitled to recover from the other party its reasonable
attorney's fees and costs. In the event that any provision of this Agreement or any other agreement delivered in connection herewith
is invalid or unenforceable under any applicable statute or rule of law, then such provision shall be deemed inoperative to the
extent that it may conflict therewith and shall be deemed modified to conform with such statute or rule of law. Any such provision
which may prove invalid or unenforceable under any law shall not affect the validity or enforceability of any other provision
of any agreement. Each party hereby irrevocably waives personal service of process and consents to process being served in any
suit, action or proceeding in connection with this Agreement or any other Transaction Document by mailing a copy thereof via registered
or certified mail or overnight delivery (with evidence of delivery) to such party at the address in effect for notices to it under
this Agreement and agrees that such service shall constitute good and sufficient service of process and notice thereof. Nothing
contained herein shall be deemed to limit in any way any right to serve process in any other manner permitted by law.

 

b.       Counterparts;
Signatures by Facsimile. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original
but all of which shall constitute one and the same agreement and shall become effective when counterparts have been signed by
each party and delivered to the other party. This Agreement, once executed by a party, may be delivered to the other party hereto
by facsimile transmission of a copy of this Agreement bearing the signature of the party so delivering this Agreement.

 

c.       Headings.
The headings of this Agreement are for convenience of reference only and shall not form part of, or affect the interpretation
of, this Agreement.

 

d.       Severability.
In the event that any provision of this Agreement is invalid or unenforceable under any applicable statute or rule of law,
then such provision shall be deemed inoperative to the extent that it may conflict therewith and shall be deemed modified to
conform with such statute or rule of law. Any provision hereof which may prove invalid or unenforceable under any law shall
not affect the validity or enforceability of any other provision hereof.

 

    9

     

    

 

e.       Entire
Agreement; Amendments. This Agreement and the instruments referenced herein contain the entire understanding of the parties
with respect to the matters covered herein and therein and, except as specifically set forth herein or therein, neither the Company
nor the Buyer makes any representation, warranty, covenant or undertaking with respect to such matters. No provision of this Agreement
may be waived or amended other than by an instrument in writing signed by the majority in interest of the Buyer.

 

f.       Notices.
All notices, demands, requests, consents, approvals, and other communications required or permitted hereunder shall be in writing
and, unless otherwise specified herein, shall be (i) personally served, (ii) deposited in the mail, registered or certified, return
receipt requested, postage prepaid, (iii) delivered by reputable air courier service with charges prepaid, (iv) via electronic
mail or (v) transmitted by hand delivery, telegram, or facsimile, addressed as set forth below or to such other address as such
party shall have specified most recently by written notice. Any notice or other communication required or permitted to be given
hereunder shall be deemed effective (a) upon hand delivery or delivery by facsimile, with accurate confirmation generated by the
transmitting facsimile machine, at the address or number designated below (if delivered on a business day during normal business
hours where such notice is to be received) or delivery via electronic mail, or the first business day following such delivery
(if delivered other than on a business day during normal business hours where such notice is to be received) or (b) on the second
business day following the date of mailing by express courier service, fully prepaid, addressed to such address, or upon actual
receipt of such mailing, whichever shall first occur. The addresses for such communications shall be:

 

If
to the Company, to:

 

Jerrick
Media Holdings, Inc. 

202 S. Dean Street Englewood, 

NJ 07631

Attn:
Jeremy Frommer, CEO

Email:
jeremy@jerrick.media

 

If to the Buyer:

 

[
                             ]

________________________

________________________

Attention:
[            ]

Email:
[      ]

 

Each
party shall provide notice to the other party of any change in address.

 

g.       Successors
and Assigns. This Agreement shall be binding upon and inure to the benefit of the parties and their successors and assigns.
Neither the Company nor the Buyer shall assign this Agreement or any rights or obligations hereunder without the prior written
consent of the other. Notwithstanding the foregoing, the Buyer may assign its rights hereunder to any person that purchases Securities
in a private transaction from the Buyer or to any of its “affiliates,” as that term is defined under the 1934 Act,
without the consent of the Company.

 

    10

     

    

 

h.       Third
Party Beneficiaries. This Agreement is intended for the benefit of the parties hereto and their respective permitted successors
and assigns, and is not for the benefit of, nor may any provision hereof be enforced by, any other person.

 

i.       Survival.
The representations and warranties of the Company and the agreements and covenants set forth in this Agreement shall survive the
closing hereunder notwithstanding any due diligence investigation conducted by or on behalf of the Buyer. The Company agrees to
indemnify and hold harmless the Buyer and all their officers, directors, employees and agents for loss or damage arising as a
result of or related to any breach or alleged breach by the Company of any of its representations, warranties and covenants set
forth in this Agreement or any of its covenants and obligations under this Agreement, including advancement of expenses as they
are incurred.

 

j.       Further
Assurances. Each party shall do and perform, or cause to be done and performed, all such further acts and things, and shall
execute and deliver all such other agreements, certificates, instruments and documents, as the other party may reasonably request
in order to carry out the intent and accomplish the purposes of this Agreement and the consummation of the transactions contemplated
hereby.

 

k.       No
Strict Construction. The language used in this Agreement will be deemed to be the language chosen by the parties to express
their mutual intent, and no rules of strict construction will be applied against any party.

 

l.       Remedies.
The Company acknowledges that a breach by it of its obligations hereunder will cause irreparable harm to the Buyer by vitiating
the intent and purpose of the transaction contemplated hereby. Accordingly, the Company acknowledges that the remedy at law for
a breach of its obligations under this Agreement will be inadequate and agrees, in the event of a breach or threatened breach
by the Company of the provisions of this Agreement, that the Buyer shall be entitled, in addition to all other available remedies
at law or in equity, and in addition to the penalties assessable herein, to an injunction or injunctions restraining, preventing
or curing any breach of this Agreement and to enforce specifically the terms and provisions hereof, without the necessity of showing
economic loss and without any bond or other security being required.

 

    11

     

    

 

IN
WITNESS WHEREOF, the undersigned Buyer and the Company have caused this Agreement to be duly executed as of the date first above
written.

 

	JERRICK
    MEDIA HOLDINGS, INC.	 
	 	 	 
	By:	 	 
	 	Jeremy
    Frommer, CEO 	 

 

BUYER:

 

[                          ]

 

	By:  	[                           ]	 
	       	[                    ]	 

 

	 	By:		 
	         	Name:
	[                       ]	 
	     	Title:	[                       ]	 

 

AGGREGATE
SUBSCRIPTION AMOUNT:

 

Aggregate
Principal Amount of the Debenture:                           $[_______]

 

Aggregate Purchase Price:

 

 

    12

     

    

 

EXHIBIT
A DEBENTURE

1-
$[ ________ ]

 

    13

     

    

 

EXHIBIT
B

Common
Stock Purchase Warrant

 

    14

     

    

 

Schedule
3(f)

 

Penthouse
Global Media, et al. v. Guccione Collection, LLC et al, (Case 2:17-cv-04980-PA- FFM filed in the United States District
Court Central District of California), filed on July 6, 2017.

 

 

15Exhibit 10.2

 

THIS
DEBENTURE AND THE COMMON STOCK ISSUABLE UPON CONVERSION OF THIS DEBENTURE (THE “SECURITIES”) HAVE NOT BEEN AND WILL
NOT BE REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT’), OR QUALIFIED UNDER APPLICABLE STATE
SECURITIES LAWS AND MAY ONLY BE ACQUIRED FOR INVESTMENT PURPOSES ONLY AND NOT WITH A VIEW TO, OR IN CONNECTION WITH, THE SALE
OR DISTRIBUTION THEREOF. THE SECURITIES MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED OR HYPOTHECATED IN THE ABSENCE OF AN EFFECTIVE
REGISTRATION STATEMENT AS TO SUCH SECURITIES UNDER THE ACT AND QUALIFICATION UNDER APPLICABLE STATE LAW WITHOUT AN OPINION OF
COUNSEL SATISFACTORY TO THE COMPANY THAT SUCH REGISTRATION AND QUALIFICATION ARE NOT REQUIRED UNDER THE ACT OR RECEIPT OF A NO-ACTION
LETTER FROM THE SECURITIES AND EXCHANGE COMMISSION.

 

US
$[ ______ ]

 

[                                                         
]

8.5%
CONVERTIBLE REDEEMABLE

DEBENTURE DUE [                       ]

 

FOR
VALUE RECEIVED, Jerrick Media Holdings, Inc., a Nevada corporation (the “Company”) promises to pay to the order
of [                  ], a
[Jurisdiction] [type of entity] and its authorized successors and permitted assigns (“Holder”), the
aggregate principal face amount of [ ___________ ] Dollars (U.S. $[ ________ ]) on [                 ] (“Maturity Date”) and
to pay interest on the principal amount outstanding hereunder at the rate of 8.5% per annum commencing on [ ]. This Debenture
contains a ~10% OID such that the purchase price is $[ ________ ]. The interest will be paid to the Holder in whose name this
Debenture is registered on the records of the Company regarding registration and transfers of this Debenture. The principal
of, and interest on, this Debenture are payable at ____________________, initially, and if changed, last appearing on the
records of the Company as designated in writing by the Holder hereof from time to time. The Company will pay each interest
payment and the outstanding

 

____ 

Initials

 

principal
due upon this Debenture before or on the Maturity Date, less any amounts required by law to be deducted or withheld, to the Holder
of this Debenture by check or wire transfer addressed to such Holder at the last address appearing on the records of the Company.
The forwarding of such check or wire transfer shall constitute a payment of outstanding principal hereunder and shall satisfy
and discharge the liability for principal on this Debenture to the extent of the sum represented by such check or wire transfer.
Interest shall be payable in Common Stock (as defined below) pursuant to paragraph 4(b) herein.

 

     

     

    

  

This
Debenture is subject to the following additional provisions:

 

1.       This
Debenture is exchangeable for an equal aggregate principal amount of Debentures of different authorized denominations, as requested
by the Holder surrendering the same. No service charge will be made for such registration or transfer or exchange, except that
Holder shall pay any tax or other governmental charges payable in connection therewith.

 

2.       The
Company shall be entitled to withhold from all payments any amounts required to be withheld under applicable laws.

 

3.       This
Debenture may be transferred or exchanged only in compliance with the Securities Act of 1933, as amended (“Act”)
and applicable state securities laws. Any attempted transfer to a non-qualifying party shall be treated by the Company as void.
Prior to due presentment for transfer of this Debenture, the Company and any agent of the Company may treat the person in whose
name this Debenture is duly registered on the Company’s records as the owner hereof for all other purposes, whether or not this
Debenture be overdue, and neither the Company nor any such agent shall be affected or bound by notice to the contrary. Any Holder
of this Debenture electing to exercise the right of conversion set forth in Section 4(a) hereof, in addition to the requirements
set forth in Section 4(a), and any prospective transferee of this Debenture, also is required to give the Company written confirmation
that this Debenture is being converted (“Notice of Conversion”) in the form annexed hereto as Exhibit A.
The date of receipt (including receipt by telecopy) of such Notice of Conversion shall be the Conversion Date.

 

4.       (a)
The Holder of this Debenture is entitled, at its option, at any time on or after 180 days from the Issuance Date, to convert
all or any amount of the principal face amount of this Debenture then outstanding into shares of the Company’s common
stock (the “Common Stock”) at a price (“Conversion Price”) for each share of
Common Stock equal to the lower of (i) $0.20 per share, or (ii) 70% of the lowest VWAP of the
Common Stock as reported on the National Quotations Bureau OTC exchange which the Company’s shares are traded or any
exchange upon which the Common Stock may be traded in the future (“Exchange”), for the ten
prior trading days including the day upon which a Notice of Conversion is received by the Company (provided such Notice of
Conversion is delivered by fax or other electronic method of communication to the Company after 4 P.M. Eastern Standard or
Daylight Savings Time if the Holder wishes to include the same day closing price). However, if the shares are issuable
upon conversion of the Debenture are registered in an effective S-1 registration statement at the time of the respective
conversion, then the Conversion Price shall equal to 85% of the lowest VWAP of the Common Stock
for the ten prior trading days including the day upon which a Notice of Conversion is received by the
Company. If the shares have not been delivered within 3 business days, the Notice of Conversion may be rescinded. Such
conversion shall be effectuated by the Company delivering the shares of Common Stock to the Holder within 3 business days of
receipt by the Company of the Notice of Conversion. Accrued, but unpaid interest shall be subject to conversion. No
fractional shares or scrip representing fractions of shares will be issued on conversion, but the number of shares issuable
shall be rounded to the nearest whole share. To the extent the Conversion Price of the Company’s Common Stock closes
below the par value per share, the Company will take all steps necessary to solicit the consent of the stockholders to reduce
the par value to the lowest value possible under law. The Company agrees to honor all conversions submitted pending this
increase. In the event the Company’s shares are not DWAC eligible, the Conversion Price shall be decreased to
65% instead of 70% if not issuable upon conversion of the Debenture in the S-1 registration or to 80% if issuable upon
conversion of the Debenture in the S-1 registration. In no event shall the Holder be allowed to effect a conversion if
such conversion, along with all other shares of Company Common Stock beneficially owned by the Holder and its affiliates
would exceed 4.99% of the outstanding shares of the Common Stock of the Company. The conversion discount and look back period
will be adjusted on a ratchet basis if the Company offers a more favorable conversion discount (whether through a straight
discount or in combination with an original issue discount) or look back period to another party while this Debenture is in
effect.

 

____ 

Initials

 

    	 	2	 

     

    

 

(b)       Interest
on any unpaid principal balance of this Debenture shall be paid at the rate of 8.5% per annum. Interest shall be paid by the Company
in cash or, after the 6th month anniversary of this Debenture, in Common Stock (“Interest Shares”). Holder may, at any
time, send in a Notice of Conversion to the Company for Interest Shares based on the formula provided in Section 4(a) above. The
dollar amount converted into Interest Shares shall be all or a portion of the accrued interest calculated on the unpaid principal
balance of this Debenture to the date of such notice.

 

(c)       During
the first six months this Debenture is in effect, the Company may redeem this Debenture by paying to the Holder an amount as follows:
(i) if the redemption is within the first 30 days this Debenture is in effect, then for an amount equal to 140% of the unpaid
principal amount of this Debenture along with any interest that has accrued during that period, (ii) if the redemption is after
the 31st day this Debenture is in effect, but less than the 180th day this Debenture is in effect, then for an amount equal to
150% of the unpaid principal amount of this Debenture along with any accrued interest. This Debenture may not be redeemed after
180 days. The redemption must be closed and paid for within 3 business days of the Company sending the redemption demand or the
redemption will be invalid and the Company may not redeem this Debenture. Such redemption must be closed and funded within 3 days
of giving notice of redemption of the right to redeem shall be null and void.

 

(d)       Upon
(i) a transfer of all or substantially all of the assets of the Company to any person in a single transaction or series of related
transactions, (ii) a reclassification, capital reorganization or other change or exchange of outstanding shares of the Common
Stock, other than a forward or reverse stock split or stock dividend, or (iii) any consolidation or merger of the Com- pany with
or into another person or entity in which the Company is not the surviving entity (other than a merger which is effected solely
to change the jurisdiction of incorporation of the Company and results in a reclassification, conversion or exchange of outstanding
shares of Common Stock solely into shares of Common Stock) (each of items (i), (ii) and (iii) being referred to as a “Sale
Event”), then, in each case, the Company shall, upon request of the Holder, redeem this Debenture in cash for 150% of the
principal amount, plus accrued but unpaid interest through the date of redemption, or at the election of the Holder, such Holder
may convert the unpaid principal amount of this Debenture (together with the amount of accrued but unpaid interest) into shares
of Common Stock immediately prior to such Sale Event at the Conversion Price.

 

(e)       In
case of any Sale Event (not to include a sale of all or substantially all of the Company’s assets) in connection with which
this Debenture is not redeemed or converted, the Company shall cause effective provision to be made so that the Holder of this
Debenture shall have the right thereafter, by converting this Debenture, to purchase or convert this Debenture into the kind and
number of shares of stock or other securities or property (including cash) receivable upon such reclassification, capital reorganization
or other change, consolidation or merger by a holder of the number of shares of Common Stock that could have been purchased upon
exercise of the Debenture and at the same Conversion Price, as defined in this Debenture, immediately prior to such Sale Event.
The foregoing provisions shall similarly apply to successive Sale Events. If the consideration received by the holders of Common
Stock is other than cash, the value shall be as determined by the Board of Directors of the Company or successor person or entity
acting in good faith.

 

____ 

Initials

 

    	 	3	 

     

    

 

5.       No
provision of this Debenture shall alter or impair the obligation of the Company, which is absolute and unconditional, to pay the
principal of, and interest on, this Debenture at the time, place, and rate, and in the form, herein prescribed.

 

6.       The
Company hereby expressly waives demand and presentment for payment, notice of non-payment, protest, notice of protest, notice
of dishonor, notice of acceleration or intent to accelerate, and diligence in taking any action to collect amounts called for
hereunder and shall be directly and primarily liable for the payment of all sums owing and to be owing hereto.

 

7.       The
Company agrees to pay all costs and expenses, including reasonable attorneys’ fees and expenses, which may be incurred by the
Holder in collecting any amount due under this Debenture.

 

8.        If
one or more of the following described “Events of Default” shall occur:

 

(a)       The
Company shall default in the payment of principal or interest on this Debenture or any other Debenture issued to the Holder by
the Company; or

 

(b)       Any
of the representations or warranties made by the Company herein or in any certificate or financial or other written statements
heretofore or hereafter furnished by or on behalf of the Company in connection with the execution and delivery of this Debenture,
or the Securities Purchase Agreement under which this Debenture was issued shall be false or misleading in any respect;

 

(c)       The
Company shall fail to perform or observe, in any respect, any material covenant, term, provision, condition, agreement or obligation
of the Company under this Debenture or any other Debenture issued to the Holder; or

 

(d)       The
Company shall (1) become insolvent; (2) admit in writing its inability to pay its debts generally as they mature; (3) make an
assignment for the benefit of creditors or commence proceedings for its dissolution; (4) apply for or consent to the appointment
of a trustee, liquidator or receiver for its or for a substantial part of its property or business; (5) file a petition for bankruptcy
relief, consent to the filing of such petition or have filed against it an involuntary petition for bankruptcy relief, all under
federal or state laws as applicable; or

 

(e)       A
trustee, liquidator or receiver shall be appointed for the Company or for a substantial part of its property or business without
its consent and shall not be discharged within sixty (60) days after such appointment; or

 

____ 

Initials

 

    	 	4	 

     

    

 

(f)       Any
governmental agency or any court of competent jurisdiction at the in- stance of any governmental agency shall assume custody or
control of the whole or any substantial portion of the properties or assets of the Company; or

 

(g)       One
or more money judgments, writs or warrants of attachment, or similar process, in excess of fifty thousand dollars ($50,000) in
the aggregate, shall be entered or filed against the Company or any of its properties or other assets and shall remain unpaid,
unvacated, unbonded or unstayed for a period of fifteen (15) days or in any event later than five (5) days prior to the date of
any proposed sale thereunder; provided, however, that the lawsuit captioned Pent- house Global Media, et al. v. Guccione
Collection, LLC et al, (Case 2:17-cv-04980-PA-FFM filed in the United States District Court Central District of California),
filed on July 6, 2017 shall not be considered an “Event of Default” pursuant to this Section 8 or any of the agreements
related to the issuance of this Debenture; or

 

(h)     If
at any point subsequent to the Issuance Date but prior to the Maturity Date, the Company defaults on or breaches any term of any
other Debenture of similar debt instrument into which the Company has entered and fails to cure such default within the appropriate
grace period; or

 

(i)       The
Company shall have its Common Stock delisted from an exchange (in- cluding the OTC Market exchange) or, if the Common Stock trades
on an exchange, then trading in the Common Stock shall be suspended for more than 10 consecutive days;

 

(j)       If
a majority of the members of the Board of Directors of the Company on the date hereof are no longer serving as members of the
Board;

 

(k)     Subject
to registration or the availability of Rule 144, the Company shall not deliver to the Holder the Common Stock pursuant to paragraph
4 herein without restrictive legend within 3 business days of its receipt of a Notice of Conversion; or

 

(l)      The
Company shall not replenish the reserve set forth in Section 12, within 3 business days of the request of the Holder.

 

(m)     The
Company shall not be “current” in its filings, which shall include no- tices of late filing, with the Securities and
Exchange Commission.

 

(n)     The Company shall lose the “bid” price for its stock in a market (including the OTC marketplace
or other exchange).

 

____ 

Initials

 

    	 	5	 

     

    

 

Then,
or at any time thereafter, unless cured within 5 days, and in each and every such case, unless such Event of Default shall have
been waived in writing by the Holder (which waiver shall not be deemed to be a waiver of any subsequent default) at the option
of the Holder and in the Holder’s sole discretion, the Holder may consider this Debenture immediately due and payable, without
presentment, demand, protest or (further) notice of any kind (other than notice of acceleration), all of which are hereby expressly
waived, anything herein or in any Debenture or other instruments contained to the contrary notwithstanding, and the Holder may
immediately, and without expiration of any period of grace, enforce any and all of the Holder’s rights and remedies provided herein
or any other rights or remedies afforded by law. Upon an Event of Default, interest shall accrue at a default interest rate of
19% per annum or, if such rate is usurious or not permitted by current law, then at the highest rate of interest permitted by
law. In the event of a breach of Section 8(k) the penalty shall be $250 per day the shares are not issued beginning on the 4th
day after the conversion notice was delivered to the Company. This penalty shall increase to $500 per day beginning on the 10th
day. The penalty for a breach of Section 8(n) shall be an increase of the outstanding principal amounts by 20%. In case of a breach
of Section 8(i), the outstanding principal due under this Debenture shall increase by 50%. Further, if a breach of Section 8(m)
occurs or is continuing after the 6 month anniversary of the Debenture, then the Holder shall be entitled to use the lowest closing
bid price during the delinquency period as a base price for the conversion. For example, if the lowest closing bid price during
the delinquency period is $0.01 per share and the conversion discount is 50% the Holder may elect to convert future conversions
at $0.005 per share. If this Debenture is not paid at maturity, the outstanding principal due under this Debenture shall increase
by 10%.

 

If
the Holder shall commence an action or proceeding to enforce any provisions of this Debenture, including, without limitation,
engaging an attorney, then if the Holder prevails in such action, the Holder shall be reimbursed by the Company for its attorneys’
fees and other costs and expenses incurred in the investigation, preparation and prosecution of such action or proceeding.

 

Make-Whole
for Failure to Deliver Loss. At the Holder’s election, if the Company fails for any reason to deliver to the Holder the
conversion shares by the by the 3rd business day following the delivery of a Notice of Conversion to the Company and if the Holder
incurs a Failure to Deliver Loss, then at any time the Holder may provide the Company written notice indicating the amounts payable
to the Holder in respect of the Failure to Deliver Loss and the Company must make the Holder whole as follows:

 

Failure
to Deliver Loss = [(Highest VWAP for the 30 trading days on or after the day of exercise) x (Number of conversion shares)]

 

The
Company must pay the Failure to Deliver Loss by cash payment, and any such cash payment must be made by the third business day
from the time of the Holder’s written notice to the Com- pany.

 

9.       In
case any provision of this Debenture is held by a court of competent jurisdiction to be excessive in scope or otherwise invalid
or unenforceable, such provision shall be adjusted rather than voided, if possible, so that it is enforceable to the maximum extent
possible, and the validity and enforceability of the remaining provisions of this Debenture will not in any way be affected or
impaired thereby.

 

____ 

Initials

 

    	 	6	 

     

    

 

10.       Neither
this Debenture nor any term hereof may be amended, waived, discharged or terminated other than by a written instrument signed
by the Company and the Holder.

 

11.       The
Company represents that it is not a “shell” issuer and has never been a “shell” issuer or that if it previously
has been a “shell” issuer that at least 12 months have passed since the Company has reported form 10 type information
indicating it is no longer a “shell issuer. Further. The Company will instruct its counsel to either (i) write a 144 opinion
to allow for sala- bility of the conversion shares or (ii) accept such opinion from Holder’s counsel.

 

12.       The
Company shall issue irrevocable transfer agent instructions reserving 6,349,200 shares (initially) of its Common Stock for conversions
under this Debenture (the “Share Reserve”). Upon full conversion of this Debenture, any shares remaining in the Share
Reserve shall be cancelled. The Company shall pay all costs associated with issuing and delivering the shares. If such amounts
are to be paid by the Holder, it may deduct such amounts from the Conversion Price. The company should at all times reserve a
minimum of three times the amount of shares required if the Debenture would be fully converted. The Holder may reasonably request
increases from time to time to re- serve such amounts. The Company will instruct its transfer agent to provide the outstanding
share information to the Holder in connection with its conversions.

 

13.       The
Company will give the Holder direct notice of any corporate actions, including but not limited to name changes, stock splits,
recapitalizations etc. This notice shall be given to the Holder as soon as possible under law.

 

14.       If
it shall be found that any interest or other amount deemed interest due hereunder violates the applicable law governing usury,
the applicable provision shall automatically be revised to equal the maximum rate of interest or other amount deemed interest
permitted under applicable law. The Company covenants (to the extent that it may lawfully do so) that it will not seek to claim
or take advantage of any law that would prohibit or forgive the Company from paying all or a portion of the principal or interest
on this Debenture.

 

15.       This
Debenture shall be governed by and construed in accordance with the laws of Nevada and shall be binding upon the successors and
assigns of each party hereto. The Holder and the Company hereby mutually waive trial by jury and consent to exclusive jurisdiction
and venue in the courts of Miami-Dade County, Florida or in the Federal courts sitting in Miami-Dade County, Florida. This Agreement
may be executed in counterparts, and the facsimile transmission of an executed counterpart to this Agreement shall be effective
as an original.

 

____ 

Initials

 

    	 	7	 

     

    

 

IN
WITNESS WHEREOF, the Company has caused this Debenture to be duly executed by an officer thereunto duly authorized.

  

Dated:
[         ]

 

	 	JERRICK MEDIA HOLDINGS, INC.
	 	 	 
	 	By:	 
	 	Name: 	          
	 	Title:	 

 

____ 

Initials

 

    	 	8	 

     

    

 

EXHIBIT
A

 

NOTICE
OF CONVERSION

 

(To
be Executed by the Registered Holder in order to Convert the Debenture)

 

The
undersigned hereby irrevocably elects to convert $________ of the above Debenture into ______ Shares of Common Stock of
Jerrick Media Holdings, Inc. (“Shares”) according to the conditions set forth in such Debenture, as of the date
written below.

 

If
Shares are to be issued in the name of a person other than the undersigned, the undersigned will pay all transfer and other taxes
and charges payable with respect thereto.

 

Date
of Conversion: ______________________________________________________

Applicable
Conversion Price: _______________________________________________

Signature: ______________________________________________________________

                                 [Print
Name of Holder and Title of Signer]

Address: _______________________________________________________________

                  _______________________________________________________________

 

SSN
or EIN: ________________________

Shares
are to be registered in the following name: _________________________________________

 

Name: _________________________________________________________________

Address: _______________________________________________________________

Tel: ___________________________________

Fax:
___________________________________

SSN
or EIN: _____________________________

 

Shares
are to be sent or delivered to the following account:

 

Account
Name: __________________________________________________________

Address: _______________________________________________________________

 

____ 

Initials

 

 

9

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