Document:

Form of Medium-Term Notes, Series K

 Exhibit 4.1 
 [Face of Note] 
 Unless this certificate is presented by an authorized
representative of The Depository Trust Company, a New York corporation (“DTC”), to the Company or its agent for registration of transfer, exchange or payment, and any certificate issued is registered in the name of Cede &
Co. or in such other name as requested by an authorized representative of DTC (and any payment is made to Cede & Co. or such other entity as is requested by an authorized representative of DTC), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR
VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL inasmuch as the registered owner hereof, Cede & Co., has an interest herein. 
  

			
	 CUSIP NO. 94986RHQ7
 REGISTERED
NO. 1
	  	PRINCIPAL AMOUNT: $                    

 WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 
 Due Nine Months or More From Date of Issue 
 Notes due March 5, 2019

 WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware
(hereinafter called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay to CEDE & Co., or registered assigns, the principal
sum of
                                         
       DOLLARS ($                    ) on March 5, 2019 (the “Stated Maturity Date”) and to
pay interest thereon from March 5, 2012 or from the most recent Interest Payment Date to which interest has been paid or duly provided for quarterly on March 5, June 5, September 5 and December 5, commencing June 5,
2012 (each, an “Interest Payment Date”), at the rate per annum specified below until the principal hereof is paid or made available for payment. The interest so payable, and punctually paid or duly provided for, on any Interest
Payment Date will, as provided in the Indenture, be paid to the Person in whose name this Security (or one or more Predecessor Securities) is registered at the close of business on the Regular Record Date for such interest next preceding such
Interest Payment Date. The Regular Record Date for an Interest Payment Date shall be the fifteenth calendar day, whether or not a Business Day, prior to such Interest Payment Date. If an Interest Payment Date is not a Business Day, interest on this
Security shall be payable on the next day that is a Business Day, with the same force and effect as if made on such Interest Payment Date, and without any interest or other payment with respect to the delay. “Business Day” shall
mean a day, other than a Saturday or Sunday, that is neither a legal holiday nor a day on which banking institutions are authorized or required by law or regulation to close in New York, New York or Minneapolis, Minnesota. 

 Except as described below for the first Interest Period, on each Interest Payment Date,
interest will be paid for the period commencing on and including the immediately preceding Interest Payment Date and ending on and including the day immediately preceding that Interest Payment Date. This period is referred to as an “Interest
Period.” The first Interest Period will commence on and include March 5, 2012 and end on and include June 4, 2012. Interest on this Security will be computed on the basis of a 360-day year of twelve 30-day months. 

The interest rate on this Security that will apply during the first eight Interest Periods (up to and including the Interest Period
ending March 4, 2014) will be equal to 2.50% per annum. For all Interest Periods commencing on or after March 5, 2014, the interest rate on this Security will be determined by the calculation agent for this Security (the
“Calculation Agent”) and will be equal to 3 month LIBOR on the Determination Date for such Interest Period plus 0.50%, subject to the Maximum Interest Rate. 
 The “Determination Date” for an Interest Period commencing on or after March 5, 2014 will be two London Banking Days prior to the first day of such Interest Period. A “London
Banking Day” is any day on which dealings in deposits in U.S. dollars are transacted in the London interbank market. 

“3 month LIBOR” means, for any Determination Date, the arithmetic mean of the offered rates for deposits in U.S. dollars
having a 3 month maturity, commencing on the second London Banking Day immediately following that Determination Date that appear on the Designated LIBOR Page as of 11:00 a.m., London time, on that Determination Date, if at least two
offered rates appear on the Designated LIBOR Page, provided that if the Designated LIBOR Page by its terms provides only for a single rate, that single rate will be used. The “Designated LIBOR Page” means the display on Reuters, or
any successor service, on page LIBOR01, or any other page as may replace that page on that service, for the purpose of displaying the London Interbank rates for U.S. dollars. 
 If (i) fewer than two offered rates appear or (ii) no rate appears and the Designated LIBOR Page by its terms provides only for a single rate, then the Calculation Agent will request the
principal London offices of each of four major banks in the London interbank market, as selected by the Calculation Agent, to provide the Calculation Agent with its offered quotation for deposits in U.S. dollars for a 3 month period commencing on
the second London Banking Day immediately following that Determination Date to prime banks in the London interbank market at approximately 11:00 a.m., London time, on that Determination Date and in a principal amount that is representative of a
single transaction in U.S. dollars in that market at that time. If at least two quotations are provided, 3 month LIBOR determined on that Determination Date will be the arithmetic mean of those quotations. 

If fewer than two quotations are provided, 3 month LIBOR will be the arithmetic mean of the rates quoted at approximately 11:00 a.m.
in New York, New York on that Determination Date by three major banks in New York, New York selected by the Calculation Agent for loans in U.S. dollars to leading European banks, having a 3 month maturity and in a principal amount that is
representative of a single transaction in U.S. dollars in that market at that time. 

  
 2 

 If the banks so selected by the Calculation Agent are not quoting as set forth above, 3
month LIBOR on such Determination Date will be determined by the Calculation Agent in a commercially reasonable manner. 
 The
“Maximum Interest Rate” is 6.00% per annum. 
 The Calculation Agent shall, upon the request of a Holder
of this Security, provide the interest rate then in effect and, if determined, the interest rate that will become effective for the next Interest Period. All calculations of the Calculation Agent, in the absence of manifest error, shall be
conclusive for all purposes and binding on the Company and the Holder hereof. The Calculation Agent shall notify the Paying Agent of each determination of the interest applicable to this Security promptly after the determination is made. Wells Fargo
Securities, LLC will initially act as Calculation Agent. The Company may appoint a successor Calculation Agent with the written consent of the Trustee. 
 Any interest not punctually paid or duly provided for will forthwith cease to be payable to the Holder on such Regular Record Date and may either be paid to the Person in whose name this Security (or one
or more Predecessor Securities) is registered at the close of business on a Special Record Date for the payment of such Defaulted Interest to be fixed by the Trustee, notice whereof shall be given to Holders of Securities of this series not less
than 10 days prior to such Special Record Date, or be paid at any time in any other lawful manner not inconsistent with the requirements of any securities exchange on which the Securities of this series may be listed, and upon such notice as
may be required by such exchange, all as more fully provided in the Indenture. 
 Payment of interest on this Security will be
made in immediately available funds at the office or agency of the Company maintained for that purpose in the City of Minneapolis, Minnesota in such coin or currency of the United States of America as at the time of payment is legal tender for
payment of public and private debts; provided, however, that, at the option of the Company, payment of interest may be paid by check mailed to the Person entitled thereto at such Person’s last address as it appears in the Security Register or
by wire transfer to such account as may have been designated by such Person. Payment of principal of and interest on this Security at Maturity will be made against presentation of this Security at the office or agency of the Company maintained for
that purpose in the City of Minneapolis, Minnesota. Notwithstanding the foregoing, for so long as this Security is a Global Security registered in the name of the Depositary, payments of principal and interest on this Security will be made to the
Depositary by wire transfer of immediately available funds. 
 This Security is not subject to redemption at the option of the
Company or, except as set forth in the next sentence, repayment at the option of the Holder hereof prior to March 5, 2019. This Security may be subject to repayment if requested by the authorized representative of a beneficial owner of this
Security as described on the reverse hereof under “Repayment upon Exercise of Survivor’s Option.” This Security is not entitled to any sinking fund. 

 
  

  
 3 

 Reference is hereby made to the further provisions of this Security set forth on the reverse
hereof, which further provisions shall for all purposes have the same effect as if set forth at this place. 
 Unless the
certificate of authentication hereon has been executed by the Trustee referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall
not be entitled to any benefit under the Indenture or be valid or obligatory for any purpose. 
 [The remainder of this page
has been left intentionally blank] 

  
 4 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly executed under its
corporate seal. 

DATED:                     

 

					
	WELLS FARGO & COMPANY
		
	By:	 	 
		
		 	 
			
		 	Its:	 	 

 [SEAL] 
  

					
		
	Attest:	 	 
		
		 	 
			
		 	Its:	 	 

 TRUSTEE’S CERTIFICATE OF 
 AUTHENTICATION 
 This is one of the Securities of the 

series designated therein described 
 in the
within-mentioned Indenture. 
  

			
	 CITIBANK, N.A.,
 as Trustee

		
	By:	 	 
		 	Authorized Signature
		
		 	OR                           
         

  

			
	 WELLS FARGO BANK, N.A.,
     as Authenticating Agent for the Trustee

		
	By:	 	 
		 	Authorized Signature

  
 5 

 [Reverse of Note] 
 WELLS FARGO & COMPANY 
 MEDIUM-TERM NOTE, SERIES K

 Due Nine Months or More From Date of Issue 
 Notes due March 5, 2019 
 This Security is one of a duly authorized
issue of securities of the Company (herein called the “Securities”), issued and to be issued in one or more series under an indenture dated as of July 21, 1999, as amended or supplemented from time to time (herein called the
“Indenture”), between the Company and Citibank, N.A., as Trustee (herein called the “Trustee,” which term includes any successor trustee under the Indenture), to which Indenture and all indentures supplemental
thereto reference is hereby made for a statement of the respective rights, limitations of rights, duties and immunities thereunder of the Company, the Trustee and the Holders of the Securities, and of the terms upon which the Securities are, and are
to be, authenticated and delivered. This Security is one of the series of the Securities designated as Medium-Term Notes, Series K, of the Company, which series is limited to an aggregate principal amount or face amount, as applicable, of
$25,000,000,000 or the equivalent thereof in one or more foreign or composite currencies. The amount payable on the Securities of this series may be determined by reference to the performance of one or more equity-, commodity- or currency-based
indices, exchange traded funds, securities, commodities, currencies, statistical measures of economic or financial performance, or a basket comprised of two or more of the foregoing, or any other market measure or may bear interest at a fixed rate
or a floating rate. The Securities of this series may mature at different times, be redeemable at different times or not at all, be repayable at the option of the Holder at different times or not at all and be denominated in different currencies.

 Article Sixteen of the Indenture shall not apply to this Security. 

The Securities are issuable only in registered form without coupons and will be either (a) book-entry securities represented by one
or more Global Securities recorded in the book-entry system maintained by the Depositary or (b) certificated securities issued to and registered in the names of, the beneficial owners or their nominees. 

The Company agrees, to the extent permitted by law, not to voluntarily claim the benefits of any laws concerning usurious rates of
interest against a Holder of this Security. 
 Modification and Waivers 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights and
obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the time Outstanding of all series to be affected, acting together as a class. The Indenture also contains 

  
 6 

 
provisions permitting the Holders of a majority in principal amount of the Securities of all series at the time Outstanding affected by certain provisions of the Indenture, acting together as a
class, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain past defaults under the Indenture and their consequences may be waived under the Indenture by the
Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such series. Any such consent or waiver by the Holder of this Security shall be conclusive and binding
upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not notation of such consent or waiver is made upon this Security.

 Defeasance 
 Section 403 and Article Fifteen of the Indenture and the provisions of clause (ii) of Section 401(1)(B) of the Indenture, relating to defeasance at any time of (a) the entire
indebtedness on this Security and (b) certain restrictive covenants and certain Events of Default, upon compliance by the Company with certain conditions set forth therein, shall not apply to this Security. The remaining provisions of
Section 401 of the Indenture shall apply to this Security. 
 Authorized Denominations 

This Security is issuable only in registered form without coupons in denominations of $1,000 or any amount in excess thereof which is an
integral multiple of $1,000. 
 Repayment upon Exercise of Survivor’s Option 

The Company has agreed to repay beneficial ownership interests in this Security, if requested by the authorized representative of the
beneficial owner of such beneficial ownership interest following the death of the beneficial owner, so long as the beneficial ownership interest in this Security was acquired by the beneficial owner at least six months prior to the request (the
“Survivor’s Option”). 
 Upon the valid exercise of the Survivor’s Option and the proper tender of a
beneficial ownership interest in this Security for repayment, the Company will repay such beneficial ownership interest in this Security, in whole or in part, at a price equal to 100% of the principal amount of the deceased beneficial owner’s
beneficial interest in this Security, plus any accrued and unpaid interest to the date of repayment. 
 To be valid, the
Survivor’s Option must be exercised by or on behalf of the Person who has authority to act on behalf of a deceased beneficial owner of this Security under the laws of the applicable jurisdiction (including, without limitation, the personal
representative of or the executor of the estate of the deceased beneficial owner or the surviving joint owner with the deceased beneficial owner). 
 A beneficial owner of this Security is a Person who has the right, immediately prior to such Person’s death, to receive the proceeds from the disposition of such beneficial owner’s interest in
this Security, as well as the right to receive the principal amount of the deceased beneficial owner’s interest in this Security plus any accrued and unpaid interest thereon. 

  
 7 

 The death of a Person holding a beneficial ownership interest in this Security as a joint
tenant or tenant by the entirety with another Person, or as a tenant in common with the deceased holder’s spouse, will be deemed the death of a beneficial owner of that beneficial ownership interest in this Security, and the entire principal
amount of the deceased beneficial owner’s interest in this Security held in this manner will be subject to repayment by the Company upon exercise of the Survivor’s Option. However, the death of a Person holding a beneficial ownership
interest in this Security as tenant in common with a Person other than such deceased holder’s spouse will be deemed the death of a beneficial owner only with respect to such deceased Person’s interest in this Security, and only the
deceased beneficial owner’s percentage interest in that beneficial ownership interest in the principal amount of this Security will be subject to repayment. 
 The death of a Person who, during his or her lifetime, was entitled to substantially all of the beneficial ownership interests in this Security will be deemed the death of the beneficial owner of this
Security for purposes of the Survivor’s Option, regardless of whether that beneficial owner was the registered holder of this Security, if the beneficial ownership interest can be established to the satisfaction of the Paying Agent. A
beneficial ownership interest will be deemed to exist in typical cases of nominee ownership, ownership under the Uniform Transfers to Minors Act or Uniform Gifts to Minors Act, community property, or other joint ownership arrangements between a
husband and wife. In addition, the beneficial ownership interest in this Security will be deemed to exist in custodial and trust arrangements where one Person has all of the beneficial ownership interest in this Security during his or her lifetime.
In the case of a joint trust, the joint tenant rules above will apply to the respective beneficial ownership interests. 
 The
Company has the discretionary right to limit the aggregate principal amount of this Security as to which exercises of the Survivor’s Option will be accepted by the Company from the authorized representative for any individual deceased
beneficial owner of this Security in any calendar year to $500,000. In addition, the Company will not permit the exercise of the Survivor’s Option for any portion of this Security with a principal amount of less than $1,000, and the Company
will not permit the exercise of the Survivor’s Option if such exercise will result in this Security having a principal amount that is not an integral multiple of $1,000. 
 An otherwise valid election to exercise the Survivor’s Option may not be withdrawn. An election to exercise the Survivor’s Option will be accepted in the order that it was received by the Paying
Agent, except for any beneficial ownership interest in this Security the acceptance of which would contravene the limitation described above. Beneficial ownership interests in this Security accepted for repayment through the exercise of the
Survivor’s Option normally will be repaid on the first Interest Payment Date that occurs 20 or more calendar days after the date of the acceptance. Each tendered beneficial ownership interest in this Security that is not accepted in a calendar
year due to the application of the limitation described in the preceding paragraph will be deemed to be tendered in the following calendar year in the order in which all such beneficial interests were originally tendered. If a beneficial ownership
interest in this Security tendered through a valid exercise of the Survivor’s Option is not accepted, the Paying Agent will deliver a notice by first-class mail to the registered holder, at that registered holder’s last known address as
indicated in the Security Register, that states the reason that the beneficial ownership interest in this Security has not been accepted for repayment. 

  
 8 

 Since this Security is a Global Security, DTC, as depository, or its nominee will be treated
as the holder of this Security and will be the only entity that can exercise the Survivor’s Option. To obtain repayment of this Security pursuant to exercise of the Survivor’s Option, the deceased beneficial owner’s authorized
representative must provide the following items to the broker or other entity through which the beneficial interest in this Security is held by the deceased beneficial owner: 

 

	 	•	 	 appropriate evidence satisfactory to the Paying Agent that: 

 

	 	(a)	the deceased was a beneficial owner of this Security at the time of death and his or her interest in this Security was acquired by the deceased beneficial owner at
least six months prior to the request for repayment, 

  

	 	(b)	the death of the beneficial owner has occurred and the date of death, and 

  

	 	(c)	the representative has authority to act on behalf of the deceased beneficial owner; 

 

	 	•	 	 if the beneficial interest in this Security is held by a nominee or trustee of, or custodian for, or other Person in a similar capacity to, the
deceased beneficial owner, a certificate satisfactory to the Paying Agent from the nominee, trustee, custodian or similar Person attesting to the deceased’s beneficial ownership in this Security; 

 

	 	•	 	 a written request for repayment signed by the authorized representative of the deceased beneficial owner with the signature guaranteed by a member firm
of a registered national securities exchange or of the Financial Industry Regulatory Authority, Inc. or a commercial bank or trust company having an office or correspondent in the United States; 

 

	 	•	 	 if applicable, a properly executed assignment or endorsement; 

 

	 	•	 	 tax waivers and any other instruments or documents that the Paying Agent reasonably requires in order to establish the validity of the beneficial
ownership in this Security and the claimant’s entitlement to payment; and 

  

	 	•	 	 any additional information the Paying Agent requires to evidence satisfaction of any conditions to the exercise of the Survivor’s Option or to
document beneficial ownership or authority to make the election and to cause the repayment of this Security. 

 In turn, the
broker or other entity will deliver each of these items to the Paying Agent and will certify to the Paying Agent that the broker or other entity represents the deceased beneficial owner. 

The Company retains the right to limit the aggregate principal amount of this Security as to which exercises of the Survivor’s
Option will be accepted by the Company from the authorized representative for any individual deceased beneficial owner in this Security in any calendar year as described above. All other questions regarding the eligibility or validity of any
exercise of the Survivor’s Option will be determined by the Paying Agent, in its sole discretion, which determination will be final and binding on all parties. 

  
 9 

 The broker or other entity will be responsible for disbursing payments received from the
Paying Agent to the authorized representative. Forms for the exercise of the Survivor’s Option may be obtained from the Paying Agent. 

Registration of Transfer 
 Upon due presentment for registration of transfer of this Security at the office or agency of the Company in the City of Minneapolis, Minnesota, a new Security or Securities of this series, with the same
terms as this Security, in authorized denominations for an equal aggregate principal amount will be issued to the transferee in exchange herefor, as provided in the Indenture and subject to the limitations provided therein and to the limitations
described below, without charge except for any tax or other governmental charge imposed in connection therewith. 
 This
Security is exchangeable for definitive Securities in registered form only if (x) the Depositary notifies the Company that it is unwilling or unable to continue as Depositary for this Security or if at any time the Depositary ceases to be a
clearing agency registered under the Securities Exchange Act of 1934, as amended, and a successor depositary is not appointed within 90 days after the Company receives such notice or becomes aware of such ineligibility, (y) the Company in
its sole discretion determines that this Security shall be exchangeable for definitive Securities in registered form and notifies the Trustee thereof or (z) an Event of Default with respect to the Securities represented hereby has occurred and
is continuing. If this Security is exchangeable pursuant to the preceding sentence, it shall be exchangeable for definitive Securities in registered form, bearing interest at the same rate, having the same date of issuance, Stated Maturity Date and
other terms and of authorized denominations aggregating a like amount. 
 This Security may not be transferred except as a whole
by the Depositary to a nominee of the Depositary or by a nominee of the Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor.
Except as provided above, owners of beneficial interests in this Global Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture.

 Prior to due presentment of this Security for registration of transfer, the Company, the Trustee and any agent of the Company
or the Trustee may treat the Person in whose name this Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 Obligation of the Company Absolute 
 No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation of the Company, which is absolute and unconditional, to pay the principal of
and interest on this Security at the times, place and rate, and in the coin or currency, herein prescribed, except as otherwise provided in this Security. 

  
 10 

 No Personal Recourse 
 No recourse shall be had for the payment of the principal of or the interest on this Security, or for any claim based hereon, or otherwise in respect hereof, or based on or in respect of the Indenture or
any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or any successor corporation, whether by virtue of any constitution, statute or rule of law, or by the
enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance hereof and as part of the consideration for the issuance hereof, expressly waived and released. 

Defined Terms 

All terms used in this Security which are defined in the Indenture shall have the meanings assigned to them in the Indenture unless
otherwise defined in this Security. 
 Governing Law 
 This Security shall be governed by and construed in accordance with the law of the State of New York, without regard to principles of conflicts of laws. 

  
 11 

 ABBREVIATIONS 

The following abbreviations, when used in the inscription on the face of this instrument, shall be construed as though they were written
out in full according to applicable laws or regulations: 
  

					
	TEN COM	 	—	  	as tenants in common
			
	TEN ENT	 	—	  	as tenants by the entireties
			
	JT TEN	 	—	  	 as joint tenants with right
 of survivorship and not
 as tenants in common

  

							
	UNIF GIFT MIN ACT —	  		  	Custodian	  	
		  	(Cust)	  		  	(Minor)

 Under Uniform Gifts to Minors Act 
  

 
  

(State) 
 Additional abbreviations may also be used though not in the above list. 
 FOR
VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 
 Please Insert Social Security or 

Other Identifying Number of Assignee 
  

 
  

 
  
  

 
  
  

 
  
 (PLEASE PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL
ZIP CODE OF ASSIGNEE) 

  
 12 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute and
appoint                                attorney to transfer the said Security on the
books of the Company, with full power of substitution in the premises. 

Dated:                     

 
  

 
  
 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the within instrument in every particular, without alteration or enlargement or any change whatever.

  
 13Form of Senior Secured Convertible Note

 Exhibit 4.1 
 NEITHER THE ISSUANCE AND SALE OF THE SECURITIES REPRESENTED BY THIS CERTIFICATE NOR THE SECURITIES INTO WHICH THESE SECURITIES ARE CONVERTIBLE 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 FORM REASONABLY ACCEPTABLE TO THE COMPANY, 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. 

 

			
	Principal Amount: $[            ]	 	Issue Date: February     , 2012

 SECURED CONVERTIBLE PROMISSORY NOTE 

FOR VALUE RECEIVED, CAMBRIDGE HEART, INC., a Delaware corporation (hereinafter called “Borrower”), hereby
promises to pay [            ] or its registered assigns (the “Holder”), address at
[            ], Fax: [            ], without demand, the sum of
[            ] Dollars ($[            ]) (“Principal Amount”), with interest accruing thereon, on
July 17, 2013 (the “Maturity Date”), if not sooner paid or modified as permitted herein. 
 This
Note has been entered into pursuant to the terms of a subscription agreement by and among the Borrower, the Holder and certain other holders (the “Other Holders”) of convertible promissory notes (the “Other Notes”),
dated of even date herewith (the “Subscription Agreement”) for an aggregate Principal Amount of up to $4,000,000. For purposes of this Note, Other Holders also includes the holders of Notes issued in the Initial Closing and Other
Notes also includes the Notes issued in the Additional Closing. Unless otherwise separately defined herein, each capitalized term used in this Note shall have the same meaning as set forth in the Subscription Agreement. The following terms shall
apply to this Note: 
 ARTICLE I 
 GENERAL PROVISIONS 
 1.1 Interest Rate. Cash interest payable on
this Note shall compound annually and accrue at the annual rate of eight percent (8%) from the Issue Date through the Maturity Date. Interest shall be payable quarterly in arrears on the last day of each calendar quarter commencing
March 31, 2012, and on the Maturity Date, accelerated or otherwise, when the principal and remaining accrued but unpaid interest shall be due and payable, or sooner as described below. Interest will be payable in cash or at the election of the
Borrower, with shares of Common Stock provided (i) an Event of Default (as defined in Article IV) has not occurred, (ii) such Common Stock is immediately resellable pursuant to Rule 144 without transfer or volume restrictions,
(iii) such payment in Common Stock would not cause the Holder to exceed the restrictions on ownership set forth in Section 2.3, (iv) the PIK Share Value (defined below) is not less than $0.20, and (v) Borrower provides Holder not
less than fifteen (15) business days prior notice of Borrower’s intention to pay interest with Common Stock. Interest paid with shares of Common Stock shall be payable on the third business day after the date such interest would be due if
paid in cash. Common Stock employed to pay interest shall be valued at eighty-five percent (85%) of the volume weighted average price of the Common Stock as reported by Bloomberg L.P. for the Principal Market for the twenty (20) trading
days ending on the due date of the interest payment being made with Common Stock (“PIK Share Value”). 

  
 1 

 1.2 Payment Grace Period. The Borrower shall not have any grace period to pay any
monetary amounts due under this Note. After the Maturity Date and during the pendency of an Event of Default, (as defined in Article IV) a default interest rate of fifteen percent (15%) per annum shall be in effect. 

1.3 Conversion Privileges. The Conversion Rights set forth in Article II shall remain in full force and effect immediately
from the date hereof and until the Note is paid in full regardless of the occurrence of an Event of Default. This Note shall be payable in full on the Maturity Date, unless previously converted into Common Stock in accordance with Article II
hereof. 
 1.4 Pari Passu. Except as otherwise set forth herein, all payments made on this Note and the Other Notes and
all actions taken by the Borrower with respect to this Note and the Other Notes, including but not limited to Mandatory Conversion, shall be made and taken pari passu with respect to this Note and the Other Notes. Notwithstanding anything to
the contrary contained herein or in the Transaction Documents, it shall not be considered non-pari passu for a Holder or Other Holder to elect to receive interest paid in shares of Common Stock or for the Borrower to actually pay interest in shares
of Common Stock to such electing Holder or Other Holder. 
 1.5 Application of Payments. Payments made in connection with
this Note shall be applied first to amounts due hereunder other than principal and interest, thereafter to Interest and finally to Principal Amount. 
 1.6 Miscellaneous. Interest on this Note shall be calculated on the basis of a 360-day year and the actual number of days elapsed. Principal and interest on this Note and other payments in
connection with this Note shall be payable at the Holder’s offices as designated above in lawful money of the United States of America in immediately available funds without set-off, deduction or counterclaim. Upon assignment of the interest of
Holder in this Note, Borrower shall instead make its payment pursuant to the assignee’s instructions upon receipt of written notice thereof. 
 ARTICLE II 
 CONVERSION RIGHTS 

The Holder shall have the right to convert the principal and any interest due under this Note into Shares of the Borrower’s Common
Stock, $0.001 par value per share (“Common Stock”) as set forth below. 
 2.1. Conversion into the
Borrower’s Common Stock. 
 (a) The Holder shall have the right from and after the date of the issuance of this Note
and then at any time until this Note is fully paid, to convert any outstanding and unpaid principal portion of this Note, and accrued but unpaid interest, at the election of the Holder (the date of giving of such notice of conversion being a
“Conversion Date”) into fully paid and non-assessable shares of Common Stock as such stock exists on the date of issuance of this Note, or any shares of capital stock of Borrower into which such Common Stock shall hereafter be
changed or reclassified, at the Conversion Price as defined in Section 2.1(b) hereof, determined as provided herein. The number of shares of Common Stock to be issued upon each conversion of this Note shall be determined by dividing that
portion of the principal of the Note and interest, if any, to be converted, by the Conversion Price. The interest on the Note Principal Amount converted prior to July 17, 2013, shall be increased by an amount equal to $200 for each $1,000 of
Note Principal being converted (pro-rated for lesser amounts of Note Principal) less the amount of interest actually paid on such Note Principal and/or which interest is being converted with such Note Principal (“Additional
Interest”). Notwithstanding the foregoing, the Additional Interest will be payable in cash or at the election of the Borrower with shares of Common Stock provided that the PIK Share Value is not less than $0.20 and provided

  
 2 

 
such payment with shares of Common Stock is subject to (i) the provisions of Section 2.3 herein, and (ii) written notification by the Borrower to the Holder within one
(1) business day of receipt by Borrower of a Conversion Notice, that such Additional Interest will be paid by Borrower with shares of Common Stock. The foregoing notwithstanding, provided that the PIK Share Value is not less than $0.20, the
Holder may insist on receiving any Additional Interest only in shares of Common Stock. The Additional Interest that is paid in shares of Common Stock will be converted at the same time and in the same manner as the other interest, if any, on such
Principal Amount except that the Conversion Price of any Additional Interest that is paid in shares of Common Stock shall be eight-five percent (85%) of the volume weighted average for the twenty (20) trading days immediately preceding the
relevant Conversion Date. Upon delivery to the Borrower of a completed Notice of Conversion, a form of which is annexed hereto as Exhibit A, Borrower shall issue and deliver to the Holder within three (3) business days after the
Conversion Date (such third day being the “Delivery Date”) that number of shares of Common Stock for the portion of the Note converted in accordance with the foregoing. Any shares of Common Stock issued or cash paid in respect of
Additional Interest also shall be payable or deliverable on the Delivery Date. The Holder will not be required to surrender the Note to the Borrower until the Note has been fully converted or satisfied. 

(b) Subject to adjustment as provided in Section 2.1(c) hereof, the conversion price (“Conversion Price”)
per share shall be $0.11. 
 (c) The Conversion Price and number and kind of shares or other securities to be issued upon
conversion determined pursuant to Section 2.1(a), shall be subject to adjustment from time to time upon the happening of certain events while this conversion right remains outstanding, as follows: 

A. Merger, Sale of Assets, etc. If (A) the Borrower effects any merger or consolidation of the Borrower with or into another
entity, (B) the Borrower effects any sale of all or substantially all of its assets in one or a series of related transactions, (C) any tender offer or exchange offer (whether by the Borrower or another entity) is completed pursuant to
which holders of Common Stock are permitted to tender or exchange their shares for other securities, cash or property, (D) the Borrower consummates a stock purchase agreement or other business combination (including, without limitation, a
reorganization, recapitalization, spin-off or scheme of arrangement) with one or more persons or entities whereby such other persons or entities acquire more than the 50% of the outstanding shares of Common Stock (not including any shares of Common
Stock held by such other persons or entities making or party to, or associated or affiliated with the other persons or entities making or party to, such stock purchase agreement or other business combination), (E) any “person” or
“group” (as these terms are used for purposes of Sections 13(d) and 14(d) of the 1934 Act) is or shall become the “beneficial owner” (as defined in Rule 13d-3 under the 1934 Act), directly or indirectly, of 50% of the aggregate
Common Stock of the Borrower), or (F) the Borrower effects any reclassification of the Common Stock or any compulsory share exchange pursuant to which the Common Stock is effectively converted into or exchanged for other securities, cash or
property (other than a reverse merger) (in any such case, a “Fundamental Transaction”), this Note, as to the unpaid principal portion thereof and accrued interest thereon, if any, shall thereafter be deemed to evidence the right to
convert into such number and kind of shares or other securities and property as would have been issuable or distributable on account of such Fundamental Transaction, upon or with respect to the securities subject to the conversion right immediately
prior to such Fundamental Transaction. The foregoing provision shall similarly apply to successive Fundamental Transactions of a similar nature by any such successor or purchaser. Without limiting the generality of the foregoing, the anti-dilution
provisions of this Section shall apply to such securities of such successor or purchaser after any such Fundamental Transaction. 
 B. Reclassification, etc. If the Borrower at any time shall, by reclassification or otherwise, change the Common Stock into the same or a different number of securities of any class or classes that
may be issued or outstanding, this Note, as to the unpaid principal portion thereof and accrued interest thereon, shall thereafter be deemed to evidence the right to purchase an adjusted number of such securities and kind of securities as would have
been issuable as the result of such change with respect to the Common Stock immediately prior to such reclassification or other change. 

  
 3 

 C. Stock Splits, Combinations and Dividends. If the shares of Common Stock are
subdivided or combined into a greater or smaller number of shares of Common Stock, or if a dividend is paid on the Common Stock in shares of Common Stock, the Conversion Price shall be proportionately reduced in case of subdivision of shares or
stock dividend or proportionately increased in the case of combination of shares, in each such case by the ratio which the total number of shares of Common Stock outstanding immediately after such event bears to the total number of shares of Common
Stock outstanding immediately prior to such event. 
 D. Share Issuance. So long as this Note is outstanding, if the
Borrower shall issue any Common Stock except for the Excepted Issuances (as defined in Section 12(a) of the Subscription Agreement), prior to the complete conversion or payment of this Note, for a consideration per share that is less than the
Conversion Price that would be in effect at the time of such issue without consent of a Majority in Interest (as defined in the Subscription Agreement), then, and thereafter successively upon each such issuance, the Conversion Price shall be reduced
to such other lower issue price. For purposes of this adjustment, the issuance of any security or debt instrument of the Borrower carrying the right to convert such security or debt instrument into Common Stock or of any warrant, right or option to
purchase Common Stock shall result in an adjustment to the Conversion Price upon the issuance of the above-described security, debt instrument, warrant, right, or option and again upon the issuance of shares of Common Stock upon exercise of such
conversion or purchase rights if such issuance is at a price lower than the then applicable Conversion Price. Common Stock issued or issuable by the Borrower for no consideration will be deemed issuable or to have been issued for $0.001 per share of
Common Stock. The reduction of the Conversion Price described in this paragraph is in addition to the other rights of the Holder described in the Subscription Agreement. 

(d) Whenever the Conversion Price is adjusted pursuant to Section 2.1(c) above, the Borrower shall
promptly, but not later than the third (3rd) business
day after the effectiveness of the adjustment, provide notice to the Holder setting forth the Conversion Price after such adjustment and setting forth a statement of the facts requiring such adjustment. Failure to provide the foregoing notice is an
Event of Default under this Note. 
 (e) Subject to the Reservation Approval (as described in Section 9(x) of the
Subscription Agreement), during the period the conversion right exists, Borrower will reserve from its authorized and unissued Common Stock not less than an amount of Common Stock equal to 150% of the amount of shares of Common Stock issuable upon
the full conversion of this Note. Borrower represents that upon issuance, such shares will be duly and validly issued, fully paid and non-assessable. Borrower agrees that its issuance of this Note shall constitute full authority to its officers,
agents, and transfer agents who are charged with the duty of executing and issuing stock certificates to execute and issue the necessary certificates for shares of Common Stock upon the conversion of this Note. 

2.2 Method of Conversion. This Note may be converted by the Holder in whole or in part as described in Section 2.1(a)
hereof and the Subscription Agreement. Upon partial conversion of this Note, a new Note containing the same date and provisions of this Note shall, at the request of the Holder, be issued by the Borrower to the Holder for the principal balance of
this Note and interest which shall not have been converted or paid, upon surrender of the existing Note. 
 2.3. Maximum
Conversion. The Holder shall not be entitled to convert on a Conversion Date that amount of the Note in connection with that number of shares of Common Stock which would be in excess of the sum of (i) the number of shares of Common Stock
beneficially owned by the Holder and its affiliates on a Conversion Date, (ii) any Common Stock issuable in connection with the unconverted portion of the Note, and 

  
 4 

 
(iii) the number of shares of Common Stock issuable upon the conversion of the Note with respect to which the determination of this provision is being made on a Conversion Date, which would
result in beneficial ownership by the Holder and its affiliates of more than 4.99% of the outstanding shares of Common Stock of the Borrower on such Conversion Date. For the purposes of the provision to the immediately preceding sentence, beneficial
ownership shall be determined in accordance with Section 13(d) of the Securities Exchange Act of 1934, as amended, and Regulation 13d-3 thereunder. Subject to the foregoing, the Holder shall not be limited to aggregate conversions of 4.99%. The
Holder shall have the authority to determine whether the restriction contained in this Section 2.3 will limit any conversion hereunder and the extent such limitation applies and to which convertible or exercisable instrument or part
thereof such limitation applies. The Holder may increase or waive the 4.99% conversion limitation described in this Section 2.3, in whole or in part, including with respect to the payment of interest in shares of Common Stock, by
designating a higher amount on such Holder’s signature page to the Subscription Agreement and also following the Issue Date upon and effective after 61 days prior written notice to the Borrower. 

2.4. Mandatory Conversion. Until the Maturity Date the Borrower will have the option exercisable, from time to time, by written
notice to the Holder (“Notice of Mandatory Conversion”) of compelling the Holder to convert all or a portion of the outstanding and unpaid principal of the Note into Common Stock at the Conversion Price then in affect
(“Mandatory Conversion”). The Notice of Mandatory Conversion, which if given, must be given on the first business day following twenty (20) consecutive trading days during which (i) the closing bid price for the Common
Stock as reported by Bloomberg, LP for the Principal Market was equal to or greater than 227% of the Conversion Price, (ii) the Registration Statement described in Section 11.1(i) of the Subscription Agreement was effective and included
therein as registered all of the Registrable Securities without giving effect to any Registration Cutback, and (iii) an Event of Default or an event which with the passage of time would become an Event of Default had not occurred
(“Lookback Period”). The date the Notice of Mandatory Conversion is given is the “Mandatory Conversion Date.” The Notice of Mandatory Conversion shall specify the principal amount of the Note which is subject to
Mandatory Conversion. The aggregate amount of Note principal subject to Mandatory Conversion by the Holder and Other Holders may not exceed twenty-five percent (25%) of the aggregate dollar volume of the Common Stock traded on the Principal
Market for the seven (7) trading days preceding the Mandatory Conversion Date. Any Mandatory Conversion hereunder shall be made and taken pari passu with respect to this Note and the Other Notes, except that the Borrower must reduce the
amount of the principal and interest subject to a Mandatory Conversion with respect to the Holder and/or any Other Holders, as the case may be, (a) to the extent necessary in order to comply with the conversion limitations applicable to such
Holder or Other Holder, as the case may be, pursuant to Section 2.3 of this Note and the Other Notes unless any such Holder or Other Holder has waived, in writing, such reduction prior to the issuance of such Holder’s or Other
Holder’s Note, in which case no such reduction will be made, and (b) by the amount of principal and interest for which a respective Holder or Other Holder, as the case may be, had delivered a Notice of Conversion to the Borrower during the
Lookback Period. Each Mandatory Conversion Date shall be a deemed Conversion Date and the Borrower will be required to deliver the Common Stock issuable pursuant to a Mandatory Conversion Notice in the same manner and time period as described in
this Note and in the Subscription Agreement. A Notice of Mandatory Conversion may be given only in connection with an amount of Common Stock which would not cause the Holder to exceed the beneficial ownership limitation set forth in
Section 2.3 of this Note. In the event Borrower fails to deliver the Common Stock issuable upon Mandatory Conversion on the Delivery Date, then (i) at the Holder’s election, such Notice of Mandatory Conversion will be null and
void or Holder may enforce the Notice of Mandatory Conversion, and (ii) Borrower’s failure may be deemed by Holder to be a non curable Event of Default. A Notice of Mandatory Conversion may be cancelled at the option of the Holder, if at
any time prior to the actual delivery of the Shares issuable upon such Mandatory Conversion an Event of Default, or an event which with the passage of time or giving of notice would become an Event of Default (whether or not such Event of Default
has been cured), occurs. 

  
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 ARTICLE III 
 ACCELERATION AND REDEMPTION 
 3.1. Optional Redemption of Principal
Amount. Provided an Event of Default or an event which with the passage of time or the giving of notice could become an Event of Default has not occurred, whether or not such Event of Default has been cured, the Borrower will have the option of
prepaying the outstanding Principal amount of this Note (“Optional Redemption”), in whole or in part, by paying to the Holder a sum of money in cash equal to two hundred percent (200%) of the Principal amount to be redeemed,
together with accrued but unpaid interest thereon and any and all other sums due, accrued or payable to the Holder arising under this Note or any Transaction Document through the Redemption Payment Date as defined below (the “Redemption
Amount”). Borrower’s election to exercise its right to prepay must be by notice in writing (“Notice of Redemption”). The Notice of Redemption shall specify the date for such Optional Redemption (the “Redemption
Payment Date”), which date shall be a date certain not sooner than thirty (30) business days after the date of the Notice of Redemption (the “Redemption Period”). A Notice of Redemption shall not be effective with
respect to any portion of the Principal Amount or interest for which the Holder has previously delivered an election to convert, or for conversions initiated or made by the Holder during the Redemption Period. On the Redemption Payment Date, the
Redemption Amount, less any portion of the Redemption Amount against which the Holder has permissibly exercised its conversion rights, shall be paid in good funds to the Holder. In the event the Borrower fails to pay the Redemption Amount on the
Redemption Payment Date as set forth herein, then (i) such Notice of Redemption will be null and void, (ii) Borrower will have no right to deliver another Notice of Redemption, and (iii) Borrower’s failure may be deemed by Holder
to be a non-curable Event of Default. A Notice of Redemption may not be given nor may the Borrower effectuate a Redemption without the consent of the Holder, if at any time during the Redemption Period an Event of Default, or an event which with the
passage of time or giving of notice could become an Event of Default (whether or not such Event of Default has been cured), has occurred. During the Optional Redemption Period, the Company must abide by all of its obligations to the Note Holder.

 3.2. Fundamental Transaction. Upon the occurrence of a Fundamental Transaction, then in addition to the Holder’s
rights described in Section 2.1(c)(A), until twenty (20) business days after the Borrower notifies the Holder of the occurrence of the Fundamental Transaction, the Holder may elect to accelerate the Maturity Date as of the date of
the Fundamental Transaction and receive payment for the then outstanding Principal Amount, and any other amount owed to the Holder pursuant to the Transaction Documents. 
 ARTICLE IV 
 EVENT OF DEFAULT 

The occurrence of any of the following events of default (“Event of Default”) shall, at the option of the Holder hereof,
make all sums of principal and interest then remaining unpaid hereon and all other amounts payable hereunder immediately due and payable, upon demand, without presentment or grace period, all of which hereby are expressly waived, except as set forth
below: 
 4.1 Failure to Pay Principal or Interest. The Borrower (i) fails to pay any installment of principal or
interest under this Note when due or (ii) fails to pay any interest or other sums due under this Note, in each case within ten (10) days after such amounts are due. 
 4.2 Breach of Covenant. The Borrower or any Subsidiary breaches any material covenant or other term or condition of the Subscription Agreement, Transaction Documents or this Note, except for a
breach of payment, in any material respect and such breach, if subject to cure, continues uncured for a period of ten (10) days. 

  
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 4.3 Breach of Representations and Warranties. Any material representation or warranty
of the Borrower made herein, in the Subscription Agreement, or the Transaction Documents shall be false or misleading in any material respect as of the date made and the Closing Date. 

4.4 Liquidation. Any dissolution, liquidation or winding up by Borrower or a Subsidiary of a substantial portion of their
business. 
 4.5 Cessation of Operations. Any cessation of operations by Borrower or a Subsidiary. 

4.6 Maintenance of Assets. The failure by Borrower or any Subsidiary to maintain any material intellectual property rights,
personal, real property, equipment, leases or other assets which are necessary to conduct its business (whether now or in the future), and such failure is not cured by Borrower within ten (10) days written notice to Borrower from Holder.

 4.7 Receiver or Trustee. The Borrower or any Subsidiary shall make an assignment for the benefit of creditors, or
apply for or consent to the appointment of a receiver or trustee for it or for a substantial part of its property or business; or such a receiver or trustee shall otherwise be appointed. 

4.8 Judgments. Any money judgment, writ or similar final process shall be entered or made in a non-appealable adjudication against
Borrower or any Subsidiary or any of its property or other assets for more than $100,000 in excess of the Borrower’s insurance coverage, unless stayed vacated or satisfied within thirty (30) days. 

4.9 Bankruptcy. Bankruptcy, insolvency, reorganization or liquidation proceedings or other proceedings or relief under any
bankruptcy law or any law, or the issuance of any notice in relation to such event, for the relief of debtors shall be instituted by or against the Borrower or any Subsidiary. 
 4.10 Delisting. An event resulting in the Common Stock no longer being quoted on the Over The Counter Bulletin Board (“OTCBB”) and that is not cured by the Borrower within five
(5) days following cessation of quotation; failure to comply with the requirements for continued quotation on the OTCBB for a period of thirty (30) consecutive trading days; or notification from the OTCBB that the Borrower is not in
compliance with the conditions for such continued quotation and such non-compliance continues for thirty (30) days following such notification. 
 4.11 Non-Payment. A default by the Borrower or any Subsidiary under any one or more obligations in an aggregate monetary amount in excess of $100,000 for more than thirty (30) days after the
due date, unless the Borrower or such Subsidiary is contesting the validity of such obligation in good faith. 
 4.12 Stop
Trade. An SEC or judicial stop trade order or OTCBB suspension that lasts for ten (10) or more consecutive trading days. 
 4.13 Failure to Deliver Common Stock or Replacement Note. Borrower’s failures to timely deliver Common Stock to the Holder pursuant to and in the form required by this Note, Sections 7 and 11
of the Subscription Agreement, and the Warrant or, if required, a replacement Note following a partial conversion and such failure is not cured by Borrower within five (5) days written notice to Borrower from Holder. 

4.14 Reservation Default. Failure by the Borrower to have reserved for issuance upon conversion of the Note or upon exercise of
the Warrants, the number of shares of Common Stock as required in the Subscription Agreement, this Note and the Warrants. 

  
 7 

 4.15 Financial Statement Restatement. The restatement after the date hereof of any
financial statements filed by the Borrower with the Securities and Exchange Commission for any date or period from two years prior to the Issue Date of this Note and until this Note is no longer outstanding, if the result of such restatement would,
by comparison to the unrestated financial statements, have constituted a Material Adverse Effect. For the avoidance of doubt, any restatement related to new accounting pronouncements shall not constitute a default under this
Section 4.15. 
 4.16 Non-Registration Event. The Borrower’s failure to materially comply with the
registration obligations set forth in Section 11 of the Subscription Agreement and the occurrence of a Non-Registration Event. 
 4.17 Reverse Splits. The Borrower effectuates a reverse split of its Common Stock without twenty (20) days prior written notice to the Holder. 

4.18 Event Described in Subscription Agreement. The occurrence of an Event of Default as described in the Subscription Agreement
or any other Transaction Document that, if susceptible to cure, is not cured during any designated cure period. 
 4.19
Notification Failure. A failure by Borrower to notify Holder of any material event of which Borrower is obligated to notify Holder pursuant to the terms of this Note or any other Transaction Document. 

4.20 Reservation Default. Failure by the Borrower to timely obtain the Reservation Approval as described in Section 9(x) of
the Subscription Agreement and failure to timely have sufficient shares available for conversion of the Notes and exercise of the Warrants. 
 4.21 Cross Default. A default by the Borrower of a material term, covenant, warranty or undertaking of any other agreement to which the Borrower and Holder are parties, or the occurrence of an
event of default under any such other agreement to which Borrower and Holder are parties which is not cured after any required notice and/or cure period. 
 4.22 Other Note Default. The occurrence of an Event of Default under any Other Note. 
 ARTICLE V 
 SECURITY INTEREST 

5. Security Interest/Waiver of Automatic Stay. This Note is secured by a security interest granted to the Collateral Agent (for
the benefit of Holder and the Other Holders) pursuant to a Security Agreement, as delivered by Borrower to Holder. The Borrower acknowledges and agrees that should a proceeding under any bankruptcy or insolvency law be commenced by or against the
Borrower or a Subsidiary, or if any of the Collateral (as defined in the Security Agreement) should become the subject of any bankruptcy or insolvency proceeding, then the Holder should be entitled to, among other relief to which the Holder may be
entitled under the Transaction Documents and any other agreement to which the Borrower or a Subsidiary and Holder are parties (collectively, “Loan Documents”) and/or applicable law, an order from the court granting immediate relief
from the automatic stay pursuant to 11 U.S.C. Section 362 to permit the Holder to exercise all of its rights and remedies pursuant to the Loan Documents and/or applicable law. THE BORROWER EXPRESSLY WAIVES THE BENEFIT OF THE AUTOMATIC STAY
IMPOSED BY 11 U.S.C. SECTION 362. FURTHERMORE, THE BORROWER EXPRESSLY ACKNOWLEDGES AND AGREES THAT NEITHER 11 U.S.C. SECTION 362 NOR ANY OTHER SECTION OF THE BANKRUPTCY CODE OR OTHER STATUTE OR RULE (INCLUDING, WITHOUT LIMITATION, 11 U.S.C. SECTION
105) 

  
 8 

 
SHALL STAY, INTERDICT, CONDITION, REDUCE OR INHIBIT IN ANY WAY THE ABILITY OF THE HOLDER TO ENFORCE ANY OF ITS RIGHTS AND REMEDIES UNDER THE LOAN DOCUMENTS AND/OR APPLICABLE LAW. The Borrower
hereby consents to any motion for relief from stay that may be filed by the Holder in any bankruptcy or insolvency proceeding initiated by or against the Borrower and, further, agrees not to file any opposition to any motion for relief from stay
filed by the Holder. The Borrower represents, acknowledges and agrees that this provision is a specific and material aspect of the Loan Documents, and that the Holder would not agree to the terms of the Loan Documents if this waiver were not a part
of this Note. The Borrower further represents, acknowledges and agrees that this waiver is knowingly, intelligently and voluntarily made, that neither the Holder nor any person acting on behalf of the Holder has made any representations to induce
this waiver, that the Borrower has been represented (or has had the opportunity to he represented) in the signing of this Note and the Loan Documents and in the making of this waiver by independent legal counsel selected by the Borrower and that the
Borrower has discussed this waiver with counsel. 
 ARTICLE VI 

MISCELLANEOUS 
 6.1 Failure or Indulgence Not Waiver. No failure or delay on the part of the Holder hereof in the exercise of any power, right or privilege hereunder shall operate as a waiver thereof, nor shall
any single or partial exercise of any such power, right or privilege preclude other or further exercise thereof or of any other right, power or privilege. All rights and remedies existing hereunder are cumulative to, and not exclusive of, any rights
or remedies otherwise available. 
 6.2 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, or (iv) transmitted by hand delivery, telegram, facsimile, or email, 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, delivery by email, 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 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 first 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: (i) if to the Borrower to: Cambridge Heart, Inc., 100 Ames Pond Drive, Tewksbury, MA 01876, Attn: Chief Financial Officer, facsimile:
(978) 654-4501, with a copy by fax only to (which shall not constitute notice): Nutter McClennen & Fish LLP, Seaport West, 155 Seaport Boulevard, Boston, MA 02210, Attn: Michelle L. Basil, Esq., facsimile: (617) 310-9477, and
(ii) if to the Holder, to the name, address and facsimile number set forth on the front page of this Note. 
 6.3
Amendment Provision. The term “Note” and all reference thereto, as used throughout this instrument, shall mean this instrument as originally executed, or if later amended or supplemented, then as so amended or supplemented.

 6.4 Assignability. This Note shall be binding upon the Borrower and its successors and assigns, and shall inure to the
benefit of the Holder and its successors and assigns. The Borrower may not assign its obligations under this Note. 

  
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 6.5 Cost of Collection. If default is made in the payment of this Note, Borrower
shall pay the Holder hereof reasonable costs of collection, including reasonable attorneys’ fees. 
 6.6 Governing
Law. This Note shall be governed by and construed in accordance with the laws of the State of New York without regard to conflicts of laws principles that would result in the application of the substantive laws of another jurisdiction. Any
action brought by either party against the other concerning the transactions contemplated by this Agreement must be brought only in the civil or state courts of New York or in the federal courts located in the State and county of New York. Both
parties and the individual signing this Agreement on behalf of the Borrower agree to submit to the jurisdiction of such courts. 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 Note 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 unenforceability of any other provision of this Note. Nothing contained herein shall be deemed or operate to
preclude the Holder from bringing suit or taking other legal action against the Borrower in any other jurisdiction to collect on the Borrower’s obligations to Holder, to realize on any collateral or any other security for such obligations, or
to enforce a judgment or other decision in favor of the Holder. This Note shall be deemed an unconditional obligation of Borrower for the payment of money and, without limitation to any other remedies of Holder, may be enforced against Borrower
by summary proceeding pursuant to New York Civil Procedure Law and Rules Section 3213 or any similar rule or statute in the jurisdiction where enforcement is sought. For purposes of such rule or statute, any other document or agreement to which
Holder and Borrower are parties or which Borrower delivered to Holder, which may be convenient or necessary to determine Holder’s rights hereunder or Borrower’s obligations to Holder are deemed a part of this Note, whether or not such
other document or agreement was delivered together herewith or was executed apart from this Note. 
 6.7 Maximum
Payments. Nothing contained herein shall be deemed to establish or require the payment of a rate of interest or other charges in excess of the maximum rate permitted by applicable law. In the event that the rate of interest required to be paid
or other charges hereunder exceed the maximum rate permitted by applicable law, any payments in excess of such maximum rate shall be credited against amounts owed by the Borrower to the Holder and thus refunded to the Borrower. 

6.8 Non-Business Days. Whenever any payment or any action to be made shall be due on a Saturday, Sunday or a public holiday under
the laws of the State of New York, such payment may be due or action shall be required on the next succeeding business day and, for such payment, such next succeeding day shall be included in the calculation of the amount of accrued interest payable
on such date. 
 6.9 Facsimile Signature. In the event that the Borrower’s signature is delivered by facsimile
transmission, PDF, electronic signature or other similar electronic means, such signature shall create a valid and binding obligation of the Borrower with the same force and effect as if such signature page were an original thereof. 

  
 10 

 6.10 Shareholder Status. The Holder shall not have rights as a shareholder of the
Borrower with respect to unconverted portions of this Note. However, the Holder will have the rights of a shareholder of the Borrower with respect to the shares of Common Stock to be received after delivery by the Holder of a Conversion Notice to
the Borrower. 
 [THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK] 

  
 11 

 IN WITNESS WHEREOF, Borrower has caused this Note to be signed in
its name by an authorized officer as of the 28th day of
February, 2012. 
  

			
	CAMBRIDGE HEART, INC.
		
	By:	 	  

		 	Name:
		 	Title:

  

	
	WITNESS:
	
	  

  
 12 

 EXHIBIT A - NOTICE OF CONVERSION 

(To be executed by the Registered Holder in order to convert the Note) 
 The undersigned hereby elects to convert $         of the principal and $             of the regular
interest and $         of Additional Interest due on the Note issued by CAMBRIDGE HEART, INC. on February 28, 2012 into Shares of Common Stock of CAMBRIDGE HEART, INC. (the “Borrower”)
according to the conditions set forth in such Note, as of the date written below. 
  

			
	Date of Conversion:	 	  

			
		
	Conversion Price:	 	  

 Number of Shares of Common Stock Beneficially Owned on the Conversion Date: Less than 5% of the outstanding Common Stock
of CAMBRIDGE HEART, INC. 
  

			
	Shares To Be Delivered:	 	  

			
		
	Signature:	 	  

			
		
	Print Name:	 	  

			
		
	Address:	 	  

			
		
		 	  

  
 13

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00200-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00200-of-00352.parquet"}]]