Document:

Exhibit 10.114

 

 

PREPAID FORWARD PURCHASE AGREEMENT

This Prepaid Forward Purchase Agreement
(as amended, supplemented, or otherwise modified from time to time in accordance with the terms hereof, this
“Agreement”), dated as of March 31, 2016 (the “Agreement Date”), is made
by and between Racine Funding Co, LLC, a New York limited liability company (“Purchaser”), on the
one hand, and Rennova Health, Inc., a Delaware corporation (“Rennova”), Biohealth Medical
Laboratory, Inc., a Florida corporation (“Biohealth”), and PB Laboratories, LLC, a Florida limited
liability company (“PB,” and collectively with Rennova and
Biohealth, jointly and severally, “Seller”), on the other hand. Christopher Eric Diamantis, an
individual who resides in Florida (“Diamantis”), is also a Party hereto and is referred to herein
as “Guarantor.” In consideration of the agreements set forth herein and other good and
valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Seller, Purchaser, and Guarantor agree
as follows:

ARTICLE I

DEFINITIONS 

Section 1. Definitions.
The following terms shall have the following meanings when used in this Agreement:

“$” or “Dollars”
means United States Dollars.

“Agreement” has the meaning given to it
in the preamble to this Agreement.

“Agreement Date” has the meaning given
to it in the preamble to this Agreement.

“Agreement Termination”
means the elimination of any previously existing right or obligation created by the terms of this Agreement within the meaning
of Section 1234A of the IRC.

“Collateral” has the meaning given to
it in the Seller Security Agreement.

“Encumbrance” means
any (a) mortgage, pledge, lien, security interest, charge, hypothecation, security agreement, security arrangement or encumbrance,
or other adverse claim against title of any kind; (b) purchase, option, call, or put agreement or arrangement; (c) subordination
agreement or arrangement; (d) prior sale, transfer, assignment, or participation by Seller of the Transferred Rights, the Proceeds,
or any interest in the Litigation; or (e) agreement or arrangement to create or effect any of the foregoing.

“Entity” means any
individual, partnership, corporation, limited liability company, association, estate, trust, business trust, governmental authority,
fund, investment account, or other person or entity.

“Guarantor Security Agreement”
means the security agreement of even date herewith, made by Guarantor for the benefit of Purchaser in connection with this Agreement.

“including” means including, but not limited
to.

“Indebtedness” means,
without duplication, all items that constitute (a) indebtedness for borrowed money or the deferred purchase price of property (other
than trade payables incurred in the ordinary course of business); (b) obligations arising under letter of credit facilities, bonds,
notes or other instruments; (c) all liabilities secured by any Encumbrance on any of Seller’s property (other than mechanics’,
repairmen’s or other like non-consensual statutory Encumbrances arising in the ordinary course of business with respect to
obligations that are not past due); and/or (d) all guarantees or other liabilities with respect to any indebtedness of any other
Entity.

“IRC” means the Internal Revenue Code
of 1986, as amended, and the regulations in effect thereunder.

“Late Payment Penalty” has the meaning
given to it in Section 2.2(b).

“Litigation” means
the cases captioned BioHealth Medical Laboratory, Inc. et al v. Connecticut General Life Insurance Company et al, Case No.
15-cv-23075, in the United States District Court for the Southern District of Florida; BioHealth Medical Laboratory, Inc. et
al v. Connecticut General Life Insurance Company et al, Case No. 16-10978, in the United States Court of Appeals for the Eleventh
Circuit; and BioHealth Medical Laboratory, Inc. et al v. Connecticut General Life Insurance Company et al, Case No. 16-cv-20807,
in the United States District Court for the Southern District of Florida, including the same matters if transferred to any other
jurisdictions or forums (arbitral, judicial, or otherwise), together with (a) any and all claims, suits, causes of action, proceedings,
and other rights relating to, or arising from, such matters, including those relating to Connecticut General Life Insurance Company
and Cigna Health and Life Insurance Company’s denial of claims for toxicology and other medical testing performed by Seller
and its affiliates, (b) any and all appellate proceedings, proceedings on remand, and enforcement, ancillary, parallel, or alternate
dispute resolution proceedings and processes arising out of or related to such matters, and (c) any additional cases, lawsuits,
arbitration matters, or other proceedings filed or initiated by or on behalf of Seller based upon the same or substantially similar
claims.

 

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“Litigation Counsel”
means Akerman LLP.

“Litigation Counsel Letter”
means the letter, in a form approved by Purchaser, from Seller to Litigation Counsel, and agreed to by Litigation Counsel, that
relates to the payment of the Proceeds to Purchaser pursuant to this Agreement.

“Party”
means each of Seller, Purchaser, and Guarantor, and Seller, Purchaser, and Guarantor are collectively referred to as the “Parties.”

“Proceeds” means
any and all proceeds, receivables, property, cash, and other consideration payable to, or on behalf of, Seller in connection with
the Litigation (whether by suit, judgment, settlement, or otherwise), including (a) any recovered attorneys’ fees and costs,
(b) any consequential, actual, punitive, exemplary, or treble damages on account thereof, and (c) any interest awarded or later
accruing on the foregoing. The Proceeds will be calculated and determined without taking into consideration and prior to deduction
of (i) any taxes payable by Seller in connection with the Proceeds, (ii) setoffs of any kind, including setoffs in respect of any
claim or counterclaim asserted against Seller by any Entity, or (iii) fees and/or expenses incurred in connection with the Litigation
or the collection of any Proceeds. If the Proceeds include non-cash components (e.g., shares of stock), Seller shall pay Purchaser
based on Proceeds including the cash value thereof, with such value expressly agreed to by Purchaser, or monetize said non-cash
Proceeds as soon as commercially reasonable in a manner expressly agreed to by Purchaser. For the avoidance of doubt, the Proceeds
do not include receivables owed by Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company to Seller
and its affiliates that are not in connection with the Litigation.

“Purchase Price” means an amount equal
to $5,000,000.

“Purchaser” has the meaning given to it
in the preamble to this Agreement.

“Security Agreements” means the Guarantor
Security Agreement and the Seller Security Agreement.

“Seller Security Agreement”
means the security agreement of even date herewith, made by Seller for the benefit of Purchaser in connection with this Agreement.

“Seller” has the
meaning given to it in the preamble to this Agreement.

“Total Investment Return”
means an amount of the Proceeds equal to the sum of: (a) the greater of (i) an amount equal to the Purchase Price plus a 20% per
annum investment return thereon, accruing daily and compounding annually, and (ii) $5,500,000, plus (b) either (x) $250,000,
if paid in full along with payment in full of the amount set forth in the foregoing clause (a) within one hundred eighty (180)
days of the Agreement Date, or (y) $500,000, if paid in full along with payment in full of the amount set forth in the foregoing
clause (a) at any time after the date that is one hundred eighty (180) days after the Agreement Date, plus (c) the product
of (i) the Proceeds minus the amounts set forth in the foregoing clauses (a) and (b), multiplied by (ii) 20% (expressed as a decimal),
plus (d) the Late Payment Penalty, if any.

“Transaction Documents”
means, collectively, this Agreement, the Security Agreements, the Litigation Counsel Letter, and any other documents, instruments,
or certificates entered into or delivered in connection with this Agreement.

“Transferred Rights”
means all of Seller’s right, title, and interest in and to the Proceeds in an amount equal to the Total Investment Return.

ARTICLE II

TERMS OF INVESTMENT

Section 2.1. Purchase Price.
Purchaser agrees, on the Agreement Date, to pay the Purchase Price to Seller in immediately available funds pursuant to
“Seller’s Wire Instructions” set forth on Exhibit A. In consideration of the Purchase Price, Seller absolutely
assigns, conveys, sells, sets over, transfers, and warrants to Purchaser all rights, title, benefits, and interests of Seller
in and to the Transferred Rights, free and clear of any Encumbrance.

Section 2.2. Investment Return.

	(a)		Seller immediately will notify Purchaser of its receipt of any Proceeds (whether by
Litigation Counsel for Seller’s account or otherwise). Within three (3) business days of Seller (or Litigation Counsel)
receiving any Proceeds, Seller will pay (or cause to be paid) the Proceeds to Purchaser until an aggregate amount equal to the
Total Investment Return has been paid to Purchaser (together with all other unpaid fees and amounts, if any, payable to Purchaser
pursuant to the Transaction Documents) in immediately available funds in accordance with “Purchaser’s Wire Instructions”
set forth on Exhibit A. Seller agrees to satisfy its obligations hereunder prior to making any other payments from the
Proceeds to any other Entity, including Seller or Seller’s equity owners. All payments to Purchaser shall be made free of
any withholding, setoff, recoupment, or deduction of any kind except as required by law. In order to secure payment of the Proceeds
and as a condition to Purchaser’s entering into this Agreement, on or prior to the Agreement Date, (i) Seller has delivered
the Litigation Counsel Letter, which provides instructions for payment of the Proceeds that are consistent with the terms of this
Section 2.2, to Litigation Counsel and Litigation Counsel has agreed to the Litigation Counsel Letter, and (ii) Seller has delivered
the Litigation Counsel Letter to Purchaser as executed by Seller and Litigation Counsel.

 

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	(b)		If Seller defaults
                                         in the timely payment of the Total Investment Return in accordance with Section 2.2(a),
                                         then, until such defaulted amount shall have been paid in full (by either Seller or Guarantor),
                                         to the extent permitted by law, all amounts outstanding under this Agreement and the
                                         other Transaction Documents shall be subject to a late payment penalty, payable on demand,
                                         of 30.0% per annum, accruing daily and compounding annually (the “Late
                                         Payment Penalty”).

	(c)		If, as of the one
                                         (1) year anniversary of the Agreement Date, Seller has not paid the Total Investment
                                         Return to Purchaser for any reason (including that no Proceeds have been generated),
                                         (I) Seller shall pay the amount set forth in clause (a) of the definition of Total Investment
                                         Return (i.e., $6,000,000 less any amounts previously paid by Seller to Purchaser hereunder)
                                         to Purchaser as of such one (1) year anniversary in immediately available funds in accordance
                                         with “Purchaser’s Wire Instructions” set forth on Exhibit A,
                                         (II) the amounts set forth in clauses (b) and (c) of the definition of Total Investment
                                         Return shall remain due and owing to Purchaser (to the extent Proceeds are generated
                                         in excess of $6,000,000), and (III) the amount set forth in clause (d) of the definition
                                         of Total Investment Return shall remain due and owing to Purchaser (to the extent applicable).
                                         If Seller fails to satisfy the covenant set forth in the foregoing clause (I), (w) Guarantor
                                         shall, within one (1) business day after the one (1) year anniversary of the Agreement
                                         Date, pay the amount set forth in such clause (I) (i.e., $6,000,000 less any amounts
                                         previously paid by Seller to Purchaser hereunder) to Purchaser in immediately available
                                         funds in accordance with “Purchaser’s Wire Instructions” set forth
                                         on Exhibit A, (x) the amount set forth in clause (a) of the definition of Total
                                         investment Return shall remain due and owing to Purchaser to the extent Proceeds are
                                         generated (and, with respect to up to the first $6,000,000 of such Proceeds received
                                         by Purchaser from Seller, Purchaser shall promptly pay over such amount to Guarantor
                                         to the extent that Guarantor satisfied his obligation pursuant to the foregoing clause
                                         (w)), (y) the amounts set forth in clauses (b) and (c) of the definition of Total Investment
                                         Return shall remain due and owing to Purchaser (to the extent Proceeds are generated
                                         in excess of $6,000,000), and (z) the amount set forth in clause (d) of the definition
                                         of Total Investment Return shall remain due and owing to Purchaser (to the extent applicable).

Section 2.3. Agreement Termination.
This Agreement creates rights and obligations of each of the Parties. The Parties intend that any rights and obligations
created as a consequence of this Agreement shall terminate (within the meaning of Section 1234A of the IRC) upon Purchaser’s
receipt of the Total Investment Return in accordance with Section 2.2. For the avoidance of doubt, Article I, Article III, Section
4.5, Article V, and Article VI shall survive any such termination.

ARTICLE III

REPRESENTATIONS AND WARRANTIES

Section 3.1. Mutual Representations.
Each Party represents and warrants to the other Party as of the Agreement Date that:

	(a)		It has the power and authority to enter into and deliver this Agreement and the other
Transaction Documents and to perform its obligations under the Transaction Documents.

	(b)		The execution, delivery, and performance of the Transaction Documents by it does not
conflict with, and will not result in a violation of, (i) any of such Party’s organizational documents; (ii) any agreement
or other instrument that may be binding upon such Party or its assets or property; or (iii) any law, governmental regulation,
court decree, or order applicable to such Party or such Party’s assets or property.

	(c)		The Transaction Documents have been duly authorized, executed, and delivered by it,
and constitute the legal, valid, and binding obligations of it, as well as its successors and assigns, enforceable in accordance
with their respective terms.

	(d)		No notice to, registration with, consent of, or any other action by any Entity (including
any court) is or will be required for such Party to perform its obligations under the Transaction Documents.

 

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	(e)		It has engaged independent legal counsel and tax advisors, who have reviewed the Transaction
Documents and advised such Party about the applicable terms and obligations.

Section 3.2. Seller’s Representations.
Seller represents and warrants to Purchaser as of the Agreement Date that:

	(a)		Seller is duly organized, validly existing, and in good standing under the laws of
the jurisdiction of its organization; is duly qualified to do business in and is in good standing in every jurisdiction where
Seller is operating its business; and has all powers and all governmental licenses, authorizations, consents, and approvals required
to carry on its business as now conducted.

	(b)		Seller is the sole legal and beneficial owner of and has good title to the Litigation,
the Proceeds, and the Transferred Rights, free and clear of any Encumbrance (except for the Encumbrance in favor of TCA Global
Credit Master Fund, LP).

	(c)		There are no suits, investigations, or proceedings pending, or to the knowledge of
Seller, threatened, against Seller that may adversely affect it, the Litigation, the Proceeds, the Transferred Rights, or its
other assets.

	(d)		Seller has not received any payments or other distributions in connection with the
Litigation. Any payments to be made to Seller with respect to the Litigation or the Proceeds are not subject to any rights of
subordination or setoff.

	(e)		Seller has provided
                                         to Purchaser true, correct, and complete copies of (i) all material documents and other
                                         information relating to the Litigation that are necessary for Purchaser to sufficiently
                                         and effectively evaluate the merits of, the likelihood that Seller will prevail in, the
                                         level of damages to be awarded in, and the likelihood of Seller to collect from, the
                                         Litigation; and (ii) financial statements and other documents of Seller as filed with
                                         the Securities and Exchange Commission; provided, however, that Seller
                                         has not provided such documents and information to the extent that such disclosure would
                                         result in the loss of protection under the attorney-client privilege (“Excluded
                                         Information”). Even without the Excluded Information, Seller has provided
                                         Purchaser with sufficient information to evaluate the merits of, the likelihood that
                                         Seller will prevail in, the level of damages to be awarded in, and the likelihood to
                                         collect from, the Litigation. Seller reasonably believes that Seller will prevail in
                                         the Litigation. The documents and information delivered to Purchaser do not contain any
                                         untrue statement by Seller of a material fact or omit to state a material fact necessary
                                         to make the statements made therein not misleading.

	(f)		Before and after giving effect to the Transaction Documents, Seller is solvent and
has the economic capability to perform its obligations under the Transaction Documents.

	(g)		(i) Seller has no Indebtedness outstanding or (ii) (A) Seller has disclosed the material
terms of such Indebtedness in writing to Purchaser, (B) Seller is not in default under the documents governing such Indebtedness,
and (C) such Indebtedness is not secured by the Collateral (except for the Encumbrance in favor of TCA Global Credit Master Fund,
LP).

	(h)		Except for the Transaction Documents, Seller has not entered into any assignment,
financing, or other investment arrangement relating to the Litigation, the Proceeds, or the Transferred Rights.

	(i)		Seller has sole control of the Litigation and any settlement decisions related thereto
and will not delegate such control to any Entity.

	(j)		Purchaser has not provided Seller with any legal, tax, or investment advice regarding
selling the Transferred Rights or entering into the Transaction Documents. Seller is capable of evaluating and understanding the
terms, risks, and conditions of the transactions contemplated by the Transaction Documents.

	(k)		Seller brought and continues to pursue the Litigation in the exercise of its independent
judgment in consultation with its counsel. Purchaser has not prompted or encouraged initiation of any Litigation, and, regardless
of the existence of this Agreement, Seller would have brought and would continue to pursue the Litigation.

ARTICLE IV

COVENANTS 

Section 4.1. Preservation of Existence;
Compliance with Laws. Seller will preserve and maintain its existence, rights, franchises, and privileges in the jurisdiction
of its organization, and will qualify and remain qualified in good standing in each jurisdiction where failure to preserve and
maintain such existence, rights, franchises, privileges, and qualification could reasonably be expected to have a material adverse
effect on the Litigation, Seller’s financial condition, or the collection of any Proceeds. Seller will not, without the prior
written consent of Purchaser, (a) operate under any other name or (b) cease operations, liquidate, dissolve, merge into, or consolidate
with any other Entity.

 

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Section 4.2. Information.
Seller agrees and undertakes to keep Purchaser informed about the progress of the Litigation and the collection of the Proceeds,
including providing sufficient details to enable Purchaser to continue to evaluate the merits of, the likelihood that Seller will
prevail in, the level of damages to be awarded in, and the likelihood of Seller to collect from, the Litigation. Seller has irrevocably
instructed Litigation Counsel to provide Purchaser with all material non-privileged information in connection with the Litigation
(including copies of documents filed in connection with the Litigation) as soon as practicable. Promptly after becoming aware thereof,
Seller will inform Purchaser of any event that could reasonably be expected to have a material adverse effect on the Litigation
or the collection of any Proceeds. In addition, Seller agrees to provide to Purchaser any documentation or information reasonably
requested by Purchaser that relates to the transaction contemplated by this Agreement or Seller’s business, including bank
statements, audited and unaudited financial statements, and tax returns, in each case promptly following each request by Purchaser.

Section 4.3. Litigation.
At all times, Seller will maintain complete control of the Litigation and any settlement decisions related thereto. Seller
will consult with Purchaser before accepting or rejecting any settlement offer in connection with the Litigation, but Seller will
have no obligation to follow Purchaser’s advice. Seller will: (a) use its best efforts to enforce its rights and prosecute
the Litigation with all due skill, care, and speed; (b) use its best efforts to prevail in the Litigation; (c) use its best efforts
to obtain an outcome in the Litigation that maximizes the amount of Proceeds; (d) use its best efforts promptly to collect any
Proceeds payable in connection with the Litigation; and (e) cause its members, managers, directors, partners, shareholders, officers,
executives, employees, and agents to promptly and fully assist Litigation Counsel as reasonably necessary in connection with the
foregoing; provided, however, that nothing in this Agreement shall require Seller to continue the Litigation to the extent
Seller reasonably determines that the Litigation no longer has merit. To the extent not paid by the Purchase Price or otherwise
covered or advanced by Litigation Counsel, Seller will be responsible for the prompt payment of any and all fees, costs and expenses
necessary to prosecute the Litigation to a successful completion.

Section 4.4. Default.
Seller shall promptly notify Purchaser of any default under the Transaction Documents.

Section 4.5. True Sale.
Seller and Purchaser intend and agree that the transactions contemplated by the Transaction Documents shall constitute a true sale
and absolute transfer of the Transferred Rights to Purchaser, thereby providing Purchaser with the full risks and benefits of ownership
of the Transferred Rights, and each of Seller and Purchaser agrees that the transactions contemplated by the Transaction Documents
shall be reflected on their respective books and records in a manner consistent with this intent and agreement. Notwithstanding
that Seller and Purchaser intend that this transaction be a true sale, in an abundance of caution, in the event that such sale
and assignment ever is characterized as a loan or other financial accommodation and not as a true sale, or that such sale shall
for any reason be ineffective or unenforceable as such, each as determined in a judicial, administrative or other proceeding (any
of which, a “recharacterization”), Seller is entering into the Seller Security Agreement to grant to Purchaser a security
interest in the Collateral.

ARTICLE V

INDEMNIFICATION 

Section 5.1. Indemnification and
Repurchase. Seller shall indemnify, defend, and hold Purchaser and its officers, directors, managers, agents, partners,
members, shareholders, controlling entities, and employees (collectively, “Indemnitees”), harmless from and against any liability, claim, cost, loss, judgment, damage, or expense (including
reasonable attorneys’ fees and expenses) (“Losses”) that any Indemnitee incurs or suffers (a)
as a result of, or arising out of, a breach of any of Seller’s representations, warranties, covenants, or agreements in
the Transaction Documents, and/or (b) in connection with the Litigation, including as a result of third-party discovery proceedings.
In addition, in the event of (i) a breach of any of Seller’s representations and warranties in the Transaction Documents,
or (ii) a breach of any of Seller’s covenants or agreements in the Transaction Documents that continues unremedied for a
period of ten (10) business days after written notice thereof (or three (3) business days, with respect to a default in the payment
of any amount owed under the Transaction Documents), Purchaser shall have the right, in addition to any other rights or remedies,
to require Seller to repurchase the Transferred Rights for an amount equal to (x) the Purchase Price less any amounts thereof
already paid to Purchaser, plus (y) interest on the Purchase Price at a rate of 30.0% per annum, accruing daily and compounding
annually, plus (z) any Losses resulting from or arising out of such breach.

 

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ARTICLE VI

MISCELLANEOUS 

Section 6.1. Governing Law.
This Agreement shall be governed by and construed in accordance with the laws of the State of New York (without regard to any principles
of law that would require the application of the laws of another state).

Section 6.2. Income Tax Treatment.
For income tax purposes, the transaction set forth herein shall be considered and treated as a prepaid forward contract, and in
any event does not represent indebtedness for federal income tax purposes. Each Party will be responsible for the payment of its
own income tax liabilities incurred in connection with the Transaction Documents in a manner consistent with such treatment. To
the maximum extent permitted by law, the payment of the Total Investment Return to Purchaser shall constitute an Agreement Termination
resulting in a disposition of any assets created or transferred as a result of this Agreement. Seller will not issue any Form 1099
to Purchaser in connection with payments made to Purchaser under this Agreement.

Section 6.3. Relationship of the Parties;
Election Out of Partnership Status. The relationship between Seller, on the one hand, and Purchaser, on the other,
shall be that of seller and buyer. Neither is a trustee or agent for the other, nor does either have any fiduciary obligations
to the other. This Agreement and the other Transaction Documents are not intended to create, and shall not be construed to create,
a joint venture or a relationship of partnership or an association for profit between or among Seller and Purchaser or any other
Entity. Notwithstanding any provision herein that this Agreement and operations hereunder shall not constitute a partnership, if,
for federal income tax purposes, this Agreement and the operations hereunder are regarded as a partnership (the “Partnership”),
each Party hereby affected elects to be excluded from the application of all of the provisions of Subchapter “K”, Chapter
1, Subtitle “A”, of the IRC as permitted and authorized by IRC Section 761 and the regulations promulgated thereunder.
Purchaser is authorized and directed to execute on behalf of the Partnership such evidence of this election as may be required
by the Secretary of the Treasury of the United States or the Internal Revenue Service. Should there be any requirement that each
Party hereby affected give further evidence of this election, each Party shall execute such documents and furnish such other evidence
as may be required by the Internal Revenue Service or as may be necessary to evidence this election. No Party shall give any notices
or take any other action inconsistent with the election made hereby. In making the foregoing election, each Party states that the
income derived by such Party from operations hereunder can be adequately determined without the computation of partnership taxable
income.

Section 6.4. Arbitration.
Any controversy or claim arising out of or relating to this Agreement or any other Transaction Document, or the breach thereof,
shall be settled by confidential arbitration administered by the American Arbitration Association under its
Commercial Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction.
For the avoidance of doubt, the Parties agree that even claims for emergency equitable relief, such as a temporary restraining
order, may be sought only in arbitration pursuant to this Section 6.4. The arbitrator will have the authority to: (a) compel adequate
discovery for the resolution of the dispute, (b) award any and all remedies that any Entity would be entitled to seek in a court
of law, and (c) determine its own jurisdiction by interpreting the scope of this arbitration clause and whether a controversy or
claim arises out of or relates to this Agreement or any other Transaction Document. Notwithstanding the foregoing, this Section
6.4 shall not limit the right of Purchaser, as a secured party, to: (i) exercise self-help remedies, such as but not limited to,
setoff; (ii) initiate judicial or non-judicial foreclosure against any real or personal property collateral; (iii) exercise any
judicial or power of sale rights; or (iv) act in a court of law to obtain an interim remedy, such as, but not limited to, writ
of possession or appointment of a receiver, or additional or supplementary remedies. The prevailing party in any arbitration pursuant
to this Section 6.4, as determined by the arbitrator, shall be entitled to recover its reasonable attorneys’ fees, expert
witness fees, costs, and expenses incurred in connection with the arbitration, in addition to any other relief to which such prevailing
party may be entitled. By agreeing to binding arbitration, the Parties irrevocably and voluntarily waive any right they may have
to a trial by jury in respect of any claim arising out of or relating to this Agreement or any other Transaction Document, or the
breach thereof. Furthermore, without intending in any way to limit this agreement to arbitrate, to the extent any claim is not
arbitrated, the Parties irrevocably and voluntarily waive any right they may have to a trial by jury in respect of such claim.
WHETHER A CLAIM IS DECIDED BY ARBITRATION OR BY TRIAL BY A JUDGE, THE PARTIES AGREE AND UNDERSTAND
THAT THE EFFECT OF THIS AGREEMENT IS THAT THEY ARE GIVING UP THE RIGHT TO TRIAL BY JURY TO THE EXTENT PERMITTED BY LAW.

 

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Section 6.5. Confidentiality.
The Parties agree that the existence of this Agreement and any other Transaction Document, and the fact of and details surrounding
the relationship between the Parties reflected by the Transaction Documents, shall be held in strictest confidence unless the Parties
agree in writing to disclose certain information (including for strategic benefit in the Litigation) or as otherwise required by
applicable law. The Parties agree that the Transaction Documents may not be used in connection with, or as the basis of documents
for, any other transaction by Seller (other than a transaction with Purchaser), Seller’s counsel, or any of Seller’s
officers, directors, managers, agents, partners, members, shareholders, controlling entities, and employees.

Section 6.6. Mutual Drafting.
The Transaction Documents will be deemed to have been jointly drafted by the Parties and no provision shall be interpreted or construed
for or against either Party because such Party actually or purportedly prepared or requested such provision, any other provision
or the Transaction Documents as a whole.

Section 6.7. Transfers. 

	(a)		At any time after
                                         payment by Purchaser of the Purchase Price, Purchaser may freely sell, assign, participate,
                                         or otherwise transfer (each, a “Transfer”) all of its rights
                                         and obligations under the Transaction Documents.

	(b)		Without Purchaser’s prior written consent, Seller shall not cause or permit
any Encumbrances on (except for the Encumbrance in favor of TCA Global Credit Master Fund, LP), enter into any financing or hedging
arrangement with respect to, or Transfer any of its interests in, the Litigation, the Proceeds, the Transferred Rights, or any
other Collateral.

	(c)		Seller shall not Transfer any of its rights or obligations in the Transaction Documents.

	(d)		The Transaction Documents, including the representations, warranties, covenants, and
indemnities contained in this Agreement, shall inure to the benefit of, be binding upon, and be enforceable by and against the
Parties and their respective successors and permitted assigns.

Section 6.8. Costs and Expenses.
Each Party will pay such Party’s own costs and expenses incurred in connection with this Agreement and the other Transaction
Documents. Seller will pay Purchaser’s costs and expenses incurred in connection with enforcing Seller’s obligations
under the Transaction Documents.

Section 6.9. Amendment; Waiver.
No amendment of any provision of the Transaction Documents shall be effective unless it is in writing and signed by the Parties,
and no waiver of any provision of the Transaction Documents, nor consent to any departure by any Party from it, shall be effective
unless it is in writing and signed by the affected Party, and then such waiver or consent shall be effective only in the specific
instance and for the specific purpose for which given. No failure on the part of a Party to exercise, and no delay in exercising,
any right or remedy under this Agreement shall operate as a waiver by such Party, nor shall any single or partial exercise of any
right or remedy under the Transaction Documents preclude any other or further exercise thereof or the exercise of any other right
or remedy. The rights and remedies of each Party provided herein and in the other Transaction Documents (a) are cumulative and
are in addition to, and are not exclusive of, any rights or remedies provided by law and (b) are not conditional or contingent
on any attempt by such Party to exercise any of its rights or remedies under any other related document or against the other Party
or any other Entity.

Section 6.10. Entire Agreement.
This Agreement, the Security Agreements, and any and all other Transaction Documents embody the final, entire agreement of the
Parties hereto and supersede any and all prior commitments, agreements, representations, and understandings, whether written or
oral, relating to the subject matter hereof and shall not be contradicted or varied by evidence of prior, contemporaneous, or subsequent
oral agreements or discussions of the parties hereto.

Section 6.11. Further Assurances.
Each Party agrees to (a) execute and deliver, or cause to be executed and delivered, all such other and further agreements, documents,
and instruments and (b) take or cause to be taken all such other and further actions as the other Party may reasonably request
to effectuate the intent and purposes, and carry out the terms, of this Agreement and the other Transaction Documents.

Section 6.12. Severability; Construction.
If any provision of this Agreement or the other Transaction Documents is held invalid, the remainder of this Agreement and the
other Transaction Documents shall nevertheless remain in full force and effect, and the application of such provision to one Party
or circumstance shall not render that provision invalid or unenforceable as to any other Party or circumstance. If feasible, any
such offending provision shall be deemed to be modified to be within the limits of enforceability or validity; provided, however,
that if the offending provision cannot be so modified, it shall be stricken and all other provisions of the Transaction Documents
in all other respects shall remain valid and enforceable. If, for any reason, any provision of the Transaction Documents is invalidated
in a way that reduces the amount of the Transferred Rights payable to Purchaser, then the Parties agree to promptly modify the
Transaction Documents in a way that will allow Purchaser to receive payments equal to the lesser of (a) the maximum amount permitted
by law and (b) the Transferred Rights. The Transaction Documents shall be construed in such a manner as to give full force and
effect to all provisions of this Agreement and the other Transaction Documents; provided, however, that in the event of
any irreconcilable conflict between the terms and provisions contained in this Agreement and in any of the other Transaction Documents,
the terms and provisions of this Agreement shall control. Section or other headings contained in this Agreement are for reference
purposes only and shall not in any way affect the meaning or interpretation of this Agreement.

 

    	 	7	 

     

    

 

Section 6.13. Survival.
All representations, warranties, covenants, indemnities, and other provisions made by the Parties shall be considered to have been
relied upon by the Parties, and shall survive the execution, delivery, and performance of the Transaction Documents.

Section 6.14. Notices.
All notices given pursuant to the Transaction Documents shall be in writing and shall be deemed effective upon: (a) personal delivery
to the Party to be notified; (b) in the case of e-mail, upon the receiving Party of such e-mail acknowledging receipt in writing;
or (c) one (1) business day after deposit with a nationally recognized overnight courier for next business day delivery with written
verification of receipt. Communications shall be sent to the appropriate addresses as set forth on Exhibit A, or to such
e-mail address or address as subsequently modified by written notice given in accordance with this Section 6.14.

Section 6.15. Counterparts.
This Agreement and the other Transaction Documents may be executed in multiple counterparts and all of such counterparts taken
together shall be deemed to constitute one and the same instrument. Transmission by facsimile, electronic mail or other form of
electronic transmission of an executed counterpart of any Transaction Document shall be deemed to constitute due and sufficient
delivery of such counterpart. Each fully executed counterpart of this Agreement and any other Transaction Document shall be deemed
to be a duplicate original.

 

[Signature Page Follows]

 

    	 	8	 

     

    

 

IN WITNESS WHEREOF, the parties hereto have
duly executed this Agreement as of the Agreement Date.

 

SELLER: 

RENNOVA HEALTH, INC.

 

 

By:                         

Name: 

Title: 

 

 

BIOHEALTH MEDICAL LABORATORY, INC.

 

By:                     

Name: 

Title: 

 

 

PB LABORATORIES, LLC

 

By:                     

Name: 

Title: 

 

 

PURCHASER: 

RACINE FUNDING CO, LLC

 

By:                     

Name: 

Title: 

 

 

GUARANTOR:

 

 

                              

Christopher
Eric Diamantis

 

 

 

 

 

 

 

 

 

 

    	 	9Form of Medium-Term Notes, Series K, Principal at Risk Securities Linked

 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. 94986RQ53 
	
FACE AMOUNT: $                   
          

 REGISTERED NO.      

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Lowest Performing of the S&P 500®
Index 
 and the Russell 2000® Index due July 8, 2021 

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, an amount equal to the
Redemption Amount (as defined below) on the Stated Maturity Date (as defined below), unless this Security is redeemed prior to the Stated Maturity Date as provided below under “Optional Redemption,” and to pay Contingent Coupon Payments
(as defined below) on the Face Amount of this Security to the extent provided herein on the Contingent Coupon Payment Dates specified herein at the Contingent Coupon Rate (as defined below) until the earlier of the Stated Maturity Date and the
Optional Redemption Date (as defined below), if any. The “Initial Stated Maturity Date” shall be July 8, 2021. If the Final Calculation Day (as defined below) is not postponed, the Initial Stated Maturity Date will be the
“Stated Maturity Date.” If the Final Calculation Day is postponed, the “Stated Maturity Date” shall be the later of (i) the Initial Stated Maturity Date and (ii) the third Business Day (as defined below)
after the Final Calculation Day as postponed. 
 “Face Amount” shall mean, when used with respect to this
Security, the amount set forth on the face of this Security as its “Face Amount.” 
 Optional Redemption 

The Company may, at its option, redeem this Security, in whole but not in part, on any Optional Redemption Date (as defined
below) by giving notice to the Holder hereof on or before the 

 
Calculation Day (as defined below) immediately preceding that Optional Redemption Date. If this Security is redeemed, the Holder hereof will receive the Optional Redemption Price (as defined
below) plus a final Contingent Coupon Payment (as defined below), if any, on the applicable Optional Redemption Date. Unless the Company defaults in the payment of the Optional Redemption Price plus the final Contingent Coupon Payment, if any, this
Security will cease to be outstanding on such Optional Redemption Date, no additional Contingent Coupon Payments will be payable on this Security and the Holder hereof will have no further rights under this Security after such Optional Redemption
Date. The “Optional Redemption Price” is equal to the Face Amount of this Security. The “Optional Redemption Dates” shall be the Contingent Coupon Payment Dates (as defined below) following each Calculation Day
scheduled to occur from July 2017 to April 2021, inclusive. 
 Payment of Contingent Coupon Payments, the Redemption Amount and
the Optional Redemption Price 
 On each quarterly Contingent Coupon Payment Date, the Company shall pay a
Contingent Coupon Payment if, and only if, the Closing Level (as defined below) of the Lowest Performing Index (as defined below) on the related Calculation Day (as defined below) is greater than or equal to its Coupon Threshold Level (as defined
below). A “Contingent Coupon Payment,” if payable as provided herein, shall be equal to the product of (i) the Face Amount of this Security, (ii) the Contingent Coupon Rate, and (iii) 90/360. The “Contingent
Coupon Payment Dates” shall be the fourth Business Day following each Calculation Day, as each such Calculation Day may be postponed as herein provided, provided that the Contingent Coupon Payment Date with respect to the Final Calculation
Day will be the Stated Maturity Date. The “Contingent Coupon Rate” is 7.00% per annum. Any Contingent Coupon Payments will be rounded to the nearest cent, with one-half cent rounded upward. 

Any Contingent Coupon Payment so payable, and punctually paid or duly provided for, on any Contingent Coupon 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 Contingent Coupon Payment next preceding such
Contingent Coupon Payment Date. The Regular Record Date for a Contingent Coupon Payment Date shall be the date one Business Day prior to such Contingent Coupon Payment Date. 

Any Contingent Coupon Payment 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 any Contingent Coupon Payment 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; provided, however, that, at the option of the Company, payment of any 

  
 2 

 
Contingent Coupon Payment 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. Payments of any Contingent Coupon Payment and the Redemption Amount or the Optional Redemption Price, as applicable, 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 and at any other office or agency maintained by the Company for such purpose. Notwithstanding the foregoing, for so long as this Security is a Global
Security registered in the name of the Depositary, any payments on this Security will be made to the Depositary by wire transfer of immediately available funds. 

Payment of the Redemption Amount or the Optional Redemption Price, as applicable, and any Contingent Coupon Payments on this
Security will be made 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. 

Definitions Relating to Redemption Amount, the Optional Redemption Price and Contingent Coupon Payments 

If this Security is not redeemed prior to the Stated Maturity Date as provided above under “Optional Redemption,”
the “Redemption Amount” of this Security will equal: 
  

	 	•	 	 if the Ending Level of the Lowest Performing Index on the Final Calculation Day (as defined below) is greater
than or equal to its Downside Threshold Level: the Face Amount; or 

  

	 	•	 	 if the Ending Level of the Lowest Performing Index on the Final Calculation Day is less than its Downside
Threshold Level: 

  

											
		 	 	 	 Face Amount x     
  
	 	  Performance Factor of the Lowest Performing   Index on the Final Calculation Day	 	 	  	

 All calculations with respect to the Redemption Amount will be rounded to the nearest one hundred-thousandth,
with five one-millionths rounded upward (e.g., 0.000005 would be rounded to 0.00001); and the Redemption Amount will be rounded to the nearest cent, with one-half cent rounded upward. 

“Index” shall mean each of the S&P 500 Index and the Russell 2000® Index. 
 The “Pricing Date” shall mean July 1,
2016. 
 The “Lowest Performing Index” on any Calculation Day will be the Index with the lowest Performance
Factor on that Calculation Day. 
 The “Performance Factor” with respect to an Index on any Calculation Day
is its Closing Level on such Calculation Day divided by its Starting Level (expressed as a percentage). 

  
 3 

 The “Starting Level” with respect to the S&P 500 Index is
2102.95, its Closing Level on the Pricing Date, and with respect to the Russell 2000® Index is 1156.770, its Closing Level on the Pricing Date. 

The “Ending Level” of an Index will be its Closing Level on the Final Calculation Day. 

The “Coupon Threshold Level” with respect to the S&P 500 Index is 1261.77, which is equal to 60% of its
Starting Level, and with respect to the Russell 2000® Index is 694.062, which is equal to 60% of its Starting Level. 

The “Downside Threshold Level” with respect to the S&P 500 Index is 1051.475, which is equal to 50% of
its Starting Level, and with respect to the Russell 2000® Index is 578.385, which is equal to 50% of its Starting Level. 

The “Closing Level” with respect to each Index on any Trading Day means the official closing level of that
Index reported by the relevant Index Sponsor on such Trading Day, as obtained by the Calculation Agent on such Trading Day from the licensed third-party market data vendor contracted by the Calculation Agent at such time; in particular, taking into
account the decimal precision and/or rounding convention employed by such licensed third-party market data vendor on such date, subject to the provisions set forth below under “—Market Disruption Events” and “—Discontinuance
of an Index; Alteration of Method of Calculation.” 
 “Index Sponsor” shall mean the sponsor or
publisher of an Index. 
 “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. 

The “Calculation Days” shall be the 1st day of each January, April, July and October, commencing October 2016
and ending April 2021, and the Final Calculation Day. If any such day is not a Trading Day with respect to either Index, that Calculation Day for each Index will be postponed to the next succeeding day that is a Trading Day with respect to each
Index. A Calculation Day is also subject to postponement due to the occurrence of a Market Disruption Event (as defined below). The “Final Calculation Day” is July 1, 2021. If a Market Disruption Event occurs or is continuing
with respect to either Index on any Calculation Day, then such Calculation Day will be postponed for each Index to the first succeeding day that is a Trading Day for each Index and on which a Market Disruption Event has not occurred and is not
continuing for either Index; however, if such first succeeding Trading Day has not occurred as of the eighth day that is a Trading Day for each Index after the originally scheduled Calculation Day, that eighth day shall be deemed to be the
Calculation Day for each Index. If a Calculation Day has been postponed to that eighth day and a Market Disruption Event occurs or is continuing with respect to either Index on that eighth day, the Calculation Agent will determine the Closing Level
of that Index on that day in accordance with the formula for and method of calculating the Closing Level of such Index last in effect prior to commencement of the Market Disruption Event, using the closing price (or, with respect to any relevant
security, if a Market Disruption Event has occurred with respect to such security, its good faith estimate of the value of such security at the Scheduled Closing Time of the Relevant Stock Exchange for such security or, if

  
 4 

 
earlier, the actual closing time of the regular trading session of such Relevant Stock Exchange) on that day of each security included in such Index. As used herein, “closing
price” means, with respect to any security on any date, the Relevant Stock Exchange traded or quoted price of such security as of the Scheduled Closing Time of the Relevant Stock Exchange for such security or, if earlier, the actual closing
time of the regular trading session of such Relevant Stock Exchange. 
 “Calculation Agent Agreement” shall
mean the Calculation Agent Agreement dated as of March 18, 2015 between the Company and the Calculation Agent, as amended from time to time. 

“Calculation Agent” shall mean the Person that has entered into the Calculation Agent Agreement with the
Company providing for, among other things, whether a Contingent Coupon Payment will be made, the Optional Redemption Price, if any, and the Redemption Amount, if any, which term shall, unless the context otherwise requires, include its successors
under such Calculation Agent Agreement. The initial Calculation Agent shall be Wells Fargo Securities, LLC. Pursuant to the Calculation Agent Agreement, the Company may appoint a different Calculation Agent from time to time after the initial
issuance of this Security without the consent of the Holder of this Security and without notifying the Holder of this Security. 
 Certain Definitions

 A “Trading Day” with respect to an Index means a day, as determined by the Calculation Agent, on
which (i) the Relevant Stock Exchanges with respect to each security underlying such Index are scheduled to be open for trading for their respective regular trading sessions and (ii) each Related Futures or Options Exchange with respect to
such Index is scheduled to be open for trading for its regular trading session. 
 The “Relevant Stock
Exchange” for any security underlying an Index means the primary exchange or quotation system on which such security is traded, as determined by the Calculation Agent. 

The “Related Futures or Options Exchange” for an Index means an exchange or quotation system where trading
has a material effect (as determined by the Calculation Agent) on the overall market for futures or options contracts relating to such Index. 

Discontinuance Of An Index; Alteration Of Method Of Calculation 

If an Index Sponsor discontinues publication of an Index, and such Index Sponsor or another entity publishes a successor or
substitute equity index that the Calculation Agent determines, in its sole discretion, to be comparable to such Index (a “Successor Equity Index”), then, upon the Calculation Agent’s notification of that determination to the
Trustee and the Company, the Calculation Agent will substitute the Successor Equity Index as calculated by the relevant Index Sponsor or any other entity for purposes of calculating the Closing Level of such Index on any date of determination. Upon
any selection by the Calculation Agent of a Successor Equity Index, the Company will cause notice to be given to the Holder of this Security. 

In the event that an Index Sponsor discontinues publication of an Index prior to, and the discontinuance is continuing on, a
Calculation Day and the Calculation Agent determines that no Successor Equity Index is available at such time, the Calculation Agent will calculate a substitute 

  
 5 

 
Closing Level for such Index in accordance with the formula for and method of calculating such Index last in effect prior to the discontinuance, but using only those securities that comprised
such Index immediately prior to that discontinuance. If a Successor Equity Index is selected or the Calculation Agent calculates a level as a substitute for such Index, the Successor Equity Index or level will be used as a substitute for such Index
for all purposes, including the purpose of determining whether a Market Disruption Event exists. 
 If on a
Calculation Day an Index Sponsor fails to calculate and announce the level of an Index, the Calculation Agent will calculate a substitute Closing Level of such Index in accordance with the formula for and method of calculating such Index last in
effect prior to the failure, but using only those securities that comprised such Index immediately prior to that failure; provided that, if a Market Disruption Event occurs or is continuing on such day with respect to such Index, then the
provisions set forth above under the definition of “Calculation Days” shall apply in lieu of the foregoing. 

If at any time the relevant Index Sponsor makes a material change in the formula for or the method of calculating an Index, or
in any other way materially modifies such Index (other than a modification prescribed in that formula or method to maintain such Index in the event of changes in constituent stock and capitalization and other routine events), then, from and after
that time, the Calculation Agent will, at the close of business in New York, New York, on each date that the Closing Level of such Index is to be calculated, calculate a substitute Closing Level of such Index in accordance with the formula for and
method of calculating such Index last in effect prior to the change, but using only those securities that comprised such Index immediately prior to that change. Accordingly, if the method of calculating an Index is modified so that the level of such
Index is a fraction or a multiple of what it would have been if it had not been modified, then the Calculation Agent will adjust such Index in order to arrive at a level of such Index as if it had not been modified. 

Market Disruption Events 

A “Market Disruption Event” with respect to an Index means any of the following events as determined by the
Calculation Agent in its sole discretion: 
  

	 	(A)	 The occurrence or existence of a material suspension of or limitation imposed on trading by the Relevant Stock
Exchanges or otherwise relating to securities which then comprise 20% or more of the level of such Index or any Successor Equity Index at any time during the one-hour period that ends at the Close of Trading on that day, whether by reason of
movements in price exceeding limits permitted by those Relevant Stock Exchanges or otherwise. 

  

	 	(B)	 The occurrence or existence of a material suspension of or limitation imposed on trading by any Related
Futures or Options Exchange or otherwise in futures or options contracts relating to such Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the one-hour period that ends at the Close of Trading on that
day, whether by reason of movements in price exceeding limits permitted by the Related Futures or Options Exchange or otherwise. 

  
 6 

	 	(C)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect transactions in, or obtain market values for, securities that then comprise 20% or more of the level of such Index or any Successor Equity Index on their Relevant Stock Exchanges at any time during
the one-hour period that ends at the Close of Trading on that day. 

	 	

	 	(D)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect transactions in, or obtain market values for, futures or options contracts relating to such Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the
one-hour period that ends at the Close of Trading on that day. 

	 	

	 	(E)	 The closure on any Exchange Business Day of the Relevant Stock Exchanges on which securities that then
comprise 20% or more of the level of such Index or any Successor Equity Index are traded or any Related Futures or Options Exchange with respect to such Index or any Successor Equity Index prior to its Scheduled Closing Time unless the earlier
closing time is announced by the Relevant Stock Exchange or Related Futures or Options Exchange, as applicable, at least one hour prior to the earlier of (1) the actual closing time for the regular trading session on such Relevant Stock
Exchange or Related Futures or Options Exchange, as applicable, and (2) the submission deadline for orders to be entered into the Relevant Stock Exchange or Related Futures or Options Exchange, as applicable, system for execution at such actual
closing time on that day. 

	 	

	 	(F)	 The Relevant Stock Exchange for any security underlying such Index or Successor Equity Index or any Related
Futures or Options Exchange fails to open for trading during its regular trading session. 

 For purposes
of determining whether a Market Disruption Event has occurred with respect to an Index: 
  

	 	(1)	 the relevant percentage contribution of a security to the level of such Index or any Successor Equity Index
will be based on a comparison of (x) the portion of the level of such Index attributable to that security and (y) the overall level of such Index or Successor Equity Index, in each case immediately before the occurrence of the Market
Disruption Event; 

  

	 	(2)	 the “Close of Trading” on any Trading Day for such Index or any Successor Equity Index means
the Scheduled Closing Time of the Relevant Stock Exchanges with respect to the securities underlying such Index or Successor Equity Index on such Trading Day; provided that, if the actual closing time of the regular trading session of any such
Relevant Stock Exchange is earlier than its Scheduled Closing Time on such Trading Day, then (x) for purposes of clauses (A) and (C) of the definition of “Market Disruption Event” above, with respect to any security
underlying such Index or 

  
 7 

	 	 
Successor Equity Index for which such Relevant Stock Exchange is its Relevant Stock Exchange, the “Close of Trading” means such actual closing time and (y) for purposes of
clauses (B) and (D) of the definition of “Market Disruption Event” above, with respect to any futures or options contract relating to such Index or Successor Equity Index, the “Close of Trading” means the latest actual
closing time of the regular trading session of any of the Relevant Stock Exchanges, but in no event later than the Scheduled Closing Time of the Relevant Stock Exchanges; 

 

	 	(3)	 the “Scheduled Closing Time” of any Relevant Stock Exchange or Related Futures or Options
Exchange on any Trading Day for such Index or any Successor Equity Index means the scheduled weekday closing time of such Relevant Stock Exchange or Related Futures or Options Exchange on such Trading Day, without regard to after hours or any other
trading outside the regular trading session hours; and 

  

	 	(4)	 an “Exchange Business Day” means any Trading Day for such Index or any Successor Equity Index
on which each Relevant Stock Exchange for the securities underlying such Index or any Successor Equity Index and each Related Futures or Options Exchange with respect to such Index or any Successor Equity Index are open for trading during their
respective regular trading sessions, notwithstanding any such Relevant Stock Exchange or Related Futures or Options Exchange closing prior to its Scheduled Closing Time. 

Calculation Agent 

The Calculation Agent will determine whether a Contingent Coupon Payment will be made, the Optional Redemption Price, if any,
and the Redemption Amount, if any. In addition, the Calculation Agent will (i) determine if adjustments are required to the Closing Level of an Index under the circumstances described in this Security, (ii) if publication of an Index is
discontinued, select a Successor Equity Index or, if no Successor Equity Index is available, determine the Closing Level of such Index under the circumstances described in this Security, and (iii) determine whether a Market Disruption Event has
occurred. 
 The Company covenants that, so long as this Security is Outstanding, there shall at all times be a Calculation
Agent (which shall be a broker-dealer, bank or other financial institution) with respect to this Security. 

All determinations made by the Calculation Agent with respect to this Security will be at the sole discretion of the
Calculation Agent and, in the absence of manifest error, will be conclusive for all purposes and binding on the Company and the Holder of this Security. 

Redemption and Repayment 

This Security is not subject to repayment at the option of the Holder hereof prior to July 8, 2021. This Security is
subject to redemption prior to July 8, 2021 as set forth under “Optional Redemption” above. This Security is not entitled to any sinking fund. 

  
 8 

 Acceleration 

If an Event of Default, as defined in the Indenture, with respect to this Security shall occur and be continuing, the
Redemption Amount (calculated as set forth in the next two sentences) of this Security may be declared due and payable in the manner and with the effect provided in the Indenture. The amount payable to the Holder hereof upon any acceleration
permitted under the Indenture will be equal to the Redemption Amount hereof calculated as provided herein, plus a portion of a final Contingent Coupon Payment, if any. The Redemption Amount and any final Contingent Coupon Payment will be calculated
as though the date of acceleration were the Final Calculation Day. The final Contingent Coupon Payment, if any, will be prorated from and including the immediately preceding Contingent Coupon Payment Date to but excluding the date of acceleration.

  
  

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] 

  
 9 

 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

  
 10 

 [Reverse of Note] 

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Lowest Performing of the S&P 500®
Index 
 and the Russell 2000® Index due July 8, 2021 

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 

  
 11 

 
time Outstanding of all series to be affected, acting together as a class. The Indenture also contains 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. Solely for the purpose of determining whether any consent, waiver, notice or other action or Act to be taken or given by the Holders of Securities pursuant to the Indenture has been given or taken by the Holders of Outstanding Securities in
the requisite aggregate principal amount, the principal amount of this Security will be deemed to be equal to the amount set forth on the face hereof as the “Face Amount” hereof. 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. 
 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 Face 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 

  
 12 

 
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 Contingent Coupon Payments, if any, and the Redemption Amount or the Optional Redemption Price, as applicable, on this Security at the times, place and rate, and in the coin or
currency, herein prescribed, except as otherwise provided in this Security. 
 No Personal Recourse 

No recourse shall be had for the payment of any Contingent Coupon Payments or the Redemption Amount or the Optional Redemption
Price, as applicable, 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. 

  
 13 

 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)

  
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 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. 

  
 15

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