Document:

Allianz Index Advantage Variable Annuity Application[Contract number ]  ®                                        Individual Owner first name  MI  Last name  Jr., Sr., III  Mailing address      Email address    City  State  ZIP code    Home telephone number          1. Annuity Registration  Ownership is [ Individual/Joint Qualified plan Custodian Trust (Include the date of the trust in the name.) UTMA/UGMA Other ]OwnerNon-individual owner name (Attach Non-Individual Ownership Form or Qualified Plan Acknowledgement Form if applicable.) Social Security Number/TIN  Street address (required if a PO Box was used for mailing address)  Joint Owner  City    State  ZIP code  Cell phone number  GenderMale Female  Date of birth (mm/dd/yyyy)    Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)    Annuitant (Complete if different from Owner.)  Street address (required if a PO Box was used for mailing address)    Relationship of Annuitant to OwnerSpouse under a legally recognized marriage    Other:                   First name  MI  Last name        Jr., Sr., III  Mailing address        Email address      City    State  ZIP code    Home telephone number    GenderMale Female  Date of birth (mm/dd/yyyy)    Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)        Relationship to OwnerSpouse under a legally recognized marriage Other:         Social Security Number/TIN      Allianz Life Insurance Company of North America  IXA-APP-01  1  [(5/2018)]  First name  MI  Last name        Jr., Sr., III  Mailing address        Email address      City    State  ZIP code    Home telephone number    City      State  ZIP code    Cell phone number  GenderMale Female  Social Security Number/TIN  Date of birth (mm/dd/yyyy)      Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)   

 

       2. Purchase Payment (This section must be completed.) Make check(s) payable to Allianz Life Insurance Company of North America (Allianz).    Include replacement forms if requiredMethod of Payment (Select all that apply)Purchase Payment enclosed with application. Total amount enclosed: $ Plan type at prior financial institution or contribution instructions:      Contribution to Roth IRA for year                   Qualified Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other   Roth (Qualified)    Roth IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment        This Contract will be funded by money requested or facilitated by Allianz with transfer forms included. If 1035 exchange or tax-qualified transfer, complete the [Authorization to Transfer Funds form].Total expected amount: $ This Contract will be funded by money requested or facilitated by Allianz when transfer forms are received at a later date. If 1035 exchange or tax-qualified transfer, complete the [Authorization to Transfer Funds form].Total expected amount: $ This Contract will be funded by money not requested or facilitated by Allianz. Total expected amount: $ Plan type at prior financial institution or contribution instructions:                      Qualified Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other   Roth (Qualified)  Contribution to Roth IRA for year     Roth IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment  3. Plan Specifics (This section must be completed to indicate how this Contract should be issued.)                Nonqualified: Qualified plans: IRA:Inherited IRA:  Nonqualified401(a) defined contribution plan  401(a) one person defined benefit plan    Traditional IRA Inherited IRA    SEP IRAInherited Roth IRA  Roth IRA  Roth IRA (conversion of existing IRA)  4. Electronic Transfer and Allocation Instructions      Yes Electronic Authorization – Allianz accepts allocation and transfer instructions by electronic notification. Electronic authorizations include, but are not limited to, requests received by telephone, fax, email, or on our website. By selecting “yes,” I am authorizing and directing Allianz to act on electronic instructions from me as well as my Financial Professional and/or anyone authorized by him/ her to transfer and allocate Contract Value among the Allocation Options. If the box is not checked, electronic instructions will be accepted only from me, the Owner. Allianz will use reasonable procedures to confirm that these electronic instructions are genuine. As long as these procedures are followed, the company and its officers, employees, representatives, and/or agents will be held harmless for any claim, liability, loss, or cost arising from unauthorized or fraudulent instructions. We reserve the right to deny any electronic transfer request or allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.]                                      IXA-APP-01  2  [(5/2018)] 

 

 5. Replacement (This section must be completed.)          Yes No Do you have existing life insurance policies or annuity contracts?Yes No Will the annuity contract applied for replace or change existing policies or contracts?Notice to Financial Professional: If the Owner does have existing life insurance policies or annuity contracts and the applicationis being written in an NAIC replacement model state, Allianz requires that you must present and read to the Owner the Replacement of Life Insurance or Annuity form and return the notice, signed by both the Financial Professional and Owner, with the Application. Replacement forms must be signed and dated on or before the application signed date.  6. Optional Death Benefit    [ Maximum Anniversary Value Death Benefit1]  7. Index Effective Date (This section must be completed.)      The Index Effective Date can be any Business Day from the Issue Date up to and including the first Quarterly Contract Anniversary. However, it cannot be the 29th, 30th, or 31st of a month. If the Index Effective Date would occur on the 29th, 30th, or 31st of a month, or on a day that is not a Business Day, we change the Index Effective Date to be the next available Business Day.If the Index Effective Date is not the Issue Date, Purchase Payments allocated to the Index Option(s) will be placed in the [AZL® Government Money Market Fund] until the Index Effective Date.[ Earliest Index Effective Date – If chosen, the earliest Index Effective Date is the Issue Date of the Contract when the initial Purchase Payment, application, and requirements are received in good order. This option is not designed to accommodate multiple Purchase Payments (e.g., 1035 exchanges, tax qualified transfers/rollovers, etc.) expected before the first Quarterly Contract Anniversary.ORDeferred Index Effective Date – If chosen, the deferred Index Effective Date is the first Quarterly Contract Anniversary. You can change the Index Effective Date prior to the first Quarterly Contract Anniversary by contacting Allianz. This option is designed to accommodate multiple Purchase Payments expected before the first Quarterly Contract Anniversary.]  8. Allocation Options              Allocations must be in whole percentages (e.g., 33.3% or dollars are not permitted) which total 100%.If Purchase Payments are received before the Index Effective Date and you select an Index Option, the following will occur:Your Purchase Payments will be placed in the [AZL® Government Money Market Fund].Then, on the Index Effective Date we will rebalance your Contract Value among your selected Allocation Options below.If additional Purchase Payments are received after the Index Effective Date and you select an Index Option, then your Purchase Payment will be placed in the [AZL® Government Money Market Fund] until the next Index Anniversary.We only allow allocations (both Purchase Payments and transfers of Contract Value) into the Index Options on the Index Effective Date and on subsequent Index Anniversaries.We only allow transfers of Index Option Value from the Index Options to the Variable Options on every [sixth Index Anniversary].Please see the current prospectus for Allocation Option requirements and allocation of additional Purchase Payments received after the Index Effective Date.Variable Options  IXA-APP-01  3  [(5/2018)]  Asset Allocation % AZL® MVP Balanced Index Strategy Fund % AZL® MVP Growth Index Strategy Fund  Cash Equivalent   % AZL® Government Money Market Fund  Index Options  Index Performance Strategy % EURO STOXX 50® % Nasdaq-100® Index % Russell 2000® Index % S&P 500® Index  Index Protection Strategy % EURO STOXX 50® % Nasdaq-100® Index % Russell 2000® Index % S&P 500® Index  Index Guard Strategy % EURO STOXX 50® % Nasdaq-100® Index % Russell 2000® Index % S&P 500® Index  Index Precision Strategy % EURO STOXX 50® % Nasdaq-100® Index % Russell 2000® Index % S&P 500® Index  Total of % (must equal 100%)[1 Carries an additional charge] 

 

 IXA-APP-01  4  [(5/2018)]  8. Allocation Options (continued)  [The S&P 500® Index is comprised of 500 stocks representing major U.S. industrial sectors.S&P® is a registered trademark of Standard & Poor’s Financial Services LLC (“S&P”). This trademark has been licensed for use by S&P Dow Jones Indices LLC. S&P marks are trademarks of S&P. These trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of North America (“Allianz”). The S&P 500® Index (“the Index”) is a product of S&P Dow Jones Indices LLC and/or its affiliates and have been licensed for use by Allianz.Allianz products are not sponsored, endorsed, sold, or promoted by S&P Dow Jones Indices LLC, Dow Jones, S&P, or any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices make no representation or warranty, express or implied, to the owners of the Allianz products or any member of the public regarding the advisability of investments generally or in Allianz products particularly or the ability of the Index and Average to track general market performance. S&P Dow Jones Indices’ only relationship to Allianz with respect to the Index and Average is the licensing of the Index and Average and certain trademarks, service marks, and/or trade names of S&P Dow Jones Indices and/or its third-party licensors. The Index and Average are determined, composed, and calculated by S&P Dow Jones Indices without regard to Allianz or the products. S&P Dow Jones Indices have no obligation to take the needs of Allianz or the owners of the products into considerationin determining, composing, or calculating the Index and Average. S&P Dow Jones Indices are not responsible for and have not participated in the design, development, pricing, and operation of the products, including the calculation of any interest payments or any other values credited to the products. S&P Dow Jones Indices have no obligation or liability in connection with the administration, marketing, or trading of products. There is no assurance that investment products based on the Index and Average will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC and its subsidiaries are not investment advisors. Inclusion of a security or futures contract within an index is not a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security or futures contract, nor is it considered to be investment advice. Notwithstanding the foregoing, CME Group Inc. and its affiliates may independently issue and/or sponsor financial products unrelated to products currently being issued by Allianz, but which may be similar to and competitive with Allianz products. In addition, CME Group Inc., an indirect minority owner of S&P Dow Jones Indices LLC, and its affiliates may trade financial products which are linked to the performance of the Index and Average. It is possible that this trading activity will affect the value of the products.S&P DOW JONES INDICES DO NOT GUARANTEE THE ADEQUACY, ACCURACY, TIMELINESS, AND/OR THE COMPLETENESS OF THE INDEX AND AVERAGE OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT THERETO. S&P DOW JONES INDICES SHALL NOT BE SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR AS TO RESULTS TO BE OBTAINED BY ALLIANZ, OWNERS OF THE PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE INDEX AND AVERAGE OR WITH RESPECT TO ANY DATA RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING LOSSES, LOST TIME, OR GOODWILL, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD-PARTY BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW JONES INDICES AND ALLIANZ OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES.][The NASDAQ-100 Index® includes 100 of the largest domestic and international non-financial securities listed on The NASDAQ Stock Market® based on market capitalization.The Product(s) is not sponsored, endorsed, sold or promoted by Nasdaq, Inc. or its affiliates (Nasdaq, with its affiliates, are referred to as the “Corporations”). The Corporations have not passed on the legality or suitability of, or the accuracy or adequacy of descriptions and disclosures relating to, the Product(s). The Corporations make no representation or warranty, express or implied to the owners of the Product(s) or any member of the public regarding the advisability of investing in securities generally or in the Product(s) particularly, or the ability of the Nasdaq-100 Index® to track general stock market performance. The Corporations’ only relationship to Allianz Life Insurance Company of North America (“Licensee”) is in the licensing of the NASDAQ®, and Nasdaq-100 Index® registered trademarks, and certain trade names of the Corporationsand the use of the Nasdaq-100 Index® which is determined, composed and calculated by NASDAQ without regard to Licensee or the Product(s). Nasdaq has no obligation to take the needs of the Licensee or the owners of the Product(s) into consideration in determining, composing or calculating the Nasdaq-100 Index®. The Corporations are not responsible for and have not participated in the determination of the timing of, prices at, or quantities of the Product(s) to be issued or in the determination or calculation of the equation by which the Product(s) is to be converted into cash. The Corporations have no liability in connection with the administration, marketing or trading of the Product(s).THE CORPORATIONS DO NOT GUARANTEE THE ACCURACY AND/OR UNINTERRUPTED CALCULATION OF THE NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY LICENSEE, OWNERS OF THE PRODUCT(S), OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL THE CORPORATIONS HAVE ANY LIABILITY FOR ANY LOST PROFITS OR SPECIAL, INCIDENTAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES, EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES.] 

 

 IXA-APP-01  5  [(5/2018)]  8. Allocation Options (continued)  [The Russell 2000® Index is an equity index that measures the performance of the 2,000 smallest companies in the Russell 3000® Index, which is made up of 3,000 of the biggest U.S. stocks. The Russell 2000® Index is constructed to provide a comprehensive and unbiased small-capbarometer and is completely reconstituted annually to ensure larger stocks do not affect the performance and characteristics of the true small-cap index.The Russell 2000® Index (the “Index”) is a trademark of Frank Russell Company (“Russell”) and has been licensed for use by Allianz Life Insurance Company of North America (“Allianz”). Allianz products are not in any way sponsored, endorsed, sold or promoted by Russell or the London Stock Exchange Group companies (“LSEG”) (together the “Licensor Parties”) and none of the Licensor Parties make any claim, prediction, warranty or representation whatsoever, expressly or impliedly, either as to (i) the results to be obtained from the use of the Index (upon which the Allianz product is based), (ii) the figure at which the Index is said to stand at any particular time on any particular day or otherwise, or (iii) the suitability of the Index for the purpose to which it is being put in connection with the Allianz product. None of the Licensor Parties have provided or will provide any financial or investment advice or recommendation in relation to the Index to Allianz or to its clients. The Index is calculated by Russell or its agent. None of the Licensor Parties shall be (a) liable (whether in negligence or otherwise) to any person for any error in the Index or (b) under any obligation to advise any person of any error therein.][The EURO STOXX 50®, Europe’s leading Blue-chip index for the Eurozone, provides a blue-chip representation of supersector leaders in the Eurozone. The index covers 50 stocks from 11 Eurozone countries: Austria, Belgium, Finland, France, Germany, Ireland, Italy, Luxembourg, the Netherlands, Portugal and Spain.STOXX Limited, Deutsche Börse Group and their licensors, research partners or data providers have no relationship to Allianz Life Insurance Company of North America (“Allianz”), other than the licensing of the EURO STOXX 50® and the related trademarks for use in connection with Allianz products.STOXX, Deutsche Börse Group and their licensors, research partners or data providers do not:sponsor, endorse, sell or promote Allianz products.recommend that any person invest in Allianz products or any other securities.have any responsibility or liability for or make any decisions about the timing, amount or pricing of Allianz products.have any responsibility or liability for the administration, management or marketing of Allianz products.consider the needs of Allianz products or the owners of Allianz products in determining, composing or calculating the EURO STOXX 50 or have any obligation to do so.STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty, and exclude any liability (whether in negligence or otherwise), in connection with the Allianz products or their performance.STOXX does not assume any contractual relationship with the purchasers of Allianz products or any other third parties.Specifically,STOXX, Deutsche Börse Group and their licensors, research partners or data providers do not give any warranty, express or implied, and exclude any liability about:The results to be obtained by Allianz products, the owner of Allianz products or any other person in connection with the use of the EURO STOXX 50 and the data included in the EURO STOXX 50;The accuracy, timeliness, and completeness of the EURO STOXX 50 and its data;The merchantability and the fitness for a particular purpose or use of the EURO STOXX 50 and its data;The performance of Allianz products generally.STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty and exclude any liability, for any errors, omissions or interruptions in the EURO STOXX 50 or its data;Under no circumstances will STOXX, Deutsche Börse Group or their licensors, research partners or data providers be liable (whether in negligence or otherwise) for any lost profits or indirect, punitive, special or consequential damages or losses, arising as a result of such errors, omissions or interruptions in the EURO STOXX 50 or its data or generally in relation to Allianz products, even in circumstances where STOXX, Deutsche Börse Group or their licensors, research partners or data providers are aware that such loss or damage may occur.The licensing Agreement between Allianz and STOXX is solely for their benefit and not for the benefit of the owners of Allianz products or any other third parties.] 

 

                                                 IXA-APP-01  6  [(5/2018)]  9. Beneficiary Designation (If additional space is needed, attach a complete list signed and dated by Owner(s).)                  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable Trust Non-individual Beneficiary name              Email    Street address        City    State    ZIP code  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable Trust Non-individual Beneficiary name              Email    Street address        City    State    ZIP code  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable Trust Non-individual Beneficiary name              Email    Street address        City    State    ZIP code 

 

 10. Financial Professional  Notice to Financial Professional: Applicable product training must be completed for the state for which this sale occurred.By signing below, the Financial Professional certifies to the following:I am FINRA registered and state licensed for variable annuity contracts in all required jurisdictions; and I provided the Owner(s) with the most current prospectus.The Owner statement regarding existing policies or annuity contracts is true and accurate to the best of my knowledge and belief.The Owner statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate to the best of my knowledge and belief.I hereby certify that I only used sales materials that were previously approved by Allianz in my presentation.I further certify that I left a copy of all sales material used during my presentation with the applicant.I have provided the Owner with all appropriate disclosure and replacement requirements prior to the completion of this application.If this is a replacement, include a copy of each disclosure statement and a list of companies involved.            11. Certification of Taxpayer Identification Number    IXA-APP-01  7  [(5/2018)]  [If you are applying for this product and/or requesting payments as a U.S. Person, the IRS requires you to agree to the following statements. If you are not a U.S. Person, you are not eligible to apply for this product.Under penalties of perjury, I certify that:The Taxpayer Identification Number shown on this form is correct or I am waiting for a number to be issued to me.I am not subject to backup withholding because:I am exempt from backup withholding, orI have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, orThe IRS has notified me that I am no longer subject to backup withholding.I am a U.S. person, andThe Foreign Account Tax Compliance Act (FATCA) code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.Check the box if the IRS has notified you that you are currently subject to backup withholding because you failed to report interest and dividends on your tax return.]                Financial Professional’s signature (Primary)          First and last name (please print)              Address            Email            Financial Professional’s signature (Secondary)          First and last name (please print)              Email                      Broker/dealer name (please print)            Authorized signature broker/dealer (if required)                        Commission options (please check one) A B C           

 

 12. Statement of Owner        [The following state requires Owners to read and acknowledge the statement for your state below.District of Columbia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.]By signing below, I, the Owner, acknowledge the applicable statement(s) mentioned above and understand and agree to the following:I received a prospectus and have determined that the variable annuity applied for is not unsuitable for my investment objectives, financial situation, and financial needs. It is a long-term commitment to meet my financial needs and goals.I understand that the Contract Value may increase or decrease depending on the investment results of the Allocation Options and that there is no guaranteed minimum Variable Account Value.To the best of my knowledge and belief, all statements and answers in this application are complete and true.No representative is authorized to modify this agreement or waive any Allianz rights or requirements.If this Contract is being funded by an indirect rollover, I have complied with the requirement that only one rollover is permitted within a one year period from all of the IRAs I own.For information on current benefit features, restrictions or charges please review with your Financial Professional.Please send me a statement of additional information. (Also available at [www.allianzlife.com])As the authorized signer, please sign your name and date below in the appropriate space or we will not be able to process your request.Signed at (City and State)Owner’s signature: Date: MM/DD/YYYYJoint Owner’s signature: Date: MM/DD/YYYYAlternate signatures, if applicableTrust: as trustee of the: Date: TRUSTEE’S SIGNATURE TRUST NAME (PRINTED) MM/DD/YYYYPower of attorney: by: Date: OWNER’S NAME (PRINTED) ATTORNEY IN FACT’S SIGNATURE(S) MM/DD/YYYY    IXA-APP-01  8  [(5/2018)] 

 

 Please submit your form through one of the options below: Email completed forms to:[variableannuity@send.allianzlife.com]ORWeb Upload:You can scan and upload your signed and completed form by logging in to your account at [Allianzlife.com]OR  Mail:[Applications that HAVE a check attached:Regular mailAllianz Life Insurance Company of North America NW 5989PO Box 1450Minneapolis, MN 55485-5989]  [Overnight mailAllianz Life Insurance Company of North America NW 59891801 Parkview DriveShoreview, MN 55126]  OR  [Applications that DO NOT HAVE a check attached:Regular mailAllianz Life Insurance Company of North America PO Box 561Minneapolis, MN 55440-0561]  [Overnight mailAllianz Life Insurance Company of North America 5701 Golden Hills DriveGolden Valley, MN 55416-1297]  OR[Fax: 763.765.7912][Any questions? Call us at 800.624.0197]    IXA-APP-01  9  [(5/2018)]Exhibit 10.26

 

PUT
OPTION AGREEMENT

 

This
PUT OPTION AGREEMENT (this “Agreement”), dated as of March 3, 2015 (the “Effective
Date”), is made by and between InterCloud Systems, Inc., a Delaware corporation (the “Company”),
and Forward Investments, LLC, a Delaware limited liability company (“Optionee”).

 

WHEREAS,
the Company has previously issued one or more convertible promissory notes to Optionee; and

 

WHEREAS,
the Company now desires to sell to Optionee a right to cause the Company to issue one or more additional convertible
promissory notes to Optionee pursuant to the terms hereinafter provided.

 

NOW,
THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties
hereto hereby agree as follows:

 

1.
Sale of Put Option. In consideration of Thirty Thousand Dollars ($30,000) payable by Optionee to the Company in immediately
available funds, which the Company acknowledges it has already been advanced and has received as of the date of this Agreement,
the Company hereby sells to Optionee an irrevocable option to require, from time to time, the Company to borrow from Optionee
(the “Put Option”) up to Eight. Million Dollars ($8,000,000) in aggregate principal amount (the “Maximum
Amount”) in One Million Dollar ($1,000,000) increments pursuant to one or more convertible promissory notes, each in
the form of Exhibit A attached hereto (each, a “Note” and, collectively, the “Notes”).
Company and Optionee agree that thirty thousand dollars represents the fair market value of the Put Option as of the Effective
Date.

 

2.
Exercise Mechanics.

 

(a)  
Optionee may exercise the Put Option from time to time by giving written notice thereof to the Company (an “Exercise
Notice”) at any time during the period commencing on the Effective Date and ending at 5:00 p.m. (New York City time)
on March 3, 2020 (“Put Option Period”). Notwithstanding anything to the contrary contained herein, during the
period of time during which the 12% convertible debentures placed by Aegis Capital on or about December 13, 2013 (the “Aegis
Notes”) remain outstanding, which period shall not be deemed to run later than July 15, 2015, Optionee shall not be
permitted to exercise the Put Option without the prior written approval of the Company, and provided further that in the event
a Fundamental Transaction occurs, the Company agrees to provide. Optionee with written approval for the Put Option to be exercised
immediately prior to the occurrence of the Fundamental Transaction. The Put Option and this Agreement shall terminate and be of
no force or effect upon written notice from Optionee to the Company indicating Optionee desires to terminate both this Agreement
and the Put Option.

 

(b)  Promptly
following its receipt of an Exercise Notice the Company shall execute and deliver a Note to Optionee for the principal amount
contained in such Exercise Notice and Optionee simultaneous with receipt of such Note, wire to Company the principal amount contained
in such Exercise Notice.

 

    

     

    

 

3. Dilution
Adjustment in Case of Fundamental. Transaction. If, at any time during the Put Option Period a Fundamental
Transaction occurs, then, at or prior to the consummation of such Fundamental Transaction, the amount of Common. Stock that
Optionee would be entitled to receive in any exercise of the Put Option shall be adjusted so that Optionee would receive for
each share that would have been issuable upon conversion of Available Principal had it been advanced by Optionee pursuant to
one or more Notes immediately prior to the occurrence of such Fundamental Transaction, the number of shares of Common Stock
of the successor or acquiring corporation or of the Company, if it is the surviving corporation, and any additional
consideration (the “Alternate Consideration”) receivable as a result of such Fundamental. Transaction by a
holder of the number of shares of Common Stock for which the Available Principal, if advanced, would have been convertible
immediately prior to such Fundamental Transaction. For purposes of any such conversion, the determination of the Conversion
Price (as defined in the Note) shall be appropriately adjusted to apply to such Alternate Consideration based on the amount
of Alternate Consideration issuable in respect of one (1) share of Common Stock in such Fundamental Transaction, and Company
shall apportion the Conversion. Price among the Alternate Consideration in a reasonable manner reflecting the relative value
of any different components of the Alternate Consideration. If holders of shares of Common Stock are given any choice as to
the securities, cash or property to be received in a Fundamental Transaction, then Optionee shall be given the same choice as
to the Alternate Consideration it receives for any Available Principal hereunder following such Fundamental Transaction, The
Company shall cause any successor entity in a Fundamental Transaction in which the Company is not the survivor to assume in
writing all of the obligations of the Company under this Agreement. In the event a Fundamental Transaction occurs, then upon
the written request of Optionee, the Company shall require the acquirer of shares of Common Stock to acquire the Put Option
for a price equal to the same consideration Optionee would have received had (i) the unexercised portion of the Put Option
been exercised immediately prior to such acquisition and (ii) the resulting Note that would have therefore been issued been
immediately converted into shares of Common Stock pursuant to the terms of the resulting Note and (iii) such converted shares
sold in such Fundamental Transaction.

 

4.
Certain Definitions. As used in this Agreement, the following capitalized terms have the following meanings:

 

“Available
Principal” means the Maximum Amount less the aggregate principal amounts outstanding under all Notes issued
hereunder on the date in question.

 

“Common
Stock” means the Company’s issued and outstanding common stock as registered under the Securities Act of 1933, as amended,
and traded on any Trading Market.

 

“Fundamental
Transaction” means any transaction or series of related transactions whereby the Company, directly or indirectly, effects
a (i) merger or consolidation of the Company with or into another Person, (ii) sale, lease, license, assignment, transfer, conveyance
or other disposition of all or substantially all of its assets, (iii) purchase offer, tender offer or exchange offer (whether
by the Company or another Person) that is completed pursuant to which holders of shares of Common Stock are permitted to sell,
tender or exchange their shares for other securities, cash or property, (iv) reclassification, reorganization or recapitalization
of the Common Stock or any compulsory share exchange pursuant to which all outstanding shares of Common Stock are effectively
converted into or exchanged for other securities, cash or property, or (v) consummation of the transactions contemplated by a
stock or securities purchase agreement or other business combination (including, without limitation, a reorganization, recapitalization,
spin-off or scheme of arrangement) with another Person whereby such other Person acquires more than 50% of the outstanding shares
of Common Stock (not including any shares of Common Stock held by the other Person or other Persons making or party to, or associated
or affiliated with the other Persons making or party to, such stock or share purchase agreement or other business combination).

 

“Person”
means an individual, a partnership, a corporation (including a business trust), a joint stock company, a limited liability
company, an unincorporated association, a joint venture or other entity or a governmental authority.

 

    	 	2	 

     

    

 

“Trading
Market” means whichever of the New York Stock Exchange, the NYSE AMEX, the NASDAQ Capital Market, the NASDAQ Global Market,
the NASDAQ Global Select Market or OTC Bulletin Board on which the Common Stock is listed or quoted for trading on the date in
question.

 

5.
Miscellaneous.

 

(a)  
Waiver and Amendment; Entire Agreement, Title Headings. No provision of this Agreement may be amended, waived or modified
except upon the written consent of the Company and Optionee. No failure on the part of Optionee to exercise, and no delay in exercising,
any right hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any right hereunder by Optionee
preclude any other or further exercise thereof or the exercise of any other right. This Agreement constitutes the entire agreement
of the Company and Optionee with respect to the matters set forth herein. Title headings used herein shall not be construed to
impart meaning to the terms of this Agreement.

 

(b)  Assignment.
Neither this Agreement nor any rights or obligations of the Company hereunder may be assigned, conveyed or transferred, in
whole or in part other than as set forth in this Agreement, The rights and obligations of the Company and Optionee under this
Agreement shall be binding upon and benefit their respective permitted successors, assigns, heirs, administrators and transferees.

 

(c)  Notices.
Any and all notices or other communications or deliveries hereunder (including any Exercise Notice) shall be in writing and
shall be deemed given and effective on the earliest of (i) the date of transmission, if such notice or communication is delivered
via email to the email address specified in this Section prior to 5:00 p.m. (New York City time) on a Trading Day, (ii) the next
Trading Day after the date of transmission, if such notice or communication is delivered via email to the email address specified
in this Section on a day that is not a Trading Day or later than 5:00 p.m. (New York City time) on any Trading Day, (iii) the
Trading Day following the date of mailing, if sent by nationally recognized overnight courier service or (iv) upon actual receipt
by the party to whom such notice is required to be given. The addresses for such communications shall be: (i) if to the Company,
to InterCloud Systems, Inc., 1030 Broad Street, Suite 102, Shrewsbury NJ 07702, Attention: Tim Larkin, email address:tlarkin@intercloudsys.com,
and (ii) if to Optionee, to the address or email address appearing in Company’s records or such other address as Optionee
may provide to the Company in accordance with this Section, with a mandatory copy of any notice to Optionee not sent by email
to be simultaneously emailed to the email address of Optionee appearing in the Company’s records with a simultaneous cc
by email to: DougShooker@postHarvard.edu.

 

(d)  Waiver
of Jury Trial. THE COMPANY, AFTER CONSULTING OR HAVING HAD THE OPPORTUNITY TO CONSULT WITH COUNSEL, KNOWINGLY, VOLUNTARILY
AND INTENTIONALLY HEREBY IRREVOCABLY WAIVES ITS RIGHT TO A TRIAL BY JURY IN ANY ACTION ARISING OUT OF THIS AGREEMENT AND THE TRANSACTIONS
CONTEMPLATED HEREUNDER.

 

(e)  Severability.
If one or more provisions of this Agreement are held to be unenforceable under applicable law, such provision(s) shall be
excluded from this Agreement and the balance of this Agreement shall be interpreted as if such provision(s) were so excluded and
shall be enforceable in accordance with its terms.

 

(f)
Governing Law; Jurisdiction. The provisions of this Agreement shall be governed by and construed in accordance with the
laws of the State of New Jersey without reference to conflict of law provisions. Any action or proceeding in connection with this
Agreement shall be brought in any court of record of the State of New Jersey or the United States in such state, and the parties
hereto irrevocably consent to and confer personal jurisdiction of such court over them by such court.

 

[Signature
page follows.]

 

    	 	3	 

     

    

 

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

 

	 	COMPANY:
	 	 	 
	 	InterCloud Systems, Inc.
	 	 	 
	 	By:	/s/ Timothy A. Larkin

	 	Name:	Timothy A. Larkin
	 	Title:	CFO
	 	 	 
	 	OPTIONEE:
	 	 	 
		Forward Investments, LLC
	 	 	 
	 	By:	/s/ Douglas Shooker
	 	Name:	Douglas Shooker
	 	Title:	Manager

 

 

[SIGNATURE
PAGE TO PUT OPTION AGREEMENT]

 

    	 	4	 

     

    

 

Exhibit
A

 

Form of Note

 

    

     

    

 

Exhibit
A

 

THIS
CONVERTIBLE PROMISSORY NOTE (THIS “NOTE”) AND THE SECURITIES ISSUABLE UPON CONVERSION HEREOF HAVE NOT
BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”), APPLICABLE STATE SECURITIES
LAWS, OR APPLICABLE LAWS OF ANY FOREIGN JURISDICTION. THIS NOTE AND SUCH SECURITIES HAVE BEEN ACQUIRED FOR INVESTMENT AND NOT
WITH A VIEW TO DISTRIBUTION OR RESALE, AND MAY NOT BE OFFERED, SOLD, PLEDGED, HYPOTHECATED, RENOUNCED OR OTHERWISE TRANSFERRED
IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT UNDER THE ACT AND ANY APPLICABLE STATE SECURITIES LAWS AND IN THE ABSENCE
OF COMPLIANCE WITH APPLICABLE LAWS OF ANY FOREIGN JURISDICTION, OR THE AVAILABILITY OF AN EXEMPTION FROM THE REGISTRATION PROVISIONS
OF THE ACT AND APPLICABLE STATE SECURITIES LAWS.

 

Convertible
promissory note

 

	$[PRINCIPAL
    AMOUNT] 	[DATE
    OF ISSUANCE]

 

For
value received,
pursuant to that certain Put Option Agreement dated as of October 22, 2014 and thereafter amended by and between InterCloud
Systems, Inc., f/k/a Genesis Group Holdings, Inc., a Delaware corporation with a place of business at 1030 Broad Street, Suite
102, Shrewsbury, New Jersey 07702 (“Company”), and Forward Investments, LLC, a Delaware limited liability
company, together with its assignees, transferees and successors in interest (collectively, “Holder”), and
an exercise notice delivered by Holder thereunder, Company promises to pay to the order of Holder in lawful money of the United
States of America the principal sum of $[PRINCIPAL AMOUNT], together with 10% interest per annum on such principal
sum (the “Interest Rate”), compounded daily. All unpaid principal, together with any accrued and unpaid interest,
and all expenses, fees and other amounts payable hereunder, shall be due and payable on the earliest of (i) the Maturity Date,
as defined below, (ii) the date on which such amounts are due and payable upon or after the occurrence of an Event of Default,
as defined below, provided that prior to repaying this Note, the Company shall obtain from Holder the written statement of whether
Holder chooses to be repaid or waive such default (in which case the Note would remain outstanding) or convert this Note pursuant
to the conversion provisions in Section 6 below and Company shall implement such choice or (iii) the date on which such
amounts are converted in accordance with Section 6 below. The Maturity Date for this Note (the “Maturity Date”)
shall initially be [30 MONTHS FROM DATE OF ISSUANCE], provided that Holder, in its sole discretion, may at any time on
or prior to the occurrence of the Maturity Date then in effect, extend such date to any date which is on or prior to [48 MONTHS
FROM DATE OF ISSUANCE], such extension to be evidenced by the written notice thereof to be delivered to the Company by Holder,
and Holder shall be permitted to perform any number of extensions.

 

    	 	A-1	 

     

    

 

This
Note is subject to the terms, conditions and provisions set forth below:

 

1.  Definitions.
As used in this Note, the following capitalized terms have the following meanings:

 

“Common
Stock” means Company’s issued and outstanding common stock as registered under the Securities Act and traded on any Trading
Market.

 

“Conversion
Amount” has the meaning given in Section 6 hereof.

 

“Conversion Notice” has the meaning given
in Section 6 hereof.

 

“Conversion
Price” has the meaning given in Section 6 hereof. 

 

“Event of Default” has the meaning given
in Section 4 hereof.

 

“Fundamental
Transaction” means any transaction or series of related transactions whereby the Company, directly or indirectly, effects
a (i) merger or consolidation of the Company with or into another Person, (ii) sale, lease, license, assignment, transfer, conveyance
or other disposition of all or substantially all of its assets, (iii) purchase offer, tender offer or exchange offer (whether
by the Company or another Person) that is completed pursuant to which holders of shares of Common Stock are permitted to sell,
tender or exchange their shares for other securities, cash or property, (iv) reclassification, reorganization or recapitalization
of the Common Stock or any compulsory share exchange pursuant to which all outstanding shares of Common Stock are effectively
converted into or exchanged for other securities, cash or property, or (v) consummation of the transactions contemplated by a
stock or securities purchase agreement or other business combination (including, without limitation, a reorganization, recapitalization,
spin-off or scheme of arrangement) with another Person whereby such other Person acquires more than 50% of the outstanding shares
of Common Stock (not including any shares of Common Stock held by the other Person or other Persons making or party to, or associated
or affiliated with the other Persons making or party to, such stock or share purchase agreement or other business combination).

 

“Maximum
Rate” has the meaning given in Section 2 hereof.

 

“New
Note” has the meaning given in Section 8 hereof.

 

“Note Register” has the meaning given in Section
8 hereof.

 

“Obligations”
shall mean and include any and all loans, advances, debts, liabilities and obligations, howsoever arising, owed by Company
to Holder of every kind and description (whether or not evidenced by any note or instrument and whether or not for the payment
of money), now existing or hereafter arising under or pursuant to the terms of this Note.

 

“Person” shall
mean and include an individual, a partnership, a corporation (including a business trust), a joint stock company, a limited
liability company, an unincorporated association, a joint venture or other entity or a governmental authority.

 

“Securities
Act” means the Securities Act of 1933, as amended.

 

“Trading
Day” means (i) a day on which the Common Stock is traded on a Trading Market, or (ii) if the Common Stock is not quoted
on a Trading Market, a day on which the Common Stock is quoted in the over-the-counter market as reported by the Pink Sheets,
LLC (or any similar organization or agency succeeding to its functions of reporting prices).

 

    	 	A-2	 

     

    

 

“Trading
Market” means whichever of the New York Stock Exchange, the NYSE AMEX, the NASDAQ Capital Market, the NASDAQ Global Market,
the NASDAQ Global Select Market, or OTC Bulletin Board on which the Common Stock is listed or quoted for trading on the date in
question.

 

2.  Interest;
Maximum Rate. Interest on this Note shall accrue at the Interest Rate, beginning on the date hereof, and be payable
semi-annually in arrears on each June 30 and December 31, commencing on [June 30] [December 31],
20[    ], provided that prior to paying Holder any interest in cash the Company shall first obtain
Holder’s election of whether it chooses to convert such interest payment into shares of Common Stock pursuant to
Section 6 herein or receive such interest payment in cash. Any amounts not paid when due under this Note shall accrue
interest at the rate of 20% per annum until such past due amounts have been paid in full. It is expressly
agreed and provided that the total liability of Company under this Note for payments in the nature of interest shall not
exceed the maximum lawful rate authorized under applicable law (the “Maximum Rate”), and, without limiting
the foregoing, in no event shall any rate of interest or default interest, or both of them, when aggregated with any other
sums in the nature of interest that Company may be obligated to pay under this Note exceed such Maximum Rate. It is
agreed that if the maximum contract rate of interest allowed by law and applicable to this Note is increased or decreased by
statute or any official governmental action subsequent to the date hereof, the new maximum contract rate of interest allowed
by law will be the Maximum Rate applicable to this Note from the effective date forward, unless such application is precluded
by applicable law. If under any circumstances whatsoever, interest in excess of the Maximum Rate is paid by Company to Holder
with respect to indebtedness evidenced by this Note, such excess shall be applied by Holder to all other unpaid portions of
the Obligations or be refunded to Company at the election of Holder.

 

3.  No
Prepayment; Order of Payments. This Note may not be prepaid in full or in part without the prior written consent of Holder.
All payments received hereunder shall be applied first to the payment of accrued interest and any fees or expenses payable hereunder
and the balance applied to the unpaid principal balance then outstanding.

 

4.  Events
of Default. The occurrence of any of the following shall constitute an “Event of Default” under this Note:

 

(a)  Failure
to Pay. Company shall fail to pay when due any principal, interest, expenses, fees and other amounts payable hereunder on
the applicable due date;

 

(b)  Failure
to Perform. Company shall fail to perform any of its obligations under this Note when due;

 

(c)  Breach.
Any of the representations made by Company in this Note shall be false or misleading in any material respect;

 

    	 	A-3	 

     

    

 

(d)  Change
of Control. Company (i) shall initiate or participate in any Fundamental Transactions or (ii) is subject to the acquisition
in one or more related transactions by any Person or “group” of Persons (as such term is defined in Section 13(d) and
14(d) of the Act, and the related regulations) who have expressed intent to acquire more than 50% of the total voting power of
outstanding voting securities of Company;

 

(e)  No
Listing. Shares of Common Stock shall not be listed or quoted or are otherwise suspended from trading on a Trading Market
for a period of five consecutive Trading Days;

 

(f)  Voluntary
Bankruptcy or Insolvency Proceedings. Company shall commence a voluntary case or other proceeding seeking liquidation, reorganization
or other relief with respect to itself or its debts under any bankruptcy, insolvency or other similar law now or hereafter in
effect, including without limitation, any assignment for the benefit of its creditors or consent to any such relief or to the
appointment of or taking possession of its property by any official in an involuntary case or other proceeding commenced against
it;

 

(g)  Involuntary
Bankruptcy or Insolvency Proceedings. Proceedings for the appointment of a receiver, trustee, liquidator or custodian of Company
or of all or a substantial part of the property thereof, or an involuntary case or other proceedings seeking liquidation, reorganization
or other relief with respect to Company or the debts thereof under any bankruptcy, insolvency or other similar law now or hereafter
in effect shall be commenced and an order for relief entered or such proceeding shall not be dismissed or discharged within 45
days of commencement; or

 

(h)  Other
Obligations. An event of default shall occur under any contractual obligation of Company (other than under this Note), and
such event of default (i) involves the failure to make any payment, whether of principal, interest or otherwise, and whether due
by scheduled maturity, required prepayment, acceleration, demand or otherwise, in respect of any indebtedness of Company, or (ii)
causes (or permits any holder of such indebtedness or a trustee to cause) such indebtedness or a portion thereof to become due
prior to its stated maturity or prior to its regularly scheduled date of payment.

 

5.  Rights
of Holder upon Default. Upon the occurrence and during the continuance of an Event of Default, Holder may, by written notice
to Company, declare all outstanding Obligations due hereunder to be immediately due and payable without presentment, demand, protest
or any other notice of any kind, all of which are hereby expressly waived. In addition to the foregoing remedies, upon the occurrence
of any Event of Default, Holder may exercise any other right power or remedy permitted to it by law, either by suit in equity
or by action at law, or both. Upon the occurrence of any Event of Default, Holder may in its sole discretion choose to waive such
default and keep this Note outstanding pursuant to its terms herein.

 

    	 	A-4	 

     

    

 

6.  Conversion.
Without the prior written consent of Holder, Company may not convert all or any portion of the Note under any circumstances.
At any time, Holder may convert any or all of the outstanding principal amount and/or any and all accrued interest, expenses,
fees and other amounts then due and payable under this Note (collectively, the “Conversion Amount”),
including before, on or after the occurrence of any Event of Default, on at least one Trading Day prior written notice to Company
(the “Conversion Notice”), into that number of shares of Common Stock calculated by the following formula:

 

Conversion
Amount/Conversion Price, rounded up to the nearest whole number.

 

The
“Conversion Price” shall be the lower of (i) $6.36 and (ii) the lowest sale price, exercise price or conversion
price (the “Diluted Price”) at which the Company sells or issues shares of Common Stock, or any other securities,
warrants or convertible securities at any date between the date of this Note and the conversion or repayment of this Note provided
that this shall not be deemed to include penny warrants provided to parties as consideration for transactions and (iii) $2.35,
and further provided that for the period of time during which the 12% convertible debentures placed by Aegis Capital on or about
December 13, 2013 (the “Aegis Notes”) remain outstanding, which period shall not be deemed to run later than
July 15, 2015, in no event shall the Conversion Price be lowered pursuant to (ii) or (iii) if the effect of such Conversion price
reduction would lower the then existing conversion price applicable to the Aegis Notes. The Conversion Price shall, however, not
be lowered to any Diluted Price unless the Company shall first have obtained shareholder approval, to the extent such approval
is necessary (“Shareholder Approval”), for clause (ii) of this paragraph which permits the lowering of the Conversion
Price to the Diluted Price (the “Clause (ii) Protection”). Upon the request of Holder, the Company will seek at the
Company’s expense to obtain Shareholder Approval to provide Holder with the Clause (ii) Protection. However, for the period
of time that Shareholder Approval for the Clause (ii) Protection has not been obtained, the Clause (ii) Protection shall not apply.

 

To
the extent that conversion of this Note into an amount of Company common stock in excess of 19.99% of the total number of issued
and outstanding shares of Company common stock would require shareholder approval pursuant to any Nasdaq regulation applicable
to the Company, Holder agrees that the number of shares of common stock of the Company that may be acquired by Holder upon any
conversion of this Note shall be limited to the extent necessary to ensure that, following such conversion, the total number of
shares of common stock of the Company then beneficially owned by Holder and its owner does not exceed 19.99% of the total number
of issued and outstanding shares of common stock of the Company (including for such purpose the shares of common stock of the
Company issuable upon such conversion). This 19.99% provision shall be null and void if shareholder approval is obtained for any
such conversion that would exceed 19.99% and the Company agrees to seek at its own expense to obtain shareholder approval for
any conversion that would exceed 19.99% upon Holder’s request that it do so. Notwithstanding anything to the contrary herein,
this provision shall not restrict the number of shares of common stock of the Company which Holder or its owner may receive or
beneficially own through conversion of this Note or otherwise in order to determine the amount of securities or other consideration
that Holder may receive upon the occurrence of a Fundamental Transaction. In the avoidance of doubt, if, for example, a Fundamental
Transaction were to occur and Holder wished to convert this Note and sell the converted shares into such Fundamental Transaction,
Holder shall be permitted to convert without any 19.99% limitation.

 

    	 	A-5	 

     

    

 

On
conversion, Holder shall surrender this Note, duly endorsed, at the principal corporate office of Company along with written
notice to Company of Holder’s election to convert a stated portion of the Conversion Amount, and shall set forth the name or
names in which the certificate or certificates for shares of Common Stock are to be issued. Company shall thereafter issue
and deliver at such office to Holder a certificate or certificates for the number of shares of Common Stock to which Holder
shall be entitled upon conversion, together with any other securities and property to which Holder is entitled upon such
conversion under the terms of this Note, including but not limited to a New Note (as hereinafter defined) reflecting the
amount of the original Note that is not subject to the Conversion Notice. The conversion shall be deemed to have been made
immediately prior to the close of business on the date of the Conversion Notice, and the Person or Persons entitled to
receive the shares of Common Stock upon such conversion shall be treated for all purposes as the record holder or holders of
such shares of Common Stock as of such date.

 

The
Conversion Price shall be adjusted in the event of any of the following occurrences:

 

a)  Stock
Dividends and Stock Splits. If Company, at any time while this Note is outstanding: (i) pays a stock dividend or otherwise
makes a distribution or distributions payable in shares of Common. Stock on shares of Common Stock or any Common Stock equivalents
(which, for avoidance of doubt, shall not include any shares of Common Stock issued by the Company upon conversion of, or payment
of interest on, the Note), (ii) subdivides outstanding shares of Common Stock into a larger number of shares, (iii) combines (including
by way of a reverse stock split) outstanding shares of Common Stock into a smaller number of shares or (iv) issues, in the event
of a reclassification of shares of the Common Stock, any shares of capital stock of the Company, then the Conversion Price shall
be multiplied by a fraction of which the numerator shall be the number of shares of Common Stock outstanding immediately before
such event, and of which the denominator shall be the number of shares of Common Stock outstanding immediately after such event.
Any adjustment made pursuant to this Section shall become effective immediately after the record date for the determination of
stockholders entitled to receive such dividend or distribution and shall become effective immediately after the effective date
in the case of a subdivision, combination or re-classification.

 

b)  Subsequent
Rights Offerings. If Company, at any time while this Note is outstanding, shall issue rights, options or warrants to all holders
of shares of Common Stock (and not to Holder) entitling them to subscribe for or purchase warrants, securities or other property
pro rata to all or substantially all of the record holders of any class of Common Stock (the “Purchase Rights”),
then Holder will be entitled to acquire, upon the terms applicable to such Purchase Rights, the aggregate Purchase Rights
which Holder could have acquired if Holder had held the number of shares of Common Stock acquirable upon complete conversion of
this Note (without taking into account any limitations or restrictions on the convertibility of this Note) immediately before
the date on which a record is taken for the grant, issuance or sale of such Purchase Rights, or, if no such record is taken, the
date as of which the record holders of shares of Common Stock are to be determined for the grant, issue or sale of such Purchase
Rights.

 

    	 	A-6	 

     

    

 

c)  Pro
Rata Distributions. If Company, at any time while this Note is outstanding, shall distribute to all holders of shares of
Common Stock (and not to Holder) evidence of its indebtedness or assets (including cash and cash dividends) or rights or
warrants to subscribe for or purchase any security other than shares of Common Stock, then in each such case the Conversion
Price shall be adjusted by multiplying the Conversion Price in effect immediately prior to the record date fixed for
determination of stockholders entitled to receive such distribution by a fraction of which the denominator shall be the
closing price per share of Common Stock determined as of the record date mentioned above, and of which the numerator shall be
such closing price per share on such record date less the then per share fair market value at such record date of the portion
of such assets or evidence of indebtedness or rights or warrants so distributed applicable to one outstanding share of the
Common Stock as determined by the Board of Directors in good faith. In either case the adjustments shall be described in a
statement provided to Holder of the portion of assets or evidences of indebtedness so distributed or such subscription rights
applicable to one (1) share of Common Stock. Such adjustment shall be made whenever any such distribution is made and shall
become effective immediately after the record date mentioned above.

 

d)  Fundamental
Transaction. If, at any time while this Note is outstanding a Fundamental Transaction occurs, then, upon any subsequent
conversion of this Note, Holder shall have the right to receive, for each share that would have been issuable upon such
conversion immediately prior to the occurrence of such Fundamental Transaction, the number of shares of Common Stock of the
successor or acquiring corporation or of the Company, if it is the surviving corporation, and any additional consideration
(the “Alternate Consideration”) receivable as a result of such Fundamental Transaction by a holder of the
number of shares of Common Stock for which this Note is convertible immediately prior to such Fundamental Transaction
(without regard to any limitations on the conversion of this Note). For purposes of any such conversion, the determination of
the Conversion Price shall be appropriately adjusted to apply to such Alternate Consideration based on the amount of
Alternate Consideration issuable in respect of one (1) share of Common Stock in such Fundamental Transaction, and. Company
shall apportion the Conversion Price among the Alternate Consideration in a reasonable manner reflecting the relative value
of any different components of the Alternate Consideration. If holders of shares of Common Stock are given any choice as to
the securities, cash or property to be received in a Fundamental Transaction, then Holder shall be given the same choice as
to the Alternate Consideration it receives upon any conversion of this Note following such Fundamental Transaction. Company
shall cause any successor entity in a Fundamental Transaction in which Company is not the survivor (the “Successor
Entity”) to assume in writing all of the obligations of Company under this Note in accordance with the provisions of
this Section and shall, at the option of Holder, deliver to Holder in exchange for this Note a security of the Successor
Entity evidenced by a written instrument substantially similar in form and substance to this Note which is convertible for a
corresponding number of shares of capital stock of such Successor Entity (or its parent entity) equivalent to the shares of
Common Stock acquirable and receivable upon conversion of this Note (without regard to any limitations on the conversion
of this Note) at the closing of such Fundamental Transaction, and with a conversion price which applies the conversion price
hereunder to such shares of capital stock (but taking into account the relative value of the shares of Common Stock pursuant
to such Fundamental Transaction and the value of such shares of capital stock, such number of shares of capital stock and
such conversion price being for the purpose of protecting the economic value of this Note immediately prior to the
consummation of such Fundamental Transaction). Upon the occurrence of any such Fundamental Transaction, the Successor Entity
shall succeed to, and be substituted for (so that from and after the date of such Fundamental Transaction, the provisions of
this Note referring to the “Company” shall refer instead to the Successor Entity), and may exercise every right and
power of the Company and shall assume all of the obligations of the Company under this Note with the same effect as if such
Successor Entity had been named as the Company herein. In the event a Fundamental. Transaction occurs, then upon the written
request of the Holder, Company shall require the acquirer of shares of Common Stock to acquire this Note for a price equal to
the same consideration Holder would have received had the Note been fully converted immediately prior to such acquisition,
without regard to any 19.99% or other limitation, and the converted shares sold in such transaction.

 

    	 	A-7	 

     

    

 

7.  No
Charges for Conversion. Issuance of certificates for shares of Common Stock upon a conversion pursuant to Section 6 or
otherwise in respect of this Note shall be made without charge to Holder for any issue or transfer tax, withholding tax, transfer
agent fee, legal opinion and attorney fees, or other incidental tax or expense in respect of the issuance of such certificate,
all of which taxes and expenses shall be paid by Company.

 

8.  Note
Registration; New Notes for Transfers and Partial Conversions. Company shall register this Note upon records maintained by
Company for that purpose (the “Note Register”) in the name of Holder. Company may deem and treat Holder as the
absolute owner hereof for the purpose of any conversion hereof, and for all other purposes, absent actual notice to the contrary
from Holder. Company shall register the conversion of all or any portion of this Note pursuant to Section 6 in the Note
Register upon surrender of this Note to Company and shall issue a new convertible promissory note, in substantially the form of
this Note (each, a “New Note”), evidencing the remaining portion of this. Note not so converted pursuant to Section
6, if any, shall be issued to Holder.

 

9.  Representations
and Warranties of Company. Company represents and warrants to Holder that:

 

(a)  Due
Incorporation, Qualification, etc. Company (i) is a corporation duly incorporated, validly existing and in good standing under
the laws of the State of Delaware; (ii) has the power and authority to own, lease and operate its properties and carry on its
business as now conducted; and (iii) is duly qualified, licensed to do business and in good standing as a foreign corporation
in each jurisdiction where the failure to be so qualified or licensed could reasonably be expected to have a material adverse
effect on the assets, liabilities, condition (financial or otherwise) or business of Company.

 

(b)  Authority.
The execution, delivery and performance by Company of this Note and the consummation of the transactions contemplated hereby:
(i) are within the power of Company; and (ii) have been duly authorized by all necessary actions on the part of Company.

 

(c)  Enforceability.
This Note has been duly executed and delivered by Company and constitutes a legal, valid and binding obligation of Company,
enforceable against Company in accordance with its terms, except as limited by bankruptcy, insolvency or other laws of general
application relating to or affecting the enforcement of creditors’ rights generally and general principles of equity.

 

    	 	A-8	 

     

    

 

(d)  Reservation
of Shares. Company covenants that it will at all times reserve and keep available out of the aggregate of its authorized
but unissued and otherwise unreserved shares of Common Stock, solely for the purpose of enabling it to issue the shares which
are issuable and deliverable upon the conversion this entire Note (taking into account any adjustments therefor), free from
preemptive rights or any other contingent purchase rights of Persons other than Holder. Company covenants that all shares so
issuable and deliverable shall, upon issuance in accordance with the terms hereof, be duly and validly authorized, issued and
fully paid and non-assessable.

 

(e)  Private
Sale. Assuming that Holder has purchased this Note for investment purposes and not with a view to its distribution, the issuance
of this Note does not require registration under the Securities Act or any state securities laws.

 

(f)  Issuance
of Note. Neither the issuance nor the delivery of this Note is subject to any preemptive right of any stockholder of Company
or to any right of first refusal or other similar right in favor of any person or entity which has not been waived.

 

(g)  Governmental
Approvals. Company is not required to obtain any order, consent, approval or authorization of, or to make any declaration
or filing with, any governmental agency (including under any state securities or “blue sky” laws) in connection with
the execution and delivery of this Note, or the consummation of the transactions contemplated hereby.

 

(h)  Financial
Condition. Company is not entering into the arrangements contemplated by this Note with actual intent to hinder, delay or
defraud either present or future creditors. On the date hereof on a pro forma basis after giving effect to the transactions contemplated
and to all debts incurred or to be created in connection herewith, the present fair salable value of the assets of Company (on
a going concern basis) will exceed the probable liabilities of Company on its debts (including its contingent obligations).

 

10.  Notice
of Corporate Events. If Company (i) declares a dividend or any other distribution of cash, securities or other property in
respect of its shares of Common Stock, including without limitation any granting of rights or warrants to subscribe for or purchase
any capital stock of Company or any subsidiary thereof, (ii) authorizes and publicly approves, or enters into any agreement contemplating
or solicits shareholder approval for any Fundamental Transaction or (iii) publicly authorizes the voluntary dissolution, liquidation
or winding up of the affairs of Company, then Company shall deliver to Holder a notice describing the material terms and conditions
of such transaction, at least 20 Trading Days prior to the applicable record or effective date on which a Person would need to
hold Common Stock in order to participate in or vote with respect to such transaction, and Company will take all steps reasonably
necessary in order to insure that Holder is given the practical opportunity to convert this Note prior to such time so as to participate
in or vote with respect to such transaction.

 

11.  No
Rights or Liabilities as a Stockholder. This Note does not by itself entitle Holder to any voting rights or other rights as
a stockholder of Company, except as otherwise set forth herein. In the absence of conversion of this Note, no provisions of this
Note, and no enumeration herein of the rights or privileges of Holder, shall cause Holder to be a stockholder of Company for any
purpose.

 

    	 	A-9	 

     

    

 

12.  Waiver
and Amendment; Entire Agreement. No provision of this Note may be amended, waived or modified except upon the written consent
of Company and Holder. No failure on the part of Holder to exercise, and no delay in exercising, any right hereunder shall operate
as a waiver thereof; nor shall any single or partial exercise of any right hereunder by Holder preclude any other or further exercise
thereof or the exercise of any other right. This Note constitutes the entire agreement of Company and Holder with respect to the
matters set forth herein.

 

13.  Assignment.
Neither this Note nor any rights or obligations of Company hereunder may be assigned, conveyed or transferred, in whole or
in part other than as set forth in this Note. The rights and obligations of Company and Holder under this Note shall be binding
upon and benefit their respective permitted successors, assigns, heirs, administrators and transferees.

 

14.  Notices.
Any and all notices or other communications or deliveries hereunder (including any Conversion Notice) shall be in writing
and shall be deemed given and effective on the earliest of (i) the date of transmission, if such notice or communication is delivered
via email to the email address specified in this Section prior to 5:00 p.m. (New York City time) on a Trading Day, (ii) the next
Trading Day after the date of transmission, if such notice or communication is delivered via email to the email address specified
in this Section on a day that is not a Trading Day or later than 5:00 p.m. (New York City time) on any Trading Day, (iii) the
Trading Day following the date of mailing, if sent by nationally recognized overnight courier service or (iv) upon actual receipt
by the party to whom such notice is required to be given. The addresses for such communications shall be: (i) if to Company, to
InterCloud Systems, Inc., 1030 Broad Street, Suite 102, Shrewsbury, NJ 07702, Attention: Tim Larkin, email address: tlarkin@intercloudsys.com, and (ii) if to Holder, to the address or email address appearing on Company’s shareholder records or Note Register or such
other address as Holder may provide to Company in accordance with this Section 14, with a mandatory copy of any notice
to Holder not sent by email to be simultaneously emailed to the email address of Holder appearing on the Company’s Note Register
with a simultaneous cc by email to: DougShooker@post.Harvard.edu.

 

15.  Fees
and Expenses. Company agrees to pay to Holder, in addition to the principal amount due hereunder, all fees and expenses (including
court costs and legal fees and expenses) incurred or expended by Holder in connection with the negotiation, administration and
enforcement of this Note.

 

16.  Waiver
of Jury Trial. COMPANY, AFTER CONSULTING OR HAVING HAD THE OPPORTUNITY TO CONSULT WITH COUNSEL, KNOWINGLY, VOLUNTARILY AND
INTENTIONALLY HEREBY IRREVOCABLY WAIVES ITS RIGHT TO A TRIAL BY JURY IN ANY ACTION ARISING OUT OF THIS NOTE AND THE TRANSACTIONS
CONTEMPLATED HEREUNDER.

 

17.  Headings.
The headings herein are for convenience only, do not constitute a part of this Note and shall not be deemed to limit or affect
any of the provisions hereof.

 

18.  Severability. If
one or more provisions of this Note are held to be unenforceable under applicable law, such provision(s) shall be
excluded from this Note and the balance of the Note shall be interpreted as if such provision(s) were so excluded and shall
be enforceable in accordance with its terms.

 

19.  Governing
Law; Jurisdiction. The provisions of this Note shall be governed by and construed in accordance with the laws of the State
of New Jersey without reference to conflict of law provisions. Any action or proceeding in connection with this Agreement shall
be brought in any court of record of the State of New Jersey or the United States in such state, and the parties hereto irrevocably
consent to and confer personal jurisdiction of such court over them by such court.

 

20.  Registration
Rights. The Company hereby grants to Holder the right to require the Company at the Company’s expense to register under the
Securities Act within sixty days of the conversion of any portion of this Note any and all shares of Common Stock issuable to
Holder on the conversion of any portion of this Note.

 

Signatures
appear on the following page

 

    	 	A-10	 

     

    

 

In
witness whereof, the Company has caused this
Note to be issued as of the date first written above.

 

	 	Intercloud systems, inc.
	 	 	 
	 	By:	
	 	Name:	        
	 	Title:	

  

 

 

[Signature
Page to Convertible Promissory Note – InterCloud/Forward Investments, LLC]

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