Common use of Related Parties Clause in Contracts

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ____________________________________________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Dxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ____________________________________________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-): 2. Will any other person or persons have a beneficial interest in the Sharesto Securities to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsSecurities. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsSecurities. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________:

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto shares of Common Stock to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. o Yes o No The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Unitsshares of Common Stock. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Unitsshares of Common Stock. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ _________________________________ DEFINITION OF “INVESTMENTS”

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(sivestor(s): _______________________________-___________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxxxxxxx at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: _________________________________________________ _________________________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: _________________________________________________ By: ___________________________________________ _________________________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? ¨ Yes ¨ No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: __________________________________________________________________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: _______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? ¨ Yes ¨ No If either question above was answered “Yes”, please contact Xxxxx Xxxxxxxxxx at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: By:

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx & Associates for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________________________________ _________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact Davxx Xxxxx, Xsq. at (510) 000-0000 xxr additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: (Name of Entity) By: (Signature) Annex 1 DEFINITION OF “INVESTMENTS”

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-__________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ___________________________________________________________ ____________________________________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: _____________________________________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq., attorney for the Company, (000) 000-0000, for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) ___________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-___________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: _______________________________________________________ _______________________________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: _______________________________________________________ By: __________________________________________________ ___________________________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ______________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ Xxxx X. Xxxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Units to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx & Associates for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Units to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx & Associates for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ _______________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Purchased Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact Xxxxx Xxxxx, Esq. at (000) 000-0000 or xxxxx@xxxxxxxxxxxxxxxx.xxx for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Purchased Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Purchased Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: By: (Signature) (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: __________________________________ _______________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact Davxx Xxxxx, Xsq. at (510) 000-0000 xxr additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: (Name of Entity) By: (Signature) (Print Name and Title) Annex 1 DEFINITION OF “INVESTMENTS”

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes * No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Units to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes * No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx & Associates for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: By: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ____________________________________________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ (Signature) (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact _______________ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________________________________________________________________________________________________________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: _______________________________________________________________________________________ ________________________________ 2. Will any other person or persons have a beneficial interest in the Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: (Signature) (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: (Name of Entity) By: (Signature) (Print Name and Title) (1) Securities, other than securities of an issuer that controls, is controlled by, or is under common control with, the Investor that owns such securities, unless the issuer of such securities is: (i) An investment company or a company that would be an investment company but for the exclusions or exemptions provided by the Investment Company Act, or a commodity pool; or (ii) A Public Company (as defined below); (iii) A company with shareholders’ equity of not less than $50 million (determined in accordance with generally accepted accounting principles) as reflected on the company’s most recent financial statements, provided that such financial statements present the information as of a date within 16 months preceding the date on which the Investor acquires Shares; (2) Real estate held for investment purposes; (3) Commodity Shares (as defined below) held for investment purposes; (4) Physical Commodities (as defined below) held for investment purposes; (5) To the extent not securities, Financial Contracts (as defined below) entered into for investment purposes; (6) In the case of an Investor that is a company that would be an investment company but for the exclusions provided by Section 3(c)(1) or 3(c)(7) of the Investment Company Act, or a commodity pool, any amounts payable to such Investor pursuant to a firm agreement or similar binding commitment pursuant to which a person has agreed to acquire an interest in, or make capital contributions to, the Investor upon the demand of the Investor; and (7) Cash and cash equivalents held for investment purposes. Real Estate that is used by the owner or a Related Person (as defined below) of the owner for personal purposes, or as a place of business, or in connection with the conduct of the trade or business of such owner or a Related Person of the owner, will NOT be considered Real Estate held for investment purposes, provided that real estate owned by an Investor who is engaged primarily in the business of investing, trading or developing real estate in connection with such business may be deemed to be held for investment purposes. However, residential real estate will not be deemed to be used for personal purposes if deductions with respect to such real estate are not disallowed by section 280A of the Internal Revenue Code of 1986, as amended. A Commodity Interest or Physical Commodity owned, or a Financial Contract entered into, by the Investor who is engaged primarily in the business of investing, reinvesting, or trading in Commodity Shares, Physical Commodities or Financial Contracts in connection with such business may be deemed to be held for investment purposes.

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: _________________________________________________________ _________________________________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: _________________________________________________________ By: ______________________________________________________ ______________________________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_________________ Name(s) of related investor(s): 2. Will any other person or persons have a beneficial interest in the Sharesto Securities to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsSecurities. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsSecurities. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ____________________________________________________________________________________________________________________________________________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)

Related Parties. 1. To the best of the InvestorSubscriber’s knowledge, does the Investor Subscriber control, or is the Investor Subscriber controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Securities to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the InvestorSubscriber)? o Yes o No If either question above was answered “Yes”, please contact ______ Mxxxxxx Xxxxxxxxxx for additional information that will be required. The Investor Subscriber understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor Subscriber to purchase the UnitsSecurities. The Investor Subscriber agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor Subscriber agrees to provide, if requested, any additional information that may reasonably be required to substantiate the InvestorSubscriber’s status as an accredited investor or to otherwise determine the eligibility of the Investor Subscriber to purchase the UnitsSecurities. The Investor Subscriber agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor Subscriber contained herein. INDIVIDUAL: ____________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ________________________________ ________________________________

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? o Yes o No If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? o Yes o No If either question above was answered “Yes”, please contact ______ Xxxxx Xxxxx & Associates for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) ___________________________________ (Print Name and Title)

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________- 2. Will any other person or persons have a beneficial interest in the Sharesto be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact _______________ for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Units. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Units. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: _________________________________________________________________________________________________________________________________________________________________________________ ____________________________________ PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ By: ____________________________________________________________________________________________________________ ____________________ 2. Will any other person or persons have a beneficial interest in the Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact Xxxx X. Xxxxxx, Esq. at (000) 000-0000 for additional information that will be required. Exhibit 10.1 Stock Subscription Agreement The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the Shares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the Shares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) ________________________________ (Print Name and Title) Exhibit 10.1 Stock Subscription Agreement

Related Parties. 1. To the best of the Investor’s knowledge, does the Investor control, or is the Investor controlled by or under common control with, any other investor in the Company? If the answer above was answered “Yes”, please identify such related investor(s) below. Name(s) of related investor(s): _______________________________-_______________ ________________________________________________________________ ________________________________________________________________ ____________________________ 2. Will any other person or persons have a beneficial interest in the Sharesto Shares to be acquired hereunder (other than as a shareholder, partner, or other beneficial owner of equity interest in the Investor)? If either question above was answered “Yes”, please contact ______ Xxxx X. Xxxxxx, Esq. at (000) 000-0000 for additional information that will be required. The Investor understands that the foregoing information will be relied upon by the Company for the purpose of determining the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to notify the Company immediately if any representation or warranty contained in this Subscription Agreement, including this Investor Questionnaire, becomes untrue at any time. The Investor agrees to provide, if requested, any additional information that may reasonably be required to substantiate the Investor’s status as an accredited investor or to otherwise determine the eligibility of the Investor to purchase the UnitsShares. The Investor agrees to indemnify and hold harmless the Company and each officer, director, shareholder, agent and representative of the Company and their respective affiliates and successors and assigns from and against any loss, damage or liability due to or arising out of a breach of any representation, warranty or agreement of the Investor contained herein. INDIVIDUAL: ____________________________________ (Signature) ____________________________________ (Print Name) PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER: ___________________________________ (Name of Entity) By: ________________________________ (Signature) _________________________________ (Print Name and Title)