Business Activity Change Form

BUSINESS ACTIVITY CHANGE FORM

This Business Activity Change Form (the "Form") is made and entered into as of Month DD YYYY by and between Company Name: , an entity of type Corporation LLC Partnership Other with principal place of business at ("Company"), and Recipient Name: with address at ("Recipient").

RECITALS

WHEREAS, Company currently conducts business activities as set forth in its organizational records and prior notifications to Recipient and desires to amend the description and scope of such activities as described below; and

WHEREAS, Recipient is a party that maintains reliance, records, registrations, or contractual arrangements that may be affected by changes in Company’s stated business activities; and

WHEREAS, the parties desire to memorialize the changes to Company’s business activities and the respective responsibilities of the parties in connection therewith.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, the following terms shall have the meanings set forth below. "Changed Activities" means the business activities of Company described in Section 2. "Effective Date" means the date set forth in Section 3. All other capitalized terms not defined herein shall have the meanings assigned to them in any operative agreement between the parties, if applicable, or otherwise by their ordinary business meaning.

2. DESCRIPTION OF CHANGE

NAICS / industry classification change Scope of services or products Trade name or DBA Principal place of business Other:

3. EFFECTIVE DATE

The changes described in Section 2 shall become effective on Month DD YYYY (the "Effective Date"), unless otherwise agreed in writing by the parties.

4. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that: (a) it has full authority to enter into this Form and to perform its obligations hereunder; (b) the execution, delivery and performance of this Form will not violate any contract, agreement, law, rule or order to which it is subject; and (c) the person signing below on its behalf is duly authorized to bind such party.

5. COVENANTS

Company covenants that it will: (a) update internal records and registrations as required to reflect the Changed Activities; (b) provide Recipient, within thirty (30) days following the Effective Date, with any documents reasonably requested by Recipient necessary to substantiate or implement the Changed Activities; and (c) comply with all applicable laws and regulations in effecting the Changed Activities.

6. IMPACT ON EXISTING AGREEMENTS

To the extent any existing agreement between the parties requires amendment as a result of the Changed Activities, the parties shall negotiate in good faith to execute conforming amendments. No amendment to any existing agreement shall be effective unless memorialized in writing and signed by authorized representatives of both parties.

7. NOTICES

All notices, requests, demands and other communications required or permitted under this Form shall be in writing and delivered to the addresses set forth below (or to such other address as a party may designate by notice in accordance with this Section).

8. AMENDMENT; WAIVER

This Form may be amended, modified or supplemented only by an agreement in writing signed by both parties. No failure or delay by either party in exercising any right under this Form shall operate as a waiver of such right, nor shall any single or partial exercise preclude other or further exercise of that right.

9. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by and construed in accordance with the laws of the state specified below, without regard to conflict of laws principles.

If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Form, together with any documents referenced herein and properly executed amendments, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral, concerning such subject matter.

10. COUNTERPARTS

This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Signatures delivered by electronic means shall be binding for all purposes.

AUTHORIZATION

The undersigned representatives each certify and warrant that they are duly authorized to execute and deliver this Form on behalf of the party for which they sign and that the execution and delivery of this Form and the performance of such party’s obligations hereunder have been duly authorized by all necessary corporate or organizational action.

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