Business Material Change Statement

BUSINESS MATERIAL CHANGE STATEMENT

Reporting Entity Name:   Registration/ID Number:

Recipient Name:   Statement Date:

WHEREAS

WHEREAS, the Reporting Entity is engaged in the business activities described in its organizational records and has an obligation under applicable agreements and regulatory requirements to notify the Recipient of any material change that could affect the Recipient's rights, obligations or assessments of the Reporting Entity;

WHEREAS, a material change has occurred or is anticipated as described in this Statement and the Reporting Entity seeks to provide a full and accurate disclosure to the Recipient in accordance with applicable contractual or statutory notification obligations;

WHEREAS, the parties acknowledge that timely and complete disclosure of material changes facilitates mitigation of risk and continued performance under existing agreements between the parties.

SCOPE OF CHANGE

NATURE OF CHANGE (check all that apply)

Change in ownership or equity structure

Change in principal place of business or registered address

Changes to directors, officers or key management

Material change to business activities, products or services

Material change in financial condition or capital structure

Other (specify below)

SUPPORTING DOCUMENTS

IMPACT ON AGREEMENTS AND OPERATIONS

PAYMENT TERMS (IF APPLICABLE)

Notification Fee Amount:

Late Payment Fee:

TERM AND TERMINATION

Statement Effective Date:   Anticipated End Date (if any):

CONFIDENTIALITY

The Reporting Entity acknowledges that information disclosed in this Statement may be designated confidential by the Reporting Entity or may be treated as confidential under existing agreements. The Recipient agrees to maintain confidentiality of non-public information to the extent required by applicable agreements or law and not to disclose such information except as permitted by written consent or required by operation of law. Any compelled disclosure shall be coordinated with the Reporting Entity to the extent practicable.

Reporting Entity asserts that the information provided in this Statement is accurate and complete to the best of its knowledge as of the Statement Date, and acknowledges that knowingly providing false, misleading, or materially incomplete information may constitute a breach of agreement or other liability.

GOVERNING LAW

This Statement and any disputes arising out of or relating to it shall be governed by and construed in accordance with the laws of the jurisdiction specified below, without regard to conflict-of-law principles.

ENTIRE AGREEMENT

This Statement, together with any referenced attachments or supporting documents listed above, constitutes the entire statement of material change between the parties with respect to the subject matter hereof and supersedes all prior oral or written statements, notices, or understandings related to such material change, except to the extent otherwise reserved by executed agreements between the parties.

CERTIFICATION

The undersigned certifies, under penalty of perjury or applicable sanction, that the information contained in this Business Material Change Statement and any attachments is true, correct and complete to the best of the signer's knowledge and belief as of the Statement Date.

Authorized Contact for Reporting Entity

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