Business Supplemental Statement

BUSINESS SUPPLEMENTAL STATEMENT

Business Name:

WHEREAS

WHEREAS, the Business represents that it has existing organizational documents and registrations as indicated above and seeks to supplement prior filings or agreements to reflect changes in operations, representatives, or material business information; and

WHEREAS, the undersigned parties wish to document the supplemental information set forth in this Statement and to confirm that such information shall form an enforceable part of the governing agreement between the parties to which this Statement attaches or supplements.

WHEREAS, this Business Supplemental Statement is executed for the purpose of providing accurate, complete and contemporaneous supplemental disclosures and authorizations to update existing records of the business and its authorized representatives.

SUPPLEMENTAL INFORMATION

EFFECTIVE DATE

This Supplemental Statement shall be effective as of unless a later effective date is specified in an attached amendment.

PAYMENT TERMS (IF APPLICABLE)

Amount to be paid for services related to this Statement:

Late payment charge: on overdue balances, plus recovery of collection costs and reasonable attorneys' fees.

TERM AND TERMINATION

Term Commencement Date:

Term Expiration Date (if any): . If left blank, this Statement continues until terminated in accordance with the terms below.

Either party may terminate this Supplemental Statement for convenience upon days' prior written notice to the other party. Termination for material breach is effective upon written notice if the breaching party fails to cure within a commercially reasonable cure period not less than 10 days unless otherwise specified.

CONFIDENTIALITY

Each party acknowledges that information disclosed under or in connection with this Supplemental Statement that is identified as confidential or that by its nature should reasonably be considered confidential ("Confidential Information") shall be held in confidence and not disclosed to third parties except to the extent compelled by law or necessary for performance under this Statement. The receiving party shall use no less than a reasonable standard of care to protect Confidential Information and shall limit access to employees, agents or contractors with a need to know who are bound by confidentiality obligations no less protective than those herein.

Confidential Information does not include information that (a) is or becomes public through no fault of the receiving party, (b) was lawfully known by the receiving party prior to disclosure, or (c) is independently developed without use of the disclosing party's Confidential Information.

GOVERNING LAW; DISPUTE RESOLUTION

This Supplemental Statement shall be governed by and construed in accordance with the laws of the State of without regard to choice of law principles. The parties agree that any dispute arising out of or relating to this Statement shall be resolved by good faith negotiation between senior representatives, and if not resolved, by binding arbitration or such other binding forum as the parties may expressly agree in writing.

REPRESENTATIONS; COMPLIANCE

The signatory for each party represents and warrants that they are duly authorized to execute this Supplemental Statement on behalf of the party, that the information provided herein is true and correct to the best of their knowledge, and that execution and performance of this Statement will not violate any applicable law or contractual obligation.

ENTIRE AGREEMENT

This Supplemental Statement, together with any documents expressly incorporated herein, constitutes the entire agreement of the parties with respect to the subject matter herein and supersedes all prior and contemporaneous oral and written agreements, understandings, negotiations and discussions relating thereto. Any amendment or waiver must be in writing and signed by authorized representatives of both parties.

ATTACHMENTS

Please indicate attachments accompanying this Supplemental Statement:

Amendment to Agreement

Financial Statements / Schedules

Authorization or Board Resolution

CERTIFICATION

The undersigned certify under penalty of perjury that the information contained in this Supplemental Statement and in the attachments is true, correct and complete to the best of their knowledge, and that they are authorized to submit this Supplemental Statement on behalf of the party identified.

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