Legal Change Activity Form

LEGAL CHANGE ACTIVITY FORM

This Legal Change Activity Form is entered into as of Request Date: by and between Requesting Party: and Approving Party: .

RECITALS

WHEREAS, the Requesting Party is a party to that certain agreement identified below and seeks to implement a change to the rights, obligations or operational procedures under such agreement; and

WHEREAS, the Approving Party has authority to review and approve changes to the referenced agreement in accordance with its governance, approval matrices, or contractual delegation of authority; and

WHEREAS, the parties desire to document the requested change, its scope, implementation plan and required approvals using this Legal Change Activity Form.

NOW, THEREFORE, in consideration of the mutual covenants set forth herein and other good and valuable consideration, the parties agree as follows:

1. Contract Reference

2. Type of Change

Select all that apply: Amendment Termination Administrative update Scope change Other

3. Change Description

4. Scope, Objective and Business Justification

5. Effective Date and Duration

Proposed Effective Date:    Anticipated Duration (if temporary):

6. Implementation Plan and Timeline

7. Responsibilities and Assigned Parties

8. Impact Assessment

9. Confidentiality, Records, and Data Protection

All non-public information exchanged or generated in connection with this change shall be treated as confidential and subject to the confidentiality obligations under the referenced agreement. Each party shall maintain adequate records of the change, including approvals, implementation actions and impact reports.

10. Approvals

The following approvals are required before implementation. Indicate status and provide signature where required.

11. Attachments

12. Notices

All notices required or permitted under this Form shall be in writing and delivered to the address for the party set forth below or to such other address as a party may designate by notice.

13. Representations and Warranties

Each party represents and warrants that (i) it has full power and authority to enter into this Form and to perform its obligations hereunder, (ii) this Form has been duly executed and delivered by a person authorized to bind such party, and (iii) the execution and performance of this Form will not violate any other agreement, law, rule or regulation applicable to such party.

14. Amendments; Waiver

No amendment or modification of this Form shall be effective unless in writing and signed by authorized representatives of both parties. No failure or delay by either party in exercising any right shall operate as a waiver thereof, and no single or partial exercise of any right shall preclude further exercise of that or any other right.

15. Governing Law

This Form shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties below, without regard to principles of conflicts of law.

16. Entire Agreement; Severability

This Form, together with referenced approvals and attachments, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior proposals, agreements or understandings, whether written or oral, relating to such subject matter. If any provision of this Form is held to be invalid or unenforceable by a court of competent jurisdiction, the remainder of this Form shall continue in full force and effect.

17. Counterparts; Electronic Execution

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

18. Certification

The undersigned certify that they are authorized to submit, review or approve this change on behalf of their respective parties, and that the information contained herein is accurate and complete to the best of their knowledge.

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