Legal Reissue Form

LEGAL REISSUE FORM

This Legal Reissue Form is made effective as of by and between Requesting Party: whose principal address is and Issuer: whose principal address is .

RECITALS

WHEREAS, on or about the Parties executed or the Issuer issued an instrument described as (the "Original Document");

WHEREAS the Requesting Party represents that the Original Document is no longer available for use due to: (select all that apply and provide details in the attached statement);

WHEREAS the Issuer is willing, subject to the terms and conditions of this Form, to reissue a replacement document evidencing the rights and obligations described in the Original Document.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, the Parties agree as follows:

1. DEFINITIONS

"Replacement Document" means the new instrument or certificate the Issuer will deliver pursuant to this Form to replace the Original Document. "Claim" means any action, demand, cause of action, liability, loss, damage, cost or expense, including reasonable attorneys' fees.

2. REQUEST FOR REISSUE; SCOPE

2.1 Request. The Requesting Party hereby requests that the Issuer prepare and issue a Replacement Document that replicates the material terms of the Original Document described above. The Replacement Document shall be limited to:

2.2 Form and Delivery. The Replacement Document shall be prepared in substantially the same form as the Original Document, subject to lawful redactions or ministerial changes. The requested method of delivery is (check all applicable):

Electronic copy by email Overnight courier In-person pickup

3. STATEMENT AND AFFIDAVIT

3.1 Affidavit. The Requesting Party shall deliver to the Issuer, concurrently with this Form, a signed affidavit or notarized statement describing the circumstances of loss, theft, destruction or error and attesting that no person has a superior claim to the Original Document. Attach the statement below or describe additional attachments.

3.2 Existing Claims. The Requesting Party represents that, to the best of its knowledge, no third party has asserted a claim adverse to the reissue other than as set forth here:

4. FEES AND COSTS

The Requesting Party shall pay all reasonable fees and costs associated with preparing and issuing the Replacement Document, including administrative fees, notary fees and courier charges. Estimated fee:

5. REPRESENTATIONS AND WARRANTIES

5.1 Requesting Party Representations. The Requesting Party represents and warrants that it is authorized to request reissue; that the statements in the affidavit are true and accurate; and that it will indemnify and hold harmless the Issuer against any liability arising from claims relating to the Replacement Document, except to the extent caused by the Issuer's gross negligence or willful misconduct.

5.2 Issuer Representations. The Issuer represents that it will not issue a Replacement Document until it has received required documentation and fees, and that any Replacement Document issued shall mirror the substantive rights of the Original Document except for ministerial corrections or endorsements required to reflect the loss or reissue.

6. INDEMNIFICATION

The Requesting Party agrees to indemnify, defend and hold harmless the Issuer and its officers, directors, employees and agents from and against all Claims, liabilities, damages and expenses (including reasonable attorneys' fees) arising out of or connected with the reissue, except for Claims resulting from the Issuer's gross negligence or willful misconduct. The indemnity shall be subject to a cap of unless otherwise mutually agreed in writing.

7. EFFECT OF REISSUE

Upon issuance and delivery of the Replacement Document, the Replacement Document shall be treated for all purposes as the operative instrument in place of the Original Document. The Requesting Party acknowledges that the Issuer may require appropriate endorsements or notation evidencing the circumstances of reissue and that the Issuer may, in its discretion, cancel or mark the Original Document if later presented.

8. NOTICES

All notices 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).

9. GOVERNING LAW; MISCELLANEOUS

9.1 Governing Law. This Form shall be governed by and construed in accordance with the laws of the jurisdiction identified below without regard to its conflict of laws principles.

9.2 Entire Agreement. This Form constitutes the entire agreement between the Parties with respect to reissue of the Original Document and supersedes all prior understandings and agreements, whether written or oral, relating to the subject matter hereof.

9.3 Severability. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and the Parties shall negotiate in good faith to replace the invalid provision with a valid provision that most closely effects the Parties' intent.

9.4 Amendments; Waiver. Any amendment or waiver of any provision of this Form must be in writing signed by both Parties. No failure or delay by a Party in exercising any right will operate as a waiver of that right.

9.5 Counterparts. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures transmitted by electronic means shall be effective as originals.

10. ADDITIONAL TERMS AND ATTACHMENTS

By signing below, the Requesting Party certifies under penalty of perjury that the statements contained herein and in the attached affidavit are true and that no material fact has been omitted that would affect the Issuer's decision to reissue the Replacement Document.

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