Loan Debt Registration Form

LOAN DEBT REGISTRATION FORM

Administrative Details

Loan Registration Number:

Lender Information

Individual Corporation LLC Other

Borrower Information

Individual Corporation LLC Other

Loan Details

Original Agreement Date:

Late fee policy (applicable after grace period):

Prepayment permitted: Yes No   If yes, penalty:

Security and Collateral

Yes No

Repayment Schedule (Proposed)

Provide an itemized schedule or summary of payments. If attached, note attachment reference:

Representations, Warranties and Covenants

By submitting this registration, Lender and Borrower certify that the loan described herein constitutes a valid and binding obligation enforceable in accordance with its terms. Each party represents that it has full power and authority to enter this registration and that all information provided is true and complete to the best of its knowledge.

Borrower covenants to make payments when due in accordance with the repayment schedule and to preserve the priority of any security interest by executing any additional documents reasonably required by Lender to perfect or maintain such security interest.

Default and Remedies

An event of default includes failure to make any payment when due, insolvency, bankruptcy, material breach of this loan’s terms, or a representation that proves false in any material respect. Upon default, Lender may declare the entire outstanding principal, accrued interest, and other charges immediately due and payable and exercise all rights and remedies available under the loan documents and applicable law, including foreclosure on collateral and acceleration of indebtedness.

Notices

Assignment and Transfer

Lender may assign or transfer its rights under the loan and this registration to any third party. Borrower consents to such assignment and agrees to execute any instruments reasonably necessary to effect assignment or to acknowledge the assignee as Lender for the purposes of enforcement.

Governing Law

This registration and any disputes arising out of it shall be governed by and construed in accordance with the laws of the jurisdiction specified below without regard to conflict of laws principles.

Registration and Recording

Indicate whether the loan has been recorded or will be recorded with any public registry and provide the registry reference if recorded.

Recorded Not Recorded   Registry Reference:

Certifications

The undersigned certify that they are authorized representatives of the respective parties, that the loan details provided are accurate, and that they agree to the terms and conditions set forth in the governing loan documents. Misrepresentation of material facts may result in rescission or other remedies permitted by law.

I certify under penalty of perjury that the foregoing is true and correct.

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