Shareholder Update Form

SHAREHOLDER UPDATE FORM

This Shareholder Update Form (the "Form") is made effective as of Effective Date: by and between Company Name: , a corporation organized under the laws of State of Incorporation: , with principal place of business at Address: (the "Company"), and Shareholder Name: , with mailing address: (the "Shareholder").

RECITALS

WHEREAS, the Shareholder is recorded on the books of the Company as the owner of shares of stock, as evidenced by Certificate Nos.: ;

WHEREAS, the Company requires periodic written updates to its shareholder records to ensure compliance with corporate governance, transfer restrictions, and applicable securities and tax laws;

WHEREAS, the Shareholder desires to provide updated information and to certify the matters set forth in this Form to the Company.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Company and the Shareholder agree as follows:

1. UPDATE OF SHAREHOLDER INFORMATION

The Shareholder hereby updates the shareholder records of the Company as follows. The Shareholder warrants that the information supplied below is true, complete and correct as of the Effective Date.

2. OWNERSHIP, HOLDINGS AND TRANSFERS

The Shareholder confirms as of the Effective Date that the Shareholder directly or indirectly holds the following securities of the Company:

Has any portion of the recorded holdings been transferred, pledged or encumbered since the last update?

If yes, provide details including date(s), transferee(s), and consideration:

3. REPRESENTATIONS AND WARRANTIES

The Shareholder represents and warrants to the Company that: (a) the Shareholder is the lawful owner of the shares identified in this Form and has full power and authority to provide this update; (b) the shares are owned free and clear of all liens, claims and encumbrances except as disclosed herein; (c) the information set forth in this Form is true, complete and accurate in all material respects; and (d) the execution and delivery of this Form and the performance by the Shareholder of its obligations hereunder will not violate any agreement to which the Shareholder is a party or any law, judgment, order or decree applicable to the Shareholder.

4. TRANSFER RESTRICTIONS AND COMPLIANCE

The Shareholder acknowledges that any transfer of the Company's securities may be subject to the Company's bylaws, shareholder agreements, stock restriction agreements, or applicable law. The Shareholder agrees to comply with all such restrictions and to provide any documentation reasonably requested by the Company to effect or record a permitted transfer.

5. NOTICES

All notices, requests, demands and other communications required or permitted to be given under this Form shall be in writing and shall be delivered to the parties at the following addresses (or at such other addresses as a party may designate by notice):

6. AMENDMENTS; WAIVER

No amendment, modification or waiver of any provision of this Form shall be effective unless in writing and signed by both the Company and the Shareholder. A waiver of any breach or default shall not constitute a waiver of any other or subsequent breach or default.

7. GOVERNING LAW

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

8. ENTIRE AGREEMENT

This Form, together with any documents referenced herein, constitutes the entire agreement between the Company and the Shareholder with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether written or oral.

9. SEVERABILITY

If any provision of this Form is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions shall continue 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' original intent.

10. COUNTERPARTS

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

CERTIFICATION

By signing below, the Shareholder certifies under penalty of perjury that the information provided in this Form is true, complete and correct to the best of the Shareholder's knowledge, that the Shareholder has full authority to make the statements and updates herein, and that the Shareholder will promptly notify the Company in writing of any material changes to the information supplied.

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