Shareholders Status Document

SHAREHOLDERS STATUS DOCUMENT

This Shareholders Status Document is made on by and between Company Name: (the "Company"), a corporation organized under the laws of the State of Incorporation: and Shareholder Name: .

RECITALS

WHEREAS, the Company maintains a register of its issued and outstanding shares and related shareholder records and desires to confirm the status of the Shareholder's holdings for corporate, regulatory and contractual purposes; and

WHEREAS, the Shareholder represents that the information provided herein is true, complete and accurate as of the date of this Document and that no transfer or disposition of the shares described below has occurred except as expressly set forth in this Document; and

WHEREAS, the Company is issuing this document at the request of the Shareholder and for reliance by the Shareholder and any third party who is permitted by law or agreement to rely on a shareholder status certification.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. CERTIFICATION OF SHAREHOLDING

1.1 The Company certifies that as of the date of this Document the Shareholder is the record and beneficial owner of (the "Shares") of the following class: .

1.2 Shares Certificate Number(s): . Date of original issuance: .

1.3 The Shares represent approximately of the outstanding voting power of the Company, computed on a fully diluted basis as of the date of this Document, based upon total issued and outstanding shares reported by the Company of .

2. REPRESENTATIONS AND WARRANTIES

2.1 The Company represents and warrants that (a) the Company is duly organized and in good standing under the laws of the State of Incorporation and has full corporate power to execute and deliver this Document and perform its obligations hereunder; and (b) the corporate records of the Company accurately reflect the share ledger and ownership information relied upon in issuing this certification.

2.2 The Shareholder represents and warrants that as of the date hereof (a) the Shares are held free and clear of liens, encumbrances or adverse claims other than those disclosed below; and (b) the Shareholder has full power and authority to accept this Document and perform the obligations herein.

Disclosed Liens or Encumbrances (if any):

3. TRANSFER RESTRICTIONS

3.1 The Shares are subject to the transfer restrictions, preemptive rights and other limitations set forth in the Company's articles of incorporation, bylaws and any shareholders' agreement. Transfer restrictions apply: Check if transfer restrictions apply

3.2 Any certificates representing the Shares shall bear an appropriate legend referencing the applicable transfer restrictions and contractual rights. If the Company issues or has issued a written waiver of such legend, describe below:

4. VOTING RIGHTS AND DIVIDENDS

4.1 The Shares carry voting rights and dividend rights as set forth in the Company's governing documents. Specific voting rights applicable to these Shares:

5. RELIANCE AND PURPOSE

5.1 This Document is issued for the purpose of confirming the Shareholder's status and may be relied upon by the Shareholder and third parties with the Company's consent. The Company shall not be responsible for reliance by any person who does not act in good faith or who fails to verify information from the Company's official records.

6. NOTICES

Notices shall be given in writing and shall be effective upon delivery in person, by courier, by nationally recognized overnight delivery service, or three (3) business days after deposit in the United States mail, postage prepaid, to the addresses provided above or such other address as a party may designate by notice in accordance with this Section.

7. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

7.1 Governing Law. This Document shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

7.2 Entire Agreement. This Document, together with the Company's articles of incorporation, bylaws and any shareholders' agreement expressly referenced herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior written or oral agreements.

7.3 Severability. If any provision of this Document is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect and the invalid or unenforceable provision shall be replaced by a valid and enforceable provision that most closely effects the parties' intent.

8. AMENDMENTS; WAIVER; COUNTERPARTS

8.1 Amendments and Waiver. No amendment, modification or waiver of any provision of this Document shall be effective unless in writing signed by both parties. A waiver of any breach shall not constitute a waiver of any other or subsequent breach.

8.2 Counterparts. This Document 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 transmitted by electronic means shall be deemed original signatures for all purposes.

9. ADDITIONAL INFORMATION

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