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Acknowledgement of Receipt of Consideration for Shares of Stock (Issuer)

This Document can be attached to a Common Stock Purchase Agreement found here: Common Stock Purchase Agreement (with Vesting)

RECEIPT

Company Name, a Delaware corporation (the “Company”), hereby acknowledges receipt of: fill in those clauses that apply, delete inapplicable clauses

  •  A check in the amount of $Check Amount
  •  The cancellation of indebtedness in the amount of Indebtedness Cancelled
  •  A Promissory Note in the amount of $Promissory Note Amount
  •  Services rendered having a value equal to $Service Rendered Value
  •  The assignment of certain intellectual property and/or other assets having an aggregate value equal to $IP or Other Asset Value

given by Transferor Name as consideration for Certificate No. CS-Certificate No. for Purchased No. shares of Common Stock of the Company.

Dated: Date Receipt Was Signed

THE COMPANY:

Company Name

Name: Name
Title: Title

Orrick

27 407,888 0

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