Escrow Agreement {S5}

Form S-5 Rev. 03-13 COMMONWEALTH OF PUERTO RICO COMMISSIONER OF FINANCIAL INSTITUTIONS Centro Europa Building Securities Regulation Division PO Box 11855 San Juan, PR 00910-3855 Tel. (787) 723-3131 Fax (787) 724-2604 ESCROW AGREEMENT KNOW ALL MEN BY THESE PRESENTS: 1. That I, ______________________________, of ___________________ Street, in the city of _____________________, State of ________________________, being a shareholder of the ____________________________ stock in ____________________, the issuer, a corporation organized under the Uniform Securities Act of Puerto Rico in connection with an application for the registration by qualification or coordination of _____________________ shares of the ________________________________stock of the said issuer which was filed with said Commissioner on the _______ day of _________, 20____, do hereby and herewith deposit with the ____________________, as escrow agent, in conformity with the requirements of said Article 40 certificates(s) numbered _______________________________, representing, ______________________________shares, respectively, of the _______________________ stock of the said issuer, of which shares I am the sole owner. 2. That I hereby agree that the said shares represented by the said certificate(s) shall be held in escrow by the said escrow agent subject to the following conditions: (a) That there shall be no assignment, sale or disposal of any interest in any of the said shares represented by the said certificate(s) without the written consent of the said Commissioner. (b) That the said shares represented by the said certificate(s)shall not be released to me by the said Commissioner except as provided in Article 40 which rule is hereby made a part hereof in its entirety. In Witness, whereof, I have hereunder set my hand and seal this_______ day of _____________________________, 20____. (Signed)____________________ (SEAL) Witness ____________________ American LegalNet, Inc. www.FormsWorkFlow.com