Contract analysis

1. The affiant is the registered holder of, or is duly authorized to act on behalf of the registered holder of, __ shares of common stock, par value $0.001 per share, of VeloPay Systems, Inc., a Delaware corporation, represented by Certificate Number(s) __________.

2. The Certificate(s) described above have been (check one): Lost Destroyed Mutilated Stolen

3. The circumstances of the loss, destruction, mutilation, or theft are described as follows: ________________________________________ ________________________________________ ________________________________________

4. The affiant has made a diligent search for the Certificate(s) described above and has been unable to find or locate them. The affiant believes that the Certificate(s) have been irretrievably lost, destroyed, mutilated, or stolen and cannot be recovered.

5. If the Certificate(s) described above are found or recovered at any time hereafter, the affiant agrees to promptly return such Certificate(s) to the Paying Agent, Keystone Pacific Transfer Services Inc., at the address set forth in the Letter of Transmittal to which this Exhibit A is attached. Indemnification Undertaking. The affiant hereby agrees to indemnify, defend, and hold harmless VeloPay Systems, Inc. (as t