8/16/2019 NTF Section 04 01 Subject 4010001

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PPD STUDY FILES

FILE NOTE

Client Company: Resverlogix Corp

Project Name/Study Number: RVX222-CS-015

PPD Identification (job number): 575211001

Multinational Study, Central File

Country Documents File

Investigator File Site # PI name:

Investigator Site File Site # 401 PI name: Prof.dr. Goran Milicevic,MD, PhD

SectionNumber:

Section Title: Comment:

04.01 - ICF Process Due to a limited space on the ICF patient signature lineand patient long-drawn hand writing, the subject 4010001placed the date of signing on the line reserved for thelegal representative.

Pi is confirms that all data are hand written by the subject.

Name (print): Tit le:

Prof. dr. Goran Milicevic, MD, PhD Principal Investigator

Signature: Date:

Place the completed original form in the appropriate section of the PPD Study Files.