SEC Filings

10-Q
AVEXIS, INC. filed this Form 10-Q on 08/10/2017
Entire Document
 

EXHIBIT E
RESEARCH INSTITUTE ROYALTY REPORT

Licensee: _______________________    Agreement No.: ____________________________

Inventor: _______________________     Research Institute File No.: _____________________

Period Covered: From: ______/______/______Through: ______/______/______________

Prepared By: _______________________  Date: _____/______/______________________

Approved By: ______________________  Date: _____/______/___________________

 

                             If license covers several major product lines, please prepare a separate report

 

 

                                    for each line. Then combine all product line into a summary report.

 

 

 

                          Report Type:     ☐    Single Product Line Report:

 

 

                                 _____________________________________________________________________

 

 

☐    Multiproduct Summary Report:               Page 1 of ______  Pages

 

 

☐    Product Line Details:  Line: ___________  Tradename: ___________

 

 

Pages:____________

 

 

☐    Report Currency:   ☐    U.S. Dollars           ☐ Other _________________

 

 

Country

Invoice
Amount/Amount
Received if not
invoiced

[*Less:
Allowances]

Net Sales

Royalty Rate

Period Royalty Amount

This Year

Last Year

****

 

 

 

 

 

 

****

 

 

 

 

 

 

****

 

 

 

 

 

 

****

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total:

 

 

 

 

 

 

 

Total Royalty:  ______________  Conversion Rate:  ________ Royalty in U.S. Dollars:  $_____________________

 

The following royalty forecast is non-binding and for Research Institute’s internal planning purposes only:

Royalty Forecast Under This Agreement:  ****

 

Any other consideration due Research Institute during this Royalty Period:

 

Annual Payments:  ________________________                           Milestones:  ____________________________

 

Minimum Royalties:  ______________________                           Sublicense Payments: ________________________

 

On a separate page, please indicate the reason for returns or adjustments if significant. Also note any unusual occurrences that affect royalty amounts during this period. To assist Research Institute’s forecasting, please comment on any significant expected trends in sales volume.

 

 

I certify that this report is accurate and complete: ___________________________

* * * * CERTAIN INFORMATION HAS BEEN OMITTED AND FILED SEPARATELY WITH THE COMMISSION. CONFIDENTIAL TREATMENT HAS BEEN REQUESTED WITH RESPECT TO THE OMITTED PORTIONS.



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