Exhibit 10.1

 

PERFORMANCE BASED RESTRICTED STOCK AGREEMENT

 

IMMUNOGEN, INC.

 

AGREEMENT made as of the 12th day of August, 2016 (the “Grant Date”), between
ImmunoGen, Inc. (the “Company”), a Massachusetts corporation, and
                         (the “Participant”).

 

WHEREAS, the Company has adopted the ImmunoGen, Inc. 2006 Employee, Director and
Consultant Equity Incentive Plan, as amended (the “Plan”) to promote the
interests of the Company by providing an incentive for employees, directors and
consultants of the Company or its Affiliates;

 

WHEREAS, pursuant to the provisions of the Plan, the Company desires to offer to
the Participant shares of the Company’s common stock, $.01 par value per share
(“Common Stock”), in accordance with the provisions of the Plan, all on the
terms and conditions hereinafter set forth;

 

WHEREAS, Participant wishes to accept said offer; and

 

WHEREAS, the parties hereto understand and agree that any terms used and not
defined herein have the meanings ascribed to such terms in the Plan.

 

NOW, THEREFORE, in consideration of the promises and the mutual covenants
contained herein and for other good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, the parties hereto hereby agree as
follows:

 

1.                                      Terms of Grant.  The Participant hereby
accepts the offer of the Company to issue to the Participant, in accordance with
the terms of the Plan and this Agreement, Twenty Thousand (20,000) Shares of the
Company’s Common Stock (such shares, subject to adjustment pursuant to
Section 25 of the Plan and Subsection 2.1(f) hereof, the “Granted Shares”) at a
purchase price per share of $.01 (the “Purchase Price”), receipt of which is
hereby acknowledged by the Participant’s prior service to the Company and which
amount will be reported as income on the Participant’s W-2 for this calendar
year.

 

2.1.                            Forfeiture Provisions.

 

(a)                                 Lapsing Forfeiture Right.  In the event that
for any reason (i) the Participant is no longer an employee, director or
consultant of the Company or an Affiliate (such event being the “Termination”)
prior to achievement of a performance goal listed below; or (ii) the Company
does not achieve a performance goal set forth below by the fifth (5th)
anniversary of the Grant Date (the “Performance End Date”), the Participant (or
the Participant’s Survivor) shall, on the date of Termination or the Performance
End Date, as applicable, immediately forfeit to the Company (or its designee)
the number of Granted Shares which have not yet lapsed as set forth below (the
“Lapsing Forfeiture Right”).  The Lapsing Forfeiture Right shall lapse with
respect to one-third of the Granted Shares upon achievement of each of the
performance goals prior to the date of Termination or the Performance End Date,
as applicable.  The foregoing notwithstanding, if a performance goal is achieved
prior to the first anniversary of the Grant Date, then the Lapsing Forfeiture
Right as to the one-third of the Granted Shares applicable to such performance
goal shall not lapse until the first anniversary of the Grant Date, and if a
Termination occurs prior to such one-year anniversary, the Granted Shares shall
be forfeited to the Company as if the performance goal had not been achieved as
of the Termination date; provided, however, that if such Termination occurs due
to the Participant’s death or Disability (as defined in the Plan), or there
occurs a

 

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Change of Control (as defined in the Plan) prior to the first anniversary of the
Grant Date, the Granted Shares applicable to such performance goal shall not be
forfeited to the Company, and Lapsing Forfeiture Right with respect to such
Granted Shares shall lapse as of such Termination date or immediately prior to
the Change of Control transaction.

 

The Company’s Lapsing Forfeiture Right shall lapse as to one-third of the
Granted Shares upon achievement of each of the following performance goals prior
to the Performance End Date (or earlier upon a Termination):

 

·                  Mirvetuximab soravtansine (“IMGN853”) meeting its primary
endpoint in a registration trial; i.e., a clinical trial designed to
(A) ascertain efficacy and safety of IMGN853 that is needed to evaluate the
overall benefit-risk relationship of the drug and to provide an adequate basis
for physician labeling and (B) support the preparation and submission of a
biologics license application (“BLA”) for the indication under investigation in
the study as and to the extent defined in 21 C.F.R. §312.21(c), or its successor
regulation.

 

·                  Acceptance of a BLA for IMGN853 by the U.S. Food and Drug
Administration (the “FDA”).

 

·                  Receipt of marketing approval for IMGN853 from the FDA.

 

The determination of achievement of the performance goals shall be based on
certification of achievement of a performance goal by the Compensation
Committee, which certification date shall be deemed to be the vesting date and
the date of termination of the Lapsing Forfeiture Right with respect to any of
the Granted Shares for all purposes of this Agreement.

 

Any Granted Shares as to which the Company’s Lapsing Forfeiture Right has not
previously lapsed upon achievement of the above performance goals shall be
forfeited to the Company on the Performance End Date (or earlier upon a
Termination).

 

Notwithstanding the foregoing, the Company’s Lapsing Forfeiture Right shall
terminate, and the Participant’s ownership of all Granted Shares then owned by
the Participant shall become vested upon a Corporate Transaction where all stock
grants are terminated in exchange for a cash payment in accordance with
Section 25(b) of the Plan.

 

(b)                              Effect of a For Cause Termination. 
Notwithstanding anything to the contrary contained in this Agreement, in the
event the Company or an Affiliate terminates the Participant’s employment or
service for Cause (as defined in the Plan) or in the event the Administrator
determines, within one year after the Participant’s termination, that either
prior or subsequent to the Participant’s termination the Participant engaged in
conduct that would constitute Cause, all of the Granted Shares then held by the
Participant shall be forfeited to the Company immediately as of the time the
Participant is notified that he or she has been terminated for Cause or that he
or she engaged in conduct which would constitute Cause.

 

(c)                               Escrow.  The certificates representing all
Granted Shares acquired by the Participant hereunder which from time to time are
subject to the Lapsing Forfeiture Right shall be delivered to the Company and
the Company shall hold such Granted Shares in escrow as provided in this
Subsection 2.1(c). The Company shall promptly release from escrow and deliver to
the Participant the whole number of Granted Shares, if any, as to which the
Company’s Lapsing Forfeiture Right has lapsed and without the legend set forth
in Section 5. In the event of forfeiture to the Company of Granted Shares
subject to the Lapsing Forfeiture Right, the Company shall release from escrow
and cancel a certificate

 

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for the number of Granted Shares so forfeited.  Any securities distributed in
respect of the Granted Shares held in escrow, including, without limitation,
shares issued as a result of stock splits, stock dividends or other
recapitalizations, shall also be held in escrow in the same manner as the
Granted Shares.

 

(d)                                 Prohibition on Transfer.  The Participant
recognizes and agrees that all Granted Shares which are subject to the Lapsing
Forfeiture Right may not be sold, transferred, assigned, hypothecated, pledged,
encumbered or otherwise disposed of, whether voluntarily or by operation of law,
other than to the Company (or its designee).  However, the Participant, with the
approval of the Administrator, may transfer the Granted Shares for no
consideration to or for the benefit of the Participant’s Immediate Family
(including, without limitation, to a trust for the benefit of the Participant’s
Immediate Family or to a partnership or limited liability company for one or
more members of the Participant’s Immediate Family), subject to such limits as
the Administrator may establish, and the transferee shall remain subject to all
the terms and conditions applicable to this Agreement prior to such transfer and
each such transferee shall so acknowledge in writing as a condition precedent to
the effectiveness of such transfer.  The term “Immediate Family” shall mean the
Participant’s spouse, former spouse, parents, children, stepchildren, adoptive
relationships, sisters, brothers, nieces and nephews and grandchildren (and, for
this purpose, shall also include the Participant.)  The Company shall not be
required to transfer any Granted Shares on its books which shall have been sold,
assigned or otherwise transferred in violation of this Subsection 2.1(d), or to
treat as the owner of such Granted Shares, or to accord the right to vote as
such owner or to pay dividends to, any person or organization to which any such
Granted Shares shall have been so sold, assigned or otherwise transferred, in
violation of this Subsection 2.1(d).

 

(e)                                  Failure to Deliver Granted Shares to be
Forfeited.  In the event that the Granted Shares to be forfeited to the Company
under this Agreement are not in the Company’s possession pursuant to Subsection
2.1(c) above or otherwise and the Participant or the Participant’s Survivor
fails to deliver such Granted Shares to the Company (or its designee), the
Company may immediately take such action as is appropriate to transfer record
title of such Granted Shares from the Participant to the Company (or its
designee) and treat the Participant and such Granted Shares in all respects as
if delivery of such Granted Shares had been made as required by this Agreement. 
The Participant hereby irrevocably grants the Company a power of attorney which
shall be coupled with an interest for the purpose of effectuating the preceding
sentence.

 

(f)                                   Adjustments.  The Plan contains provisions
covering the treatment of Shares in a number of contingencies such as stock
splits and mergers.  Provisions in the Plan for adjustment with respect to the
Granted Shares and the related provisions with respect to successors to the
business of the Company are hereby made applicable hereunder and are
incorporated herein by reference.

 

2.2                               General Restrictions on Transfer of Granted
Shares.

 

(a)                                 The Participant agrees that in the event the
Company proposes to offer for sale to the public any of its equity securities
and such Participant is requested by the Company and any underwriter engaged by
the Company in connection with such offering to sign an agreement restricting
the sale or other transfer of Shares, then such Participant will promptly sign
such agreement and will not transfer, whether in privately negotiated
transactions or to the public in open market transactions or otherwise, any
Shares or other securities of the Company held by him or her during such period
as is determined by the Company and the underwriters, not to exceed 90 days
following the closing of the offering, plus such additional period of time as
may be required to comply with Marketplace Rule 2711 of the National Association
of Securities Dealers, Inc. or similar rules thereto (such period, the “Lock-Up
Period”).  Such agreement shall be in writing and in form and substance
reasonably satisfactory to the Company and such underwriter and pursuant to
customary and prevailing terms and conditions.  Notwithstanding whether the
Participant has signed such an agreement, the Company may impose stop-transfer
instructions with

 

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respect to the Shares or other securities of the Company subject to the
foregoing restrictions until the end of the Lock-Up Period.

 

(b)                                 The Participant acknowledges and agrees that
neither the Company nor, its shareholders nor its directors and officers, has
any duty or obligation to disclose to the Participant any material information
regarding the business of the Company or affecting the value of the Shares
before, at the time of, or following a Termination, including, without
limitation, any information concerning plans for the Company to make a public
offering of its securities or to be acquired by or merged with or into another
firm or entity.

 

3.                                      Securities Law Compliance.  The
Participant specifically acknowledges and agrees that any sales of Granted
Shares shall be made in accordance with the requirements of the Securities Act
of 1933, as amended.

 

4.                                      Rights as a Stockholder.  The
Participant shall have all the rights of a stockholder with respect to the
Granted Shares, including voting and dividend rights, subject to the transfer
and other restrictions set forth herein and in the Plan.

 

5.                                      Legend.  In addition to any legend
required pursuant to the Plan, all certificates representing the Granted Shares
to be issued to the Participant pursuant to this Agreement shall have endorsed
thereon a legend substantially as follows:

 

“The shares represented by this certificate are subject to restrictions set
forth in a Restricted Stock Agreement dated as of                      with this
Company, a copy of which Agreement is available for inspection at the offices of
the Company or will be made available upon request.”

 

6.                                      Incorporation of the Plan.  The
Participant specifically understands and agrees that the Granted Shares issued
under the Plan are being sold to the Participant pursuant to the Plan, a copy of
which Plan the Participant acknowledges he or she has read and understands and
by which Plan he or she agrees to be bound.  The provisions of the Plan are
incorporated herein by reference.

 

7.                                      Tax Liability of the Participant and
Payment of Taxes. The Participant acknowledges and agrees that any income or
other taxes due from the Participant with respect to the Granted Shares issued
pursuant to this Agreement, including, without limitation, the Lapsing
Forfeiture Right, shall be the Participant’s responsibility.  Without limiting
the foregoing, the Participant agrees that, to the extent that the lapsing of
restrictions on disposition of any of the Granted Shares or the declaration of
dividends on any such shares before the lapse of such restrictions on
disposition results in the Participant’s being deemed to be in receipt of earned
income under the provisions of the Code, the Company shall be entitled to
immediate payment from the Participant of the amount of any tax required to be
withheld by the Company.

 

Upon execution of this Agreement, the Participant may file an election under
Section 83 of the Code in substantially the form attached as Exhibit B.  The
Participant acknowledges that if he or she files such an election, the
Participant will have income for tax purposes equal to the fair market value of
the Granted Shares on the Grant Date, less the price paid for the Granted Shares
by the Participant.  The Participant acknowledges that if he or she does not
file such an election, as the Granted Shares are released from the Lapsing
Forfeiture Right in accordance with Section 2.1, the Participant will have
income for tax purposes equal to the fair market value of the Granted Shares at
such date, less the price paid for the Granted Shares by the Participant. The
Participant has been given the opportunity to obtain

 

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the advice of his or her tax advisors with respect to the tax consequences of
the purchase of the Granted Shares and the provisions of this Agreement.

 

The Participant shall be required to deposit with the Company an amount of cash
equal to the amount determined by the Company to be required with respect to the
statutory minimum of the Participant’s estimated total federal, state and local
tax and other withholding obligations with respect to the Granted Shares.  In
connection with the foregoing, any taxes or other amounts required to be
withheld by the Company by applicable law or regulation shall be paid, at the
option of the Company as follows:

 

(i)                                     requiring the Participant to deposit
with the Company an amount of cash equal to the amount determined by the Company
to be required to be withheld with respect to the statutory minimum amount of
the Participant’s total tax and other withholding obligations due and payable by
the Company or otherwise withholding from the Participant’s paycheck an amount
equal to such amounts due and payable by the Company; or

 

(ii)                                  if the Company believes that the sale of
shares can be made in compliance with applicable securities laws, authorizing,
at a time when the Participant is not in possession of material nonpublic
information, the sale by the Participant on the date that the Granted Shares
shall be released from the Lapsing Forfeiture Right such number of Granted
Shares as the Company instructs a broker to sell to satisfy the Company’s
withholding obligation, after deduction of the broker’s commission, and the
broker shall remit to the Company the cash necessary in order for the Company to
satisfy its withholding obligation.  To the extent the proceeds of such sale
exceed the Company’s withholding obligation the Company agrees to pay such
excess cash to the Participant as soon as practicable.  In addition, if such
sale is not sufficient to pay the Company’s withholding obligation the
Participant agrees to pay to the Company as soon as practicable, including
through additional payroll withholding, the amount of any withholding obligation
that is not satisfied by the sale of shares of Common Stock. The Participant
agrees to hold the Company and the broker harmless from all costs, damages or
expenses relating to any such sale.  The Participant acknowledges that the
Company and the broker are under no obligation to arrange for such sale at any
particular price.  In connection with such sale of Granted Shares, the
Participant shall execute any such documents requested by the broker in order to
effectuate the sale of Granted Shares and payment of the withholding obligation
to the Company.  The Participant acknowledges that this paragraph is intended to
comply with Section 10b5-1(c)(1)(i)(B) under the Exchange Act.

 

The Company shall not deliver any shares of Common Stock to the Participant
until it is satisfied that all required withholdings have been made.

 

8.                                      Equitable Relief.  The Participant
specifically acknowledges and agrees that in the event of a breach or threatened
breach of the provisions of this Agreement or the Plan, including the attempted
transfer of the Granted Shares by the Participant in violation of this
Agreement, monetary damages may not be adequate to compensate the Company, and,
therefore, in the event of such a breach or threatened breach, in addition to
any right to damages, the Company shall be entitled to equitable relief in any
court having competent jurisdiction.  Nothing herein shall be construed as
prohibiting the Company from pursuing any other remedies available to it for any
such breach or threatened breach.

 

9.                                      No Obligation to Maintain Relationship. 
The Company is not by the Plan or this Agreement obligated to continue the
Participant as an employee, director or consultant of the Company or an
Affiliate.  The Participant acknowledges:  (i) that the Plan is discretionary in
nature and may be suspended or terminated by the Company at any time; (ii) that
the grant of the Shares is a one-time benefit which does not create any
contractual or other right to receive future grants of shares, or benefits in
lieu of shares; (iii) that all determinations with respect to any such future
grants, including, but not limited to, the

 

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times when shares shall be granted, the number of shares to be granted, the
purchase price, and the time or times when each share shall be free from a
lapsing repurchase or forfeiture right, will be at the sole discretion of the
Company; (iv) that the Participant’s participation in the Plan is voluntary;
(v) that the value of the Shares is an extraordinary item of compensation which
is outside the scope of the Participant’s employment contract, if any; and
(vi) that the Shares are not part of normal or expected compensation for
purposes of calculating any severance, resignation, redundancy, end of service
payments, bonuses, long-service awards, pension or retirement benefits or
similar payments.

 

10.                               Notices.  Any notices required or permitted by
the terms of this Agreement or the Plan shall be given by recognized courier
service, facsimile, registered or certified mail, return receipt requested,
addressed as follows:

 

If to the Company:

 

ImmunoGen, Inc.

Attn: Finance

830 Winter Street

Waltham, MA 02451

 

If to the Participant:

 

EMPLOYEE NAME AND ADDRESS

 

or to such other address or addresses of which notice in the same manner has
previously been given.  Any such notice shall be deemed to have been given on
the earliest of receipt, one business day following delivery by the sender to a
recognized courier service, or three business days following mailing by
registered or certified mail.

 

11.                               Benefit of Agreement.  Subject to the
provisions of the Plan and the other provisions hereof, this Agreement shall be
for the benefit of and shall be binding upon the heirs, executors,
administrators, successors and assigns of the parties hereto.

 

12.                               Governing Law.  This Agreement shall be
construed and enforced in accordance with the laws of the Commonwealth of
Massachusetts, without giving effect to the conflict of law principles thereof.

 

13.                               Severability.  If any provision of this
Agreement is held to be invalid or unenforceable by a court of competent
jurisdiction, then such provision or provisions shall be modified to the extent
necessary to make such provision valid and enforceable, and to the extent that
this is impossible, then such provision shall be deemed to be excised from this
Agreement, and the validity, legality and enforceability of the rest of this
Agreement shall not be affected thereby.

 

14.                               Entire Agreement.  This Agreement, together
with the Plan, constitutes the entire agreement and understanding between the
parties hereto with respect to the subject matter hereof and supersedes all
prior oral or written agreements and understandings relating to the subject
matter hereof.  No statement, representation, warranty, covenant or agreement
not expressly set forth in this Agreement shall affect or be used to interpret,
change or restrict the express terms and provisions of this Agreement provided,
however, in any event, this Agreement shall be subject to and governed by the
Plan.

 

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15.                               Modifications and Amendments; Waivers and
Consents.  The terms and provisions of this Agreement may be modified or amended
as provided in the Plan.  Except as provided in the Plan, the terms and
provisions of this Agreement may be waived, or consent for the departure
therefrom granted, only by written document executed by the party entitled to
the benefits of such terms or provisions.  No such waiver or consent shall be
deemed to be or shall constitute a waiver or consent with respect to any other
terms or provisions of this Agreement, whether or not similar.  Each such waiver
or consent shall be effective only in the specific instance and for the purpose
for which it was given, and shall not constitute a continuing waiver or consent.

 

16.                               Consent of Spouse/Domestic Partner.  If the
Participant has a spouse or domestic partner as of the date of this Agreement,
the Participant’s spouse or domestic partner shall execute a Consent of
Spouse/Domestic Partner in the form of Exhibit A hereto, effective as of the
date hereof.  Such consent shall not be deemed to confer or convey to the spouse
or domestic partner any rights in the Granted Shares that do not otherwise exist
by operation of law or the agreement of the parties.  If the Participant
subsequent to the date hereof, marries, remarries or applies to the Company for
domestic partner benefits, the Participant shall, not later than 60 days
thereafter, obtain his or her new spouse/domestic partner’s acknowledgement of
and consent to the existence and binding effect of all restrictions contained in
this Agreement by having such spouse/domestic partner execute and deliver a
Consent of Spouse/Domestic Partner in the form of Exhibit A.

 

17.                               Counterparts.  This Agreement may be executed
in one or more counterparts, and by different parties hereto on separate
counterparts, each of which shall be deemed an original, but all of which
together shall constitute one and the same instrument.

 

18.                               Data Privacy.  By entering into this
Agreement, the Participant:  (i) authorizes the Company and each Affiliate, and
any agent of the Company or any Affiliate administering the Plan or providing
Plan record keeping services, to disclose to the Company or any of its
Affiliates such information and data as the Company or any such Affiliate shall
request in order to facilitate the grant of Shares and the administration of the
Plan; (ii) waives any data privacy rights he or she may have with respect to
such information; and (iii) authorizes the Company and each Affiliate to store
and transmit such information in electronic form.

 

[THE NEXT PAGE IS THE SIGNATURE PAGE]

 

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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the
day and year first above written.

 

 

IMMUNOGEN, INC.

 

 

 

 

 

By:

 

 

Name:

Mark J. Enyedy

 

Title:

President and Chief Executive Officer

 

 

 

 

 

 

Participant:

 

 

 

 

 

Print Name:

 

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EXHIBIT A

 

CONSENT OF SPOUSE/DOMESTIC PARTNER

 

I,                             , spouse or domestic partner of
                         , acknowledge that I have read the PERFORMANCE BASED
RESTRICTED STOCK AGREEMENT dated as of August 12, 2016 (the “Agreement”) to
which this Consent is attached as Exhibit A and that I know its contents. 
Capitalized terms used and not defined herein shall have the meanings assigned
to such terms in the Agreement.  I am aware that by its provisions the Granted
Shares granted to my spouse/domestic partner pursuant to the Agreement are
subject to a Lapsing Forfeiture Right in favor of ImmunoGen, Inc. (the
“Company”) and that, accordingly, I may be required to forfeit to the Company
any or all of the Granted Shares of which I may become possessed as a result of
a gift from my spouse/domestic partner or a court decree and/or any property
settlement in any domestic litigation.

 

I hereby agree that my interest, if any, in the Granted Shares subject to the
Agreement shall be irrevocably bound by the Agreement and further understand and
agree that any community property interest I may have in the Granted Shares
shall be similarly bound by the Agreement.

 

I agree to the Lapsing Forfeiture Right described in the Agreement and I hereby
consent to the forfeiture of the Granted Shares to the Company by my
spouse/domestic partner or my spouse/domestic partner’s legal representative in
accordance with the provisions of the Agreement.  Further, as part of the
consideration for the Agreement, I agree that at my death, if I have not
disposed of any interest of mine in the Granted Shares by an outright bequest of
the Granted Shares to my spouse or domestic partner, then the Company shall have
the same rights against my legal representative to exercise its rights to the
Granted Shares with respect to any interest of mine in the Granted Shares as it
would have had pursuant to the Agreement if I had acquired the Granted Shares
pursuant to a court decree in domestic litigation.

 

I AM AWARE THAT THE LEGAL, FINANCIAL AND RELATED MATTERS CONTAINED IN THE
AGREEMENT ARE COMPLEX AND THAT I AM FREE TO SEEK INDEPENDENT PROFESSIONAL
GUIDANCE OR COUNSEL WITH RESPECT TO THIS CONSENT.  I HAVE EITHER SOUGHT SUCH
GUIDANCE OR COUNSEL OR DETERMINED AFTER REVIEWING THE AGREEMENT CAREFULLY THAT I
WILL WAIVE SUCH RIGHT.

 

Dated as of the         day of                 , 201  .

 

 

 

 

Print name:

 

A-1

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EXHIBIT B

 

Election to Include Gross Income in Year

of Transfer Pursuant to Section 83(b)

of the Internal Revenue Code of 1986, as amended

 

In accordance with Section 83(b) of the Internal Revenue Code of 1986, as
amended (the “Code”), the undersigned hereby elects to include in his gross
income as compensation for services the excess, if any, of the fair market value
of the property (described below) at the time of transfer over the amount paid
for such property.

 

The following sets for the information required in accordance with the Code and
the regulations promulgated hereunder:

 

1.                                      The name, address and social security
number of the undersigned are:

 

Name:

Address:

Social Security No.:

 

2.                                      The description of the property with
respect to which the election is being made is as follows:

 

(    ) shares (the “Shares”) of Common Stock, $.01 par value per share, of
ImmunoGen, Inc., a Massachusetts corporation (the “Company”).

 

3.                                      This election is made for the calendar
year     , with respect to the transfer of the property to the Taxpayer on
                  (the “Grant Date”).

 

4.                                      Description of restrictions:  The
property is subject to the following restrictions:

 

In the event taxpayer’s service with the Company or an Affiliate is terminated
prior to the achievement of a performance goal set forth in the  restricted
stock agreement or a performance goal is not achieved by the fifth anniversary
of the Grant Date, the taxpayer shall forfeit one-third of the Shares for each
of the three performance goals not achieved by the applicable time.

 

5.                                      The fair market value at time of
transfer (determined without regard to any restrictions other than restrictions
which by their terms will never lapse) of the property with respect to which
this election is being made is:  $[   ] per Share  x  [    ] Shares  = 
$[      ]. was not more than $     per Share.

 

6.                                      The amount paid by taxpayer for said
property was $[    ] per Share  x  [    ] Shares  =  $[    ].

 

7.                                      The amount to include in gross income is
$[     ].

 

The undersigned taxpayer will file this election with the Internal Revenue
Service office with which taxpayer files his annual income tax return not later
than 30 days after the date of transfer of the property. A copy of the election
also will be furnished to the person for whom the services were performed.
Additionally, the undersigned will include a copy of the election with his
income tax return for the taxable year in which the property is transferred. The
undersigned is the person performing the services in connection with which the
property was transferred.

 

Signed this      day of       , 201  .

 

 

 

 

Print Name:

 

B-1

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