Exhibit 10.3

Independence Bancshares, Inc.

2013 Equity Incentive Plan

Restricted Stock Award Grant Notice

 

 

Participant Name: [Name]   Company: Independence Bancshares, Inc.   Notice: A
summary of the terms of your grant of Restricted Shares is set out in this
notice (the “Grant Notice”) but subject always to the terms of the Independence
Bancshares, Inc. 2013 Equity Incentive Plan (the “Plan”) and the Restricted
Stock Award Agreement (the “Award Agreement”).  In the event of any
inconsistency between the terms of this Grant Notice, the terms of the Plan and
the Award Agreement, the terms of the Plan and the Award Agreement shall
prevail.   Type of Award: Restricted Stock Award   Stock: Shares of common
stock, $0.01 par value per share, of the Company   Number of Shares
of Stock Subject
to Grant: _______________ shares of Stock   Grant Date: [Date]   Vesting
Schedule: Restricted Shares granted will vest (i.e., restrictions shall lapse)
in accordance with the following schedule, provided that you have provided
continuous employment to the Company or any Related Company through each such
vesting date:     First anniversary of the Grant Date – [   ] vested     Second
anniversary of the Grant Date – an additional [    ] vested     Third
anniversary of the Grant Date – an additional [       ] vested.     In addition,
the Restricted Shares granted will not vest until [insert performance vesting
condition, if applicable].     In the event of a Change of Control, all unvested
Restricted Shares will automatically vest in full immediately prior to the
consummation of the Change of Control.   Acceptance: You acknowledge receipt of,
and understand and agree to, this Grant Notice, the Award Agreement and the
Plan. You further acknowledge  

 
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  that as of the Grant Date, this Grant Notice, the Award Agreement and the Plan
set forth the entire understanding between you and the Company or any Related
Company regarding the Restricted Shares and supersede all prior oral and written
Award Agreements on the subject.

 

 

IN WITNESS WHEREOF, the Company and the Participant have duly executed and
delivered this Grant Notice as of the Grant Date.

Independence Bancshares, Inc. PARTICIPANT

 

By: ________________________________       _____________________________

Print Name: _________________________       [Name]

Title: ______________________________       Address: _____________________

____________________________

____________________________

 

Attachments:

1.       Restricted Stock Award Agreement

2.       2013 Equity Incentive Plan

 
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Independence Bancshares, Inc.

Restricted Stock Award Agreement

Pursuant to the Restricted Stock Grant Notice (the “Grant Notice”) and this
Restricted Stock Award Agreement (this “Award Agreement”), Independence
Bancshares, Inc. (the “Company”) has granted the Participant, as identified in
the Grant Notice, the number of restricted shares of the Company's Common Stock
under the Company's 2013 Equity Incentive Plan (the “Plan”) indicated in the
Grant Notice (the “Restricted Shares”). Capitalized terms not defined in this
Award Agreement but defined in the Plan or the Grant Notice will have the same
definitions as in the Plan or the Grant Notice, respectively.

1.                  Restrictions and Vesting Schedule. The Restricted Shares are
being awarded to Participant subject to the transfer and forfeiture conditions
set forth in this Award Agreement and the Plan (the "Restrictions"). Subject to
the provisions of Section 2 below, the Restricted Shares will vest, and
Restrictions shall lapse, as provided in the Participant's Grant Notice. The
period from the Date of Grant through the last Vesting Date set forth in the
Grant Notice is referred to as the "Restriction Period". Except to the extent
vesting accelerates pursuant to the terms of the Grant Notice or Section 2
below, any unvested Restricted Shares shall be automatically forfeited upon
Participant's Termination from Service.

2.                  Acceleration of Vesting. All unvested Restricted Shares
shall fully vest upon Participant's Termination from Service by the Company (i)
[insert relevant provision, if applicable], or (ii) for reason of death or
Disability of the Participant.

3.                  Assignment or Transfer of Shares. Unless otherwise provided
by the Board, prior to the vesting of the Restricted Shares, Participant may not
directly or indirectly, by operation of law or otherwise, voluntarily or
involuntarily, sell, assign, pledge, encumber, charge or otherwise transfer any
of the Restricted Shares still subject to Restrictions. The Restricted Shares
shall be forfeited if Participant violates or attempts to violate these transfer
Restrictions. After any Stock has been released from the Restrictions,
Participant shall not directly or indirectly, by operation of law or otherwise,
voluntarily or involuntarily, sell, assign, pledge, encumber, charge or
otherwise transfer any interest in the Stock except in compliance with the
provisions herein and the provisions of applicable securities laws.

4.                  Delivery of Shares. [to be determined]

5.                  Rights of Participant. Subject to the provisions of this
Award Agreement, Participant shall exercise all rights and privileges of a
shareholder of the Company with respect to the Restricted Shares deposited
pursuant to Section 4. Participant shall be deemed to be the holder for purposes
of receiving any dividends that may be paid with respect to such shares of Stock
and for the purpose of exercising any voting rights relating to such shares of
Stock, even if some or all of such shares of Stock have not yet vested and been
released from the Restrictions.

6.                  Restrictive Legends. Certificates representing the Stock
shall have endorsed thereon a legend in substantially the following form:

“THE SHARES REPRESENTED BY THIS CERTIFICATE ARE SUBJECT TO RESTRICTIONS SET
FORTH IN A RESTRICTED STOCK AWARD AGREEMENT BETWEEN THE COMPANY AND THE
REGISTERED HOLDER, OR SUCH HOLDER’S PREDECESSOR IN INTEREST, A COPY OF WHICH IS
ON FILE AT THE PRINCIPAL OFFICE OF THE COMPANY. ANY TRANSFER OR ATTEMPTED
TRANSFER OF ANY

 
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SHARES SUBJECT TO SUCH RESTRICTED STOCK AWARD IS VOID WITHOUT THE PRIOR EXPRESS
WRITTEN CONSENT OF THE COMPANY.”

The Company shall remove or cause the removal of the foregoing legend as and to
the extent of the lapse of the applicable Restrictions.

7.                  Section 83(b) Election. Participant understands that Section
83(a) of the Code taxes as ordinary income the difference between the amounts
paid for the Stock and the fair market value of the Stock as of the date any
Restrictions on the Stock lapse. Participant understands that Participant may
elect to be taxed at the time the Restricted Shares are granted rather than when
and as the Restrictions lapse, by filing an election under Section 83(b) (“83(b)
Election”) of the Code with the Internal Revenue Service within thirty (30) days
from the Date of Grant. Even if the fair market value of the Restricted Shares
at the time of the Grant equals the amount paid for the Stock, if any, the 83(b)
Election must be made to avoid income under Section 83(a) in the future.
Participant understands that failure to file such an 83(b) Election in a timely
manner may result in adverse tax consequences for Participant. Participant
further understands that an additional copy of such 83(b) Election is required
to be filed with his or her federal income tax return for the calendar year in
which the Grant Date in connection with this Award Agreement falls. Participant
further acknowledges and understands that it is Participant’s decision as to
whether to file such 83(b) Election, and neither the Company nor the Company’s
legal or financial advisors shall have any obligation or responsibility with
respect to such filing. Participant acknowledges that the foregoing is only a
summary of the effect of United States federal income taxation with respect to
purchase of the Stock hereunder, and does not purport to be complete.
Participant further acknowledges that the Company has directed Participant to
seek independent advice regarding the applicable provisions of the Code, the
income tax laws of any municipality, state or foreign country in which
Participant may reside, and the tax consequences of Participant’s death.
Participant assumes all responsibility for filing an 83(b) Election and paying
all taxes resulting from such election or the lapse of the Restrictions on the
Stock.

8.                  Refusal to Transfer. The Company shall not be required to
transfer on its books any shares of Stock of the Company which shall have been
transferred in violation of any of the provisions set forth in this Award
Agreement.

9.                  No Employment Rights. This Award Agreement is not an
employment contract and nothing in this Award Agreement shall confer upon the
Participant any right to continued employment with or service to the Company or
any Subsidiary, as the case may be, nor shall it interfere in any way with the
right of the Company or any Subsidiary to terminate the employment or service of
the Participant at any time.

10.              Governing Plan Document. The Restricted Shares granted
hereunder are subject to all the provisions of the Plan, the provisions of which
are hereby incorporated by reference herein, and is further subject to all
interpretations, amendments, rules and regulations which may from time to time
be promulgated and adopted pursuant to the Plan. Capitalized terms used herein
and not defined shall have the meanings assigned in the Plan. In the event of
any conflict between the provisions of this Award Agreement and those of the
Plan, the provisions of the Plan shall control.

11.              Adjustments. The Restricted Shares shall be subject to
adjustments as provided in Sections 4, 9, 10, 11 and 14 of the Plan.

12.              Acknowledgements. No waiver of any breach of any provision of
this Award Agreement by the Company shall be construed to be a waiver of any
succeeding breach or as a modification of such provision.

 
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13.              Miscellaneous.

(a)               Notices. All notices required or permitted hereunder shall be
in writing and shall be deemed effectively given: (a) when personally delivered
to the party to be notified; (b) when sent by confirmed facsimile to the party
to be notified; (c) five (5) business days after deposit in the United States
Mail postage prepared by certified or registered mail with return receipt
requested at any time other than during a general discontinuance of postal
service due to strike, lockout, or otherwise (in which case notice, request,
waiver or other communication shall be effectively given upon receipt) and
address to the party to be notified as set forth above; or (d) two (2) business
day after deposit with a national recognized overnight delivery service, postage
prepaid, addressed to the party to be notified as set forth above with
next-business-day delivery guaranteed. A party may change its notice address by
giving the other party ten (10) days' written of the new address in the manner
set forth above.

(b)               Successors and Assigns. This Award Agreement shall inure to
the benefit of the successors and assigns of the Company and, subject to the
restrictions on transfer herein set forth, be binding upon Participant,
Participant’s successors, and assigns.

(c)                Attorneys’ Fees; Specific Performance. Each party shall be
responsible for its own respective costs and expenses (including, without
limitation, attorneys’ fees and costs) in connection with any action brought by
any party to enforce its rights hereunder or any other legal action involving
this Award Agreement or any party’s performance hereunder.

(d)               Governing Law; Venue. This Award Agreement shall be governed
by and construed in accordance with the laws of the State of South Carolina,
without reference to principles of conflict of laws. The parties agree that any
action brought by either party to interpret or enforce any provision of this
Award Agreement shall be brought in, and each party agrees to, and does hereby,
submit to the jurisdiction and venue of, the appropriate state or federal court
for the district encompassing the Company’s principal place of business.

(e)               Entire Award Agreement; Amendment. This Award Agreement, along
with the Grant Notice and the Plan constitute the entire Award Agreement between
the parties with respect to the subject matter hereof and supersedes and merges
all prior agreements or understandings, whether written or oral. This Award
Agreement may only be amended as described in Section 11 of the Plan.

 

 
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ATTACHMENT A

ELECTION UNDER SECTION 83(B)

OF THE INTERNAL REVENUE CODE OF 1986

 

The undersigned taxpayer hereby elects, pursuant to §83(b) of the Internal
Revenue Code, to include in taxpayer's gross income or alternative minimum tax
income, as applicable, for the current taxable year, the amount of any income
that may be taxable to taxpayer in connection with taxpayer's receipt of the
property described below:

 

1.         The taxpayer's name, address and taxpayer identification number are
as follows:

 

Name:_________________________________________

Address:_______________________________________

________________________________________

SS#_______________________________________

 

2.                  Description of property with respect to which the election
is being made:

 

__________ shares of Common Stock of Independence Bancshares, Inc., a South
Carolina corporation (the “Company") granted pursuant to a Restricted Stock
Award under the Company's Equity Incentive Plan.

 

3.                  The date on which the property was transferred is.

 

The taxable year for which the election is made is calendar year 2___.

 

4.                  The property is subject to the following restrictions:

 

The Restricted Shares are subject to a vesting schedule pursuant to which
restrictions on transfer will lapse.

 

5.         The fair market value at time of transfer (determined without regard
to any restriction other than a restriction which by its terms will never lapse)
of such property is $________________.

 

6.         Amount paid for property:

 

The stock is being purchased for _____________ per share.

 

7.         Furnishing statement to employer:

 

A copy of this statement has been furnished to the Company.

 

 

Dated: _________ __, 20             _______________________________________

Taxpayer:

 

 

 

 

 
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