Exhibit 10.3

RESTRICTED STOCK AGREEMENT

 

IMMUNOGEN, INC.

 

 

AGREEMENT made as of the _______ day of ___________________, 201__ (the “Grant
Date”), between ImmunoGen, Inc. (the “Company”), a Massachusetts corporation,
and ________________________ (the “Participant”).

 

WHEREAS, the Company has adopted the ImmunoGen, Inc. 2016 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, ______________________ (_________) Shares of the Company’s Common
Stock (such shares, subject to adjustment pursuant to Section 25 of the Plan and
Subsection 2.1(h) 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.  Except as otherwise set forth in Sections 2(b),(c)
and (d) below, in the event that for any reason the Participant is no longer an
employee, director or consultant of the Company or an Affiliate (such event
being the “Termination”) prior to __________________, the Participant (or the
Participant’s Survivor) shall, on the date of Termination, immediately forfeit
to the Company (or its designee) all of the Granted Shares which have not yet
lapsed in accordance with the schedule set forth below (the “Lapsing Forfeiture
Right”). 

 

The Company’s Lapsing Forfeiture Right is as follows:

 

(i)If the Participant’s Termination is prior to [the first anniversary of the
Grant Date], all of the Granted Shares shall be forfeited to the Company.

 

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(ii)If the Participant’s Termination is on or after [the first anniversary of
the Grant Date] but prior to _______________, __% of the Granted Shares shall be
forfeited to the Company (rounded up to the next highest whole number of
shares).

 

[Continue from (ii) for additional vesting periods.]

 

(b)Effect of Termination for Disability or upon Death.  The following rules
apply if the Participant’s Termination is by reason of Disability or death:  to
the extent the Company’s Lapsing Forfeiture Right has not lapsed as of the date
of Disability or death, as case may be, the Participant shall forfeit to the
Company any or all of the Granted Shares subject to such Lapsing Forfeiture
Right; provided, however, that the Company’s Lapsing Forfeiture Right shall be
deemed to have lapsed to the extent of a pro rata portion of the Granted Shares
through the date of Disability or death, as would have lapsed had the
Participant not become Disabled or died, as the case may be.  The proration
shall be based upon the number of days accrued in such current vesting period
prior to the Participant’s date of Disability or death, as the case may be.

 

(c)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.

 

(d)Effect of Change of Control.  Except as otherwise provided in Subsection
2.1(c) above, if within a period of 2 years from the date of a Change of Control
(as defined in the Plan) that is not a Corporate Transaction where stock grants
are terminated in exchange for a cash payment in accordance with Section 25(b)
of the Plan, the Participant is terminated by the Company other than for Cause
or has left the Company for Good Reason (as defined below), then upon such
termination date 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 .  “Good Reason” shall mean the occurrence of one or more of
the following without the Participant’s consent:  (i) a change in the principal
location at which the Participant performs his duties for the Company to a new
location that is at least forty (40) miles from the prior location; (ii) a
material change in the Participant's authority, functions, duties or
responsibilities as an employee of or consultant to the Company, which would
cause the Participant’s position with the Company to become of less
responsibility, importance or scope than the highest position held by the
Participant immediately prior to the Change of Control, provided, however, that
such material change is not in connection with the termination of the
Participant’s service by the Company for Cause or death or Disability and
further provided that it shall not be considered a material change if the
Company becomes a subsidiary of another entity and the Participant continues to
hold the same position in the subsidiary that is at least as high (in both title
and responsibilities) as the highest position held by the Participant with the
Company at any time from the Grant Date to immediately prior to the Change of
Control; (iii) a material reduction in the Participant’s annual base salary or
fee; or (iv) a material reduction in the Participant’s target annual bonus as
compared to the target annual bonus set for the previous fiscal year; provided
that any definition in an agreement between the Participant and the Company or
an Affiliate, which contains a conflicting definition of “Good Reason” for
termination and which is in effect at the time of such termination, shall
supersede the definition in this Plan with respect to that Participant.

 

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

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Corporate Transaction where all stock grants are terminated in exchange for a
cash payment in accordance with Section 25(b) of the Plan.

 

(e)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(e). 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 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. 

 

(f)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(f), 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(f).

 

(g)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(e) 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.

 

(h)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

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by the Company in connection with such offering to sign an agreement restricting
the sale or other transfer of Shares, then it 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 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.

 

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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 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 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 obligations associated with the termination of the Lapsing Forfeiture Right
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.

 

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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 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

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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.

 

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:

Title: 

 

 

Participant:

 

 

Print Name:

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Exhibit 10.3

EXHIBIT A

CONSENT OF SPOUSE/DOMESTIC PARTNER

 

I, ____________________________, spouse or domestic partner of
_________________________, acknowledge that I have read the RESTRICTED STOCK
AGREEMENT dated as of _______________ (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 10.3

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 _________________.

 

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

 

In the event taxpayer’s employment with the Company or an Affiliate is
terminated, the taxpayer shall forfeit the Shares as set forth below:

 

A.If the termination takes place on or prior to ____________ all of the Shares
will be forfeited.

 

B.If the termination takes place after __________, 201_, the number of Shares
forfeited shall be ______________ (___) Shares less ____________________ (___)
Shares for each full twelve (12) month period elapsed after _____________, 201_
if the taxpayer is employed by the Company or an Affiliate.

 

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

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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:

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