Exhibit 10.4

 

July   , 2016

 

[NAME]

[ADDRESS]

 

2016 Mid-Term Cash Incentive Plan

 

Dear [       ]:

 

Reference is made to the 99 Cents Only Stores LLC (the “Company”) 2016 Mid-Term
Cash Incentive Plan (“Plan”) and to your Employment Agreement with the Company
dated [•] (“Employment Agreement”).  With respect to your Award of a Mid-Term
Bonus under the Plan (and all references to “the Participant” below shall refer
to you), the provisions of the Plan to the contrary notwithstanding:

 

1.                                      Section 3.4 of the Plan shall be
disregarded and in lieu thereof the following shall apply:

 

3.4                               Separation from Service.

 

(a)  Except as set forth in Section 3.4(b), if the Participant incurs a
Separation from Service for any reason prior to a payment hereunder, the
Participant’s Award shall automatically terminate as of the date of such
Separation from Service, and thereafter the Participant shall have no right as
to any unpaid Mid-Term Bonus.

 

(b)  In the event of the Participant’s Separation from Service prior to a
payment hereunder and prior to the occurrence of a Change in Control (i) without
Cause by the Company or (ii) for Good Reason by the Participant, the Participant
shall be eligible for a pro rata portion of the Mid-Term Bonus Award that is
earned (if any) and unpaid under Sections 3.1 and 3.2 and Appendix A of the Plan
based on the fraction:

 

(x) the numerator of which is the number of days employed during the fiscal year
in which the Initial EBITDA Goal is achieved as to the Award under Section 3.1.1
of the Plan and the denominator of which is the number of days in such fiscal
year, and

 

(y) if the Initial EBITDA Goal is achieved, the numerator of which is the number
of days in the fiscal year in which the Second EBITDA Goal is achieved (if
attained) as to the Award under Section 3.1.2 of the Plan and the denominator of
which is the number of days in such fiscal year,

 

in each case under subparagraph (x) or (y), as applicable, subject to the
attainment of the applicable performance requirements under Sections 3.1 and 3.2
of the Plan; provided, in the event of a Change in Control (1) after the date of
Separation

 

--------------------------------------------------------------------------------

 

from Service, (2) prior to the date on which the Mid-Term Bonus Award is earned
under Section 3.1.1 or 3.1.2 of the Plan, as applicable, and (3) no more than 90
days following the date of such Separation from Service, the denominator in the
fraction under subparagraph (x) or (y), as applicable, shall, if greater, be the
number of days in the fiscal year of such Change in Control through the date of
such Change in Control.

 

Notwithstanding the foregoing, all determinations with respect to any Award
payable under this Section 3.4(b) shall be made, and any payments with respect
thereto shall be paid, prior to March 15 of the calendar year following the
calendar year of the later of (1) the Participant’s Separation from Service, and
(2) the end of the applicable fiscal year with respect to which the Award is
payable (the “Short-Term Deferral Date”) and the Participant shall have no right
to any unpaid Mid-Term Bonus following the applicable Short-Term Deferral Date.

 

For purposes of this Section 3.4, the terms “Cause” and “Good Reason” shall have
the meanings ascribed thereto under the Employment Agreement and the term
“Change in Control” shall have the meaning ascribed thereto under the Number
Holdings, Inc. 2012 Stock Incentive Plan.

 

2.                                      Any amendment, suspension or termination
of the Plan or the Participant’s Award thereunder by the Plan Administrator
pursuant to Section 4.6 of the Plan shall be disregarded unless consented to in
advance in writing by the Chief Executive Officer of the Company and such
amendment, suspension or termination applies to the Participant no less
favorably than it applies to the Chief Executive Officer.

 

3.                                      Section 4.11 shall be disregarded and in
lieu thereof all disputes between the Company and you under the Plan shall be
governed by the Mutual Arbitration of Disputes agreement set forth as Exhibit D
to your Employment Agreement.

 

IN WITNESS WHEREOF, the parties have executed and delivered this letter
agreement as of the date first written above.

 

99 CENTS ONLY STORES LLC

 

 

 

 

 

By:

 

 

 

 

Its:

 

 

 

 

 

 

[NAME]

 

 

2

--------------------------------------------------------------------------------