exv10w5w5



 







    Exhibit
    10.5.5



 




    RESTRICTED
    STOCK AWARD AGREEMENT



 



    THIS RESTRICTED STOCK AWARD AGREEMENT (the
    “Agreement”) is made by and
    between          
    (“Recipient”) and InfraSource Services, Inc., a
    Delaware corporation (the “Company”), as
    of          ,
    200  . Capitalized terms used but not otherwise
    defined in this Agreement shall have the respective meanings set
    forth in the Company’s 2004 Omnibus Stock Incentive Plan
    (the “Plan”).



 



    On          ,
    200   (the “Date of Grant”), the Board of
    Directors of the Company (the “Board”), in its
    capacity as Administrator under the Plan, awarded the Recipient
    a Restricted Stock Award, pursuant to which the Recipient was
    awarded           shares
    of common stock of the Company (“Common Stock”), par
    value $.001 per share (the “Unvested Shares”),
    pursuant to and subject to the terms and conditions of the Plan
    and this Agreement. The Restricted Stock Award is made to the
    Recipient as compensation for his services as a member of the
    Board of Directors of the Company.



 



    1. Repurchase Option.



 



    (a) If Recipient’s service as a director with the
    Company or any Parent or Subsidiary is terminated for any
    reason, including death or Disability (such date of termination
    of service is hereinafter referred to as the “Termination
    Date”), the Company shall have the right, but not the
    obligation, to purchase from Recipient, or Recipient’s
    personal representative, as the case may be, any or all of the
    Recipient’s Unvested Shares that have not become vested
    pursuant to Section 1(d) of this Agreement as of the
    Termination Date, at the par value of the Unvested Shares (the
    “Repurchase Option”) and otherwise in accordance with
    the terms set forth below.



 



    (b) The Company may exercise its Repurchase Option by
    delivering personally or by registered mail, to Recipient (or
    his transferee or legal representative, as the case may be),
    within twelve (12) months after the date of termination, a
    notice in writing indicating the Company’s intention to
    exercise the Repurchase Option and setting forth a date for
    closing not later than thirty (30) days from the mailing of
    such notice. The closing shall take place at the Company’s
    office. At the closing, the holder of the certificates for the
    Unvested Shares being transferred shall deliver the stock
    certificate or certificates evidencing the Unvested Shares, and
    the Company shall deliver the purchase price therefor.



 



    (c) If the Company does not elect to exercise the
    Repurchase Option conferred above by giving the requisite notice
    within twelve (12) months following the Termination Date,
    the Repurchase Option shall terminate.



 



    (d) Subject to the provisions of Section 1(a) and 1(b)
    above, and subject to termination pursuant to section 1(c)
    above, and provided that the applicable Share Vesting Event (as
    hereinafter defined) occurs prior to the Recipient’s
    Termination Date, the Repurchase Option shall automatically
    terminate, and the Unvested Shares shall become vested
    (“Shares”) on the earlier to occur of: (i) the
    applicable Share Vesting Date (as hereinafter defined), and
    (ii) upon a Change in Control of the Company ((i) and
    (ii) individually and collectively referred to as a
    “Share Vesting Event”). The Share Vesting Date is the
    earliest date (other than a Change in Control) on which the
    Repurchase Option shall terminate with respect to all Unvested
    Shares and shall
    be          ,     .



 



    (e) For the purposes of this Agreement, “Change in
    Control” shall mean: (A) a merger, consolidation,
    share exchange, spin-out or other reorganization involving at
    least 50% of the voting securities of the Company; (B) a
    complete liquidation or dissolution of the Company; or
    (C) the sale or other disposition of all or substantially
    all of the assets of the Company and its Subsidiaries to any
    person (other than a transfer to another Subsidiary of the
    Company).



 



    2. Transferability of the Shares; Escrow.



 



    (a) Recipient hereby authorizes and directs the Secretary
    of the Company, or such other person designated by the Company,
    to take such steps as may be necessary to cause the transfer of
    the Unvested Shares as to which the Repurchase Option has been
    exercised from Recipient to the Company.



 



    (b) To insure the availability for delivery of
    Recipient’s Unvested Shares upon repurchase by the Company
    pursuant to the Repurchase Option under Section 1,
    Recipient hereby appoints the Secretary of the













 






    Company, or any other person designated by the Company as escrow
    agent, as his
    attorney-in-fact
    to sell, assign and transfer unto the Company such Unvested
    Shares, if any, repurchased by the Company pursuant to the
    Repurchase Option and shall, upon execution of this Agreement,
    deliver and deposit with the Secretary of the Company, or such
    other person designated by the Company, the share certificates
    representing the Unvested Shares, together with the stock
    assignment duly endorsed in blank, attached hereto as
    Exhibit A. The Unvested Shares and stock assignment
    shall be held by the Secretary in escrow, pursuant to the Joint
    Escrow Instructions of the Company and Recipient attached as
    Exhibit B hereto, until the Company exercises its
    Repurchase Option, until such Unvested Shares are vested, or
    until such time as this Agreement no longer is in effect. As a
    further condition to the Company’s obligations under this
    Agreement, the spouse of the Recipient, if any, shall execute
    and deliver to the Company the Consent of Spouse attached hereto
    as Exhibit C. Upon vesting of the Unvested Shares
    pursuant to the provisions of Section 1(d) of this
    Agreement, the escrow agent shall promptly deliver to the
    Recipient the certificate or certificates representing such
    Shares in the escrow agent’s possession belonging to the
    Recipient in accordance with the terms of the Joint Escrow
    Instructions, and the escrow agent shall be discharged of all
    further obligations hereunder; provided, however, that the
    escrow agent shall nevertheless retain such certificate or
    certificates if so required pursuant to other restrictions
    imposed pursuant to this Agreement.



 



    (c) The escrow agent shall not be liable for any act it may
    do or omit to do with respect to holding the Shares in escrow
    and while acting in good faith and in the exercise of its
    judgment.



 



    (d) Any purported transfer or sale of the Shares shall be
    subject to restrictions on transfer imposed by any applicable
    state and Federal securities laws. Any transferee shall hold
    such Shares subject to all the provisions hereof and shall
    acknowledge the same by signing a copy of this Agreement.



 



    3. Ownership, Voting Rights, Duties.  This
    Agreement shall not affect in any way the ownership, voting
    rights or other rights or duties of Recipient, except as
    specifically provided herein.



 



    4. Legends.  The share certificate or
    certificates evidencing the Shares issued hereunder shall be
    endorsed with the following legend (in addition to any other
    legend or legends required under applicable Federal and state
    securities laws):



 



    THE SHARES REPRESENTED BY THIS CERTIFICATE ARE SUBJECT TO
    CERTAIN RESTRICTIONS UPON TRANSFER AND RIGHTS OF REPURCHASE AS
    SET FORTH IN AN AGREEMENT BETWEEN THE COMPANY AND THE
    SHAREHOLDER, A COPY OF WHICH IS ON FILE WITH THE SECRETARY OF
    THE COMPANY.



 



    Upon lapse of such restrictions on transfer, the Company shall
    direct the Company’s transfer agent to remove such legend.



 



    5. Adjustments.  All rights and
    obligations under this Agreement are subject to Section 3
    of the Plan, the terms of which are incorporated herein by this
    reference.



 



    6. Notices.  All notices and other
    communications under this Agreement shall be in writing and
    shall be given by facsimile or first class mail, certified or
    registered with return receipt requested, and shall be deemed to
    have been duly given three days after mailing or 24 hours
    after transmission by facsimile to the respective parties named
    below:



 


	 	 	 
	

    If to Company:
    


	
 
	
    InfraSource Services, Inc.

    100 West Sixth Street

    Suite 300

    Media, PA 19063

    Attention:  General Counsel

    Facsimile:  (610) 480-8095
    

	
 
	
 
	
 

	

    If to Recipient:
    


	
 
	
 

	
 
	
 
	
    


	
 
	
 
	
    at the address listed on the
    signature page to this

    Agreement
    










    

    2








 






    Either party hereto may change such party’s address for
    notices by notice duly given pursuant hereto.



 



    7. Survival of Terms.  This Agreement
    shall apply to and bind Recipient and the Company and their
    respective permitted assignees and transferees, heirs, legatees,
    executors, administrators and legal successors.



 



    8. Section 83(b) Election.  Recipient
    hereby acknowledges that he has been informed that, with respect
    to the Unvested Shares, an election may be filed by the
    Recipient with the Internal Revenue Service, within 30 days
    after the award of the Shares, electing pursuant to
    Section 83(b) of the Code to be taxed currently on any
    difference between the aggregate acquisition price of the Shares
    and the aggregate Fair Market Value of the Shares on the date of
    acquisition. A form of such election is attached hereto as
    Exhibit D.



 



    Recipient acknowledges that it is Recipient’s sole
    responsibility and not the Company’s to file timely the
    election under Section 83(b) of the Code, even if Recipient
    requests the Company or its representative to make this filing
    on Recipient’s behalf.



 



    9. Representations.  Recipient has
    reviewed with his own tax advisors the Federal, state, local and
    foreign tax consequences of this investment and the transactions
    contemplated by this Agreement. Recipient is relying solely on
    such advisors and not on any statements or representations of
    the Company or any of its agents. Recipient understands that he
    (and not the Company) shall be responsible for any tax liability
    that may arise as a result of this investment or the
    transactions contemplated by this Agreement.



 



    10. Incorporation of Plan.  The Plan is
    hereby incorporated by reference and made a part hereof.



 



    11. Amendments.  This Agreement may be
    amended or modified at any time only by an instrument in writing
    signed by each of the parties hereto.



 



    12. Agreement Not a Contract of
    Employment.  Neither this Agreement nor any other
    action taken pursuant to this Agreement shall constitute or be
    evidence of any agreement or understanding, express or implied,
    that the Recipient has a right to continue to provide services
    as an officer, director, employee, consultant or advisor of the
    Company or any Parent, Subsidiary or affiliate of the Company
    for any period of time or at any specific rate of compensation.



 



    13. Authority of the Board.  The Board
    shall have full authority to interpret and construe the terms of
    this Agreement. The determination of the Board as to any such
    matter of interpretation or construction shall be final, binding
    and conclusive.



 



    14. Protections Against Violations of
    Agreement.  No purported sale, assignment,
    mortgage, hypothecation, transfer, pledge, encumbrance, gift,
    transfer in trust (voting or other) or other disposition of, or
    creation of a security interest in or lien on, any of the Shares
    by any holder thereof in violation of the provisions of this
    Agreement, will be valid, and the Company will not transfer any
    of said Shares on its books unless and until there has been full
    compliance with said provisions to the satisfaction of the
    Company. The foregoing restrictions are in addition to, and not
    in lieu of, any other remedies, legal or equitable, available to
    enforce said provisions.



 



    15. Market Stand-Off.  In connection with
    any underwritten public offering by the Company of its equity
    securities pursuant to an effective registration statement filed
    under the Securities Act of 1933, as amended, for such period as
    the Company or its underwriters may request (such period not to
    exceed 180 days following the date of the applicable
    offering), the Recipient shall not, directly or indirectly,
    sell, make any short sale of, loan, hypothecate, pledge, offer,
    grant or sell any option or other contract for the purchase of,
    purchase any option or other contract for the sale of, or
    otherwise dispose of or transfer, or agree to engage in any of
    the foregoing transactions with respect to, any Shares without
    the prior written consent of the Company or its underwriters.



 



    16. Representation by
    Recipient.  Recipient represents that he has read
    this Agreement and is familiar with its terms and provisions.
    Recipient hereby agrees to accept as binding, conclusive and
    final all decisions or interpretations of the Board upon any
    questions arising under this Agreement.




    

    3








 





 



    IN WITNESS WHEREOF, this Agreement is deemed made as of the date
    first set forth above.



 


	 	 	 
	

    RECIPIENT:
    


	
 
	
    INFRASOURCE SERVICES, INC.
    

	
 
	
 
	
 

	
    
Signature
    
	
 
	
    


	
 
	
 
	
 

	
    
Print
    Name
    
	
 
	
    
Title
    

	
 
	
 
	
 

	
    
Social
    Security Number
    
	
 
	
 

	
 
	
 
	
 

	
    

	
 
	
 

	
 
	
 
	
 

	
    
Residence
    Address
    
	
 
	
 










    

    4








 







    EXHIBIT A



 




    ASSIGNMENT
    SEPARATE FROM CERTIFICATE



 



    FOR VALUE
    RECEIVED,          
    (the “Recipient”) hereby sells, assigns and transfers
    unto INFRASOURCE SERVICES, INC., a Delaware corporation (the
    “Company”),          
    (          )
    shares of the Company’s Common Stock, $0.001 par value
    per share (the “Common Stock”), standing in his name
    on the books of said corporation represented by Certificate
    No.       herewith and does hereby
    irrevocably constitute and
    appoint          
    to transfer the said stock on the books of the within named
    corporation with full power of substitution in the premises.



 



    This Assignment Separate from Certificate may be used only in
    accordance with the Restricted Stock Award Agreement (the
    “Agreement”) of the Company and the undersigned,
    dated           ,
    200 .



 


	 	 	 	 	 
	

    Dated:           
    


	
 
	
 
	
    Signature: _
    _
	
 









 



    INSTRUCTIONS:  Please do not fill in any blanks
    other than the signature line. The purpose of this Assignment
    Separate from Certificate is to enable the Company to exercise
    its “repurchase option,” as set forth in the
    Agreement, without requiring additional signatures on the part
    of the Recipient. This Assignment Separate from Certificate must
    be delivered to the Company with the above Certificate
    No.   .




    

    A-1








 





 




    EXHBIT
    B



 




    JOINT
    ESCROW INSTRUCTIONS



 




              ,
    200      
    



 



    INFRASOURCE SERVICES, INC.



 



    Attention: Secretary



 



    As Escrow Agent for both INFRASOURCE SERVICES, INC., a Delaware
    corporation (the “Company”),
    and          
    (“Recipient”) of the Company’s Common Stock (the
    “Common Stock”) you are hereby authorized and directed
    to hold the documents delivered to you pursuant to the terms of
    that certain Restricted Stock Award Agreement between the
    Company and Recipient,
    dated             ,
    200  (the “Agreement”), in accordance with the
    following instructions:



 



    1. In the event the Company
    and/or any
    assignee of the Company (referred to collectively for
    convenience herein as the “Company”) exercises the
    Company’s repurchase option set forth in the Agreement (the
    “Repurchase Option”), the Company shall give to
    Recipient and to you a written notice specifying the number of
    shares of Common Stock (the “Shares”) to be purchased,
    the purchase price, and the time for a closing hereunder at the
    principal office of the Company. Recipient and the Company
    hereby irrevocably authorize and direct you to close the
    transaction contemplated by such notice in accordance with the
    terms of said notice.



 



    2. At the closing, you are directed (a) to date the
    Assignment Separate From Certificate necessary for the transfer
    in question, (b) to fill in the number of Shares being
    transferred, and (c) to deliver same, together with the
    certificate evidencing the Shares to be transferred, to the
    Company or its assignee, against the simultaneous delivery to
    you of the purchase price for the number of Shares purchased
    pursuant to the exercise of the Company’s Repurchase Option.



 



    3. Recipient hereby irrevocably authorizes the Company to
    deposit with you any certificates evidencing the Shares to be
    held by you hereunder and any additions and substitutions to
    said Shares as set forth in the Agreement. Recipient does hereby
    irrevocably constitute and appoint you as Recipient’s
    attorney-in-fact
    and agent for the term of this escrow to execute with respect to
    such Shares all documents necessary or appropriate to make such
    Shares negotiable and to complete any transaction herein
    contemplated, including but not limited to, the filing with any
    applicable state blue sky authority of any required applications
    for consent to, or notice of transfer of, the Shares. Subject to
    the provisions of this Section 3, Recipient shall exercise
    all rights and privileges of a shareholder of the Company while
    the stock is being held by you.



 



    4. Upon written request of the Recipient, but not more than
    once following any applicable Share Vesting Event, unless the
    Company’s Repurchase Option has been exercised, you will
    deliver to Recipient a certificate or certificates representing
    the aggregate number of Shares that are not then subject to the
    Company’s Repurchase Option. Within 120 days after
    Recipient’s termination of employment or service with the
    Company or any Parent or Subsidiary (each, as defined in the
    Company’s 2004 Omnibus Stock Incentive Plan), you will
    deliver to Recipient, or Recipient’s representative, as the
    case may be, a certificate or certificates representing the
    aggregate number of Shares held or issued pursuant to the
    Agreement and not purchased by the Company or its assignees
    pursuant to exercise of the Company’s Repurchase Option.



 



    5. If at the time of termination of this escrow you should
    have in your possession any documents, securities, or other
    property belonging to Recipient, you shall deliver all of the
    same to Recipient and shall be discharged of all further
    obligations hereunder.



 



    6. Your duties hereunder may be altered, amended, modified
    or revoked only by a writing signed by all of the parties hereto.



 



    7. You shall be obligated only for the performance of such
    duties as are specifically set forth herein and may rely and
    shall be protected in relying or refraining from acting on any
    instrument reasonably believed by you to be genuine and to have
    been signed or presented by the proper party or parties. You
    shall not be personally liable for any act you may do or omit to
    do hereunder as Escrow Agent or as
    attorney-in-fact
    for




    

    B-1








 






    Recipient while acting in good faith, and any act done or
    omitted by you pursuant to the advice of your own attorneys
    shall be conclusive evidence of such good faith.



 



    8. You are hereby expressly authorized to disregard any and
    all warnings given by any of the parties hereto or by any other
    person or corporation, excepting only orders or process of
    courts of law and are hereby expressly authorized to comply with
    and obey orders, judgments or decrees of any court. In case you
    obey or comply with any such order, judgment or decree, you
    shall not be liable to any of the parties hereto or to any other
    person, firm or corporation by reason of such compliance,
    notwithstanding any such order, judgment or decree being
    subsequently reversed, modified, annulled, set aside, vacated or
    found to have been entered without jurisdiction.



 



    9. You shall not be liable in any respect on account of the
    identity, authorities or rights of the parties executing or
    delivering or purporting to execute or deliver the Agreement or
    any documents or papers deposited or called for hereunder.



 



    10. You shall not be liable for the outlawing of any rights
    under the Statute of Limitations with respect to these Joint
    Escrow Instructions or any documents deposited with you.



 



    11. You shall be entitled, at the expense of the Company,
    to employ such legal counsel and other experts as you may deem
    necessary and proper to advise you in connection with your
    obligations hereunder, may rely upon the advice of such counsel,
    and may pay such counsel reasonable compensation therefor.



 



    12. Your responsibilities as Escrow Agent hereunder shall
    terminate if you shall cease to be an officer or agent of the
    Company or if you shall resign by written notice to each party.
    In the event of any such termination, the Company shall appoint
    a successor Escrow Agent.



 



    13. If you reasonably require other or further instruments
    in connection with these Joint Escrow Instructions or
    obligations in respect hereto, the necessary parties hereto
    shall join in furnishing such instruments.



 



    14. It is understood and agreed that should any dispute
    arise with respect to the delivery
    and/or
    ownership or right of possession of the securities held by you
    hereunder, you are authorized and directed to retain in your
    possession without liability to anyone all or any part of said
    securities until such disputes shall have been settled either by
    mutual written agreement of the parties concerned or as
    otherwise provided in the Agreement, but you shall be under no
    duty whatsoever to institute or defend any such proceedings.



 



    15. All notices and other communications under this Joint
    Escrow Instructions shall be in writing and shall be given by
    facsimile or first class mail, certified or registered with
    return receipt requested, and shall be deemed to have been duly
    given three days after mailing or 24 hours after
    transmission by facsimile to the




    

    B-2








 






    respective parties named below at the following addresses or at
    such other addresses as a party may designate by ten days’
    advance written notice to each of the other parties hereto:



 


	 	 	 
	

    If to Company:
    


	
 
	
    InfraSource Services, Inc.

    100 West Sixth Street

    Suite 300 

    Media, PA  19063

    Attention:  General Counsel

    Facsimile:  (610) 480-8095
    

	
 
	
 
	
 

	

    If to Recipient:
    


	
 
	
 

	
 
	
 
	
    


	
 
	
 
	
 

	
 
	
 
	
    


	
 
	
 
	
 

	
 
	
 
	
    


	
 
	
 
	
 

	
 
	
 
	
    


	
 
	
 
	
    Facsimile:
    

	
 
	
 
	
 

	

    If to the Escrow Agent:
    


	
 
	
    INFRASOURCE SERVICES, INC.
    

	
 
	
 
	
 

	
 
	
 
	
    Corporate Secretary

    100 West Sixth Street

    Suite 300 

    Media, PA  19063

    Facsimile:  (610) 480-8095
    









 



    16. By signing these Joint Escrow Instructions, you become
    a party hereto only for the purpose of said Joint Escrow
    Instructions; you do not become a party to the Agreement.



 



    17. This instrument shall be binding upon and inure to the
    benefit of the parties hereto, and their respective successors
    and permitted assigns.



 



    18. These Joint Escrow Instructions shall be governed by
    the internal substantive laws, but not the choice of law rules,
    of the State of Delaware.



 


	 	 	 
	

    RECIPIENT:
    


	
 
	
    INFRASOURCE SERVICES, INC.
    

	
 
	
 
	
 

	
    
Signature
    
	
 
	
    
By
    

	
 
	
 
	
 

	
    
Print
    Name
    
	
 
	
    
Title
    

	
 
	
 
	
 

	
    

	
 
	
 

	
 
	
 
	
 

	
    
Residence
    Address
    
	
 
	
 

	
 
	
 
	
 

	

    ESCROW AGENT
    


	
 
	
 

	
 
	
 
	
 

	
    
Corporate
    Secretary
    
	
 
	
 










    

    B-3








 







    EXHIBIT C



 




    CONSENT
    OF SPOUSE



 



    I,          ,
    spouse
    of          ,
    have read and hereby approve the Restricted Stock Award
    Agreement by and
    between          
    and INFRASOURCE SERVICES, INC., a Delaware corporation (the
    “Company”),
    dated          ,
    200  (the “Agreement”). In consideration of the
    award of the Unvested Shares to my spouse, as set forth in the
    Agreement, I hereby appoint my spouse as my
    attorney-in-fact
    with respect to the exercise of any rights or obligations under
    the Agreement and agree to be bound by the provisions of the
    Agreement insofar as I may have any rights in said Agreement or
    any shares of Common Stock issued pursuant thereto under the
    community property laws or similar laws relating to marital
    property in effect in the state of our residence as of the date
    of the signing of the foregoing Agreement.



 


	 	 	 	 	 
	

    Dated:           ,
    200 
    


	
 
	
 
	
    Signature: _
    _
	
 










    

    C-1








 







    EXHIBIT D



 




    ELECTION
    UNDER SECTION 83(b)



 




    OF THE
    INTERNAL REVENUE CODE OF 1986



 



    The undersigned taxpayer hereby elects, pursuant to
    Section 83(b) of the Internal Revenue Code of 1986, as
    amended, to include in taxpayer’s gross income for the
    current taxable year the amount of any compensation taxable to
    taxpayer in connection with taxpayer’s receipt of the
    property described below:



 



    The name address, taxpayer identification number and taxable
    year of the undersigned are as follows:



 


			
	    NAME OF TAXPAYER:
	
    

	 



			
	    NAME OF SPOUSE:
	
    

	 



			
	    ADDRESS:
	
    

	 



			
	    IDENTIFICATION NO. OF TAXPAYER:
	
    

	 



			
	    IDENTIFICATION NUMBER OF SPOUSE:
	
    

	 



			
	    TAXABLE YEAR:
	
    

	 



 



    1. The property with respect to which the election is made
    is described as
    follows:           shares
    (the “Shares”) of the Common Stock of INFRASOURCE
    SERVICES, INC. (the “Company”).



 



    2. The date on which the property was transferred
    is:          ,
    20  .



 



    3. The property is subject to the following restrictions:



 



    The Shares may not be transferred and are subject to forfeiture
    under the terms of an agreement between the taxpayer and the
    Company. These restrictions lapse upon the satisfaction of
    certain conditions in such agreement.



 



    4. The fair market value at the time of transfer,
    determined without regard to any restriction other than a
    restriction which by its terms will never lapse, of such
    property is:
    $          .



 



    5. The amount (if any) paid for such property is:
    $          .



 



    The undersigned has submitted a copy of this statement to the
    person for whom the services were performed in connection with
    the undersigned’s receipt of the above-described property.
    The transferee of such property is the person performing the
    services in connection with the transfer of said property.



 



    The undersigned understands that the foregoing election may
    not be revoked except with the consent of the Commissioner.



 


	 	 	 	 	 
	

    Dated:     20  
    


	
 
	
    

	
 
	
 

	
 
	
 
	
    Taxpayer
    
	
 
	
 









 



    The undersigned spouse of taxpayer joins in this election.



 


	 	 	 	 	 
	

    Dated:     20  
    


	
 
	
    

	
 
	
 

	
 
	
 
	
    Spouse of Taxpayer
    
	
 
	
 










    

    D-1