Exhibit 4.1


 


PAYSIGN, INC. 


RESTRICTED STOCK AGREEMENT 


FOR 


[name]


 


 


1.               
 Award of Restricted Stock. Paysign, Inc., a Nevada corporation (the “Company”) hereby
grants (the “Award”), as of __________________ (the “Date of Grant”), to ________________
(the “Recipient”), _________________ restricted shares of the Company’s Common Stock, par value
$0.001 per share (collectively the “Restricted Stock”). This Award is being issued pursuant to the Company’s
2018 Incentive Compensation Plan (the “Plan”), which is incorporated herein for all purposes. The Recipient
hereby acknowledges receipt of a copy of the Plan and agrees to be bound by all of the terms and conditions hereof and thereof
and all applicable laws and regulations.


 


2.               
Definitions. Unless otherwise provided herein, terms used herein that are defined in the Plan and not
defined herein shall have the meanings attributed thereto in the Plan.


 


3.               
Vesting of Restricted Stock.


 


(a)             
General Vesting. The shares of Restricted Stock shall become vested in the following amounts, at the following
times and upon the following conditions, provided that the Continuous Service of the Recipient continues through and on the applicable
Vesting Date:


 


	Percentage of Restricted Stock	 	Vesting Date
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 


 


Except as otherwise provided in Sections
3(b) and (c) and 5 hereof, or in the Plan, there shall be no proportionate or partial vesting of shares of Restricted Stock in
or during the months, days or periods prior to each Vesting Date, and all vesting of shares of Restricted Stock shall occur only
on the applicable Vesting Date. The applicable Vesting Date shall be determined in reference to the date of execution of the offer
letter between the Company and the Recipient.


 


(b)            
Acceleration of Vesting Upon Change in Control. In the event that a “Change in Control” (as defined
in the Plan) of the Company occurs during the Recipient’s Continuous Service, the shares of Restricted Stock subject to this
Agreement shall become immediately vested as of the date of the Change in Control.


 


(c)             
Acceleration of Vesting at Company Discretion. Notwithstanding any other term or provision of this Agreement,
the Board shall be authorized, in its sole discretion, based upon its review and evaluation of the performance of the Recipient
and of the Company, to accelerate the vesting of any shares of Restricted Stock under this Agreement, at such times and upon such
terms and conditions as the Board shall deem advisable.


 


4.               
Delivery of Restricted Stock.


 


(a)             
Issuance of Stock Certificates and Legends. At the election of the Company, stock certificates representing
the Restricted Stock may be issued in the name of the Recipient either (i) on multiple occasions after each Vesting Date at the
time a portion of the Restricted Stock becomes Vested Shares, or (ii) in one or more stock certificates on the Date of Grant which
shall be held and retained by the Records Administrator of the Company until the date (the “Applicable Date”)
on which the shares (or a portion thereof) subject to this Restricted Stock award become Vested Shares pursuant to Section 3
hereof, subject to the provisions of Section 5 hereof. All such stock certificates shall bear the following legends, along
with such other legends that the Board shall deem necessary and appropriate or which are otherwise required or indicated pursuant
to any applicable stockholders’ agreement:


 


 


 






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THE SHARES REPRESENTED BY THIS CERTIFICATE ARE SUBJECT TO SUBSTANTIAL
VESTING AND OTHER RESTRICTIONS AS SET FORTH IN THE RESTRICTED STOCK AGREEMENT BETWEEN THE ISSUER AND THE ORIGINAL HOLDER OF THE
SHARES, A COPY OF WHICH MAY BE OBTAINED AT THE PRINCIPAL OFFICE OF THE ISSUER. SUCH RESTRICTIONS ARE BINDING ON TRANSFEREES OF
THESE SHARES, AND INCLUDE VESTING CONDITIONS WHICH MAY RESULT IN THE COMPLETE FORFEITURE OF THE SHARES.


 


(b)            
Stock Powers. The Recipient shall deposit with the Company stock powers or other instruments of transfer or
assignment, duly endorsed in blank with signature(s) guaranteed, corresponding to each certificate representing shares of Restricted
Stock until such shares become Vested Shares. If the Recipient shall fail to provide the Company with any such stock power or other
instrument of transfer or assignment, the Recipient hereby irrevocably appoints the Secretary of the Company as his attorney-in-fact,
with full power of appointment and substitution, to execute and deliver any such power or other instrument which may be necessary
to effectuate the transfer of the Restricted Stock (or assignment of distributions thereon) on the books and records of the Company.


 


(c)             
Delivery of Stock Certificates. In the event the Company issues certificates representing Restricted Stock
pursuant to Section 4(a)(ii), on or after each Applicable Date, upon written request to the Company by the Recipient, the Company
shall promptly cause a new certificate or certificates to be issued for and with respect to all shares that become Vested Shares
on that Applicable Date, which certificate(s) shall be delivered to the Recipient as soon as administratively practicable after
the date of receipt by the Company of the Recipient’s written request. The new certificate or certificates shall continue
to bear those legends and endorsements that the Company shall deem necessary or appropriate (including those relating to restrictions
on transferability and/or obligations and restrictions under the Securities Laws).


 


(d)            
Issuance Without Certificates. If the Company is authorized to issue Shares without certificates, then the
Company may, in the discretion of the Board, issue Shares pursuant to this Agreement without certificates, in which case any references
in this Agreement to certificates shall instead refer to whatever evidence may be issued to reflect the Recipient’s ownership
of the Shares subject to the terms and conditions of this Agreement.


 


5.               
Forfeiture of Non-Vested Shares. If the Recipient’s Continuous Service with the Company and the Related
Entities is terminated for any reason, any Shares of Restricted Stock that are not Vested Shares, and that do not become Vested
Shares pursuant to Section 3 hereof as a result of such termination, shall be forfeited immediately upon such termination
of Continuous Service and revert back to the Company without any payment to the Recipient. The Board shall have the power and authority
to enforce on behalf of the Company any rights of the Company under this Agreement in the event of the Recipient’s forfeiture
of Non-Vested Shares pursuant to this Section 5.


 


6.               
Rights with Respect to Restricted Stock.


 


(a)             
General. Except as otherwise provided in this Agreement, the Recipient shall have, with respect to all of
the shares of Restricted Stock actually issued, whether Vested Shares or Non-Vested Shares, all of the rights of a holder of shares
of common stock of the Company, including without limitation (i) the right to vote such Restricted Stock, (ii) the right
to receive dividends, if any, as may be declared on the Restricted Stock from time to time, and (iii) the rights available
to all holders of shares of common stock of the Company upon any merger, consolidation, reorganization, liquidation or dissolution,
stock split-up, stock dividend or recapitalization undertaken by the Company; provided, however, that all of such rights shall
be subject to the terms, provisions, conditions and restrictions set forth in this Agreement (including without limitation conditions
under which all such rights shall be forfeited). Any Shares issued to the Recipient as a dividend with respect to shares of Restricted
Stock shall have the same status and bear the same legend as the shares of Restricted Stock and shall be held by the Company, if
the shares of Restricted Stock that such dividend is attributed to is being so held, unless otherwise determined by the Board.
In addition, notwithstanding any provision to the contrary herein, any cash dividends declared with respect to shares of Restricted
Stock subject to this Agreement shall be held in escrow by the Board until such time as the shares of Restricted Stock that such
cash dividends are attributed to shall become Vested Shares, and in the event that such shares of Restricted Stock are subsequently
forfeited, the cash dividends attributable to such portion shall be forfeited as well.


 


(b)            
Adjustments to Shares. If at any time while this Agreement is in effect (or Shares granted hereunder shall
be or remain unvested while Recipient’s Continuous Service continues and has not yet terminated or ceased for any reason),
there shall be any increase or decrease in the number of issued and outstanding Shares of the Company through the declaration of
a stock dividend or through any recapitalization resulting in a stock split-up, combination or exchange of such Shares, then and
in that event, the Board shall make any adjustments it deems fair and appropriate, in view of such change, in the number of shares
of Restricted Stock then subject to this Agreement. If any such adjustment shall result in a fractional Share, such fraction shall
be disregarded.


 


 


 






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(c)             
No Restrictions on Certain Transactions. Notwithstanding any term or provision of this Agreement to the contrary,
the existence of this Agreement, or of any outstanding Restricted Stock awarded hereunder, shall not affect in any manner the right,
power or authority of the Company to make, authorize or consummate: (i) any or all adjustments, recapitalizations, reorganizations
or other changes in the Company’s capital structure or its business; (ii) any merger, consolidation or similar transaction
by or of the Company; (iii) any offer, issue or sale by the Company of any capital stock of the Company, including any equity
or debt securities, or preferred or preference stock that would rank prior to or on parity with the Restricted Stock and/or that
would include, have or possess other rights, benefits and/or preferences superior to those that the Restricted Stock includes,
has or possesses, or any warrants, options or rights with respect to any of the foregoing; (iv) the dissolution or liquidation
of the Company; (v) any sale, transfer or assignment of all or any part of the stock, assets or business of the Company; or
(vi) any other corporate transaction, act or proceeding (whether of a similar character or otherwise).


 


7.               
Transferability. Unless otherwise determined by the Board, the shares of Restricted Stock are not transferable
unless and until they become Vested Shares in accordance with this Agreement, otherwise than by will or under the applicable laws
of descent and distribution. The terms of this Agreement shall be binding upon the executors, administrators, heirs, successors
and assigns of the Recipient. Except as otherwise permitted pursuant to the first sentence of this Section, any attempt to effect
a Transfer of any shares of Restricted Stock prior to the date on which the shares become Vested Shares shall be void ab initio.
For purposes of this Agreement, “Transfer” shall mean any sale, transfer, encumbrance, gift, donation, assignment,
pledge, hypothecation, or other disposition, whether similar or dissimilar to those previously enumerated, whether voluntary or
involuntary, and including, but not limited to, any disposition by operation of law, by court order, by judicial process, or by
foreclosure, levy or attachment.


 


8.               
Tax Matters; Section 83(b) Election.


 


(a)             
Section 83(b) Election. If the Recipient properly elects, within thirty (30) days of the Date of
Grant, to include in gross income for federal income tax purposes an amount equal to the fair market value (as of the Date of Grant)
of the Restricted Stock pursuant to Section 83(b) of the Internal Revenue Code of 1986, as amended (the “Code”),
the Recipient shall make arrangements satisfactory to the Company to pay to the Company any federal, state or local income taxes
required to be withheld with respect to the Restricted Stock. If the Recipient shall fail to make such tax payments as are required,
the Company shall, to the extent permitted by law, have the right to deduct from any payment of any kind (including without limitation,
the withholding of any Shares that otherwise would be issued to the Recipient under this Agreement) otherwise due to the Recipient
any federal, state or local taxes of any kind required by law to be withheld with respect to the Restricted Stock.


 


(b)            
No Section 83(b) Election. If the Recipient does not properly make the election described in Section
8(a) above, to the extent the Restricted Stock is not registered under Section 5 of the Securities Act of 1933 (the “Securities
Act”), the Recipient shall, no later than the date or dates as of which the restrictions referred to in this Agreement
hereof shall lapse, pay to the Company, or make arrangements satisfactory to the Board for payment of, any federal, state or local
taxes of any kind required by law to be withheld with respect to the Restricted Stock (including without limitation the vesting
thereof). The Recipient hereby agrees to indemnify and hold the Company harmless against all claims, liabilities and costs, including
attorney’s fees, arising from or resulting from the Recipient’s failure to pay such federal, state and local taxes
or failure to reimburse the Company for federal, state and local taxes that the Company may be required to withhold on account
of the issuance or vesting of shares of Restricted Stock under this Agreement, and the Company shall, to the extent permitted by
law, have the right to deduct from any payment of any kind (including without limitation, the withholding of any Shares that otherwise
would be distributed to the Recipient under this Agreement) otherwise due to Recipient any federal, state, or local taxes of any
kind required by law to be withheld with respect to the Restricted Stock.


 


(c)             
Recipient’s Responsibilities for Tax Consequences. Tax consequences on the Recipient (including without
limitation federal, state, local and foreign income tax consequences) with respect to the Restricted Stock (including without limitation
the grant, vesting and/or forfeiture thereof) are the sole responsibility of the Recipient. The Recipient shall consult with his
or her own personal accountant(s) and/or tax advisor(s) regarding these matters, the making of a Section 83(b) election, and
the Recipient’s filing, withholding and payment (or tax liability) obligations.


 


(d)            
Consent to Sell Vested Shares to Pay Withholding Tax Liability. In lieu of paying the Company in cash any
federal, state or local tax required by law to be withheld by the Company with respect to the Restricted Stock pursuant to Section
8(b), and if the Restricted Stock is registered under Section 5 of the Securities Act, the Recipient hereby authorizes the Company
to sell through a brokerage firm selected by the Company a sufficient amount of Vested Shares as they become Vested Shares to satisfy
such withholding liability. Such sales will be conducted on the following basis: (i) the amount of Vested Shares to be sold shall
be the amount necessary to result in net proceeds equal to the amount the Company is required to withhold on the gross income reportable
to the Recipient on the newly Vested Shares, as determined on each Vesting Date by the Company’s outside payroll vendor;
(ii) the newly Vested Shares shall be sold within two trading days or a reasonable amount of time based on market conditions, as
determined solely by the Company’s designated broker, after communication of such amount by the Company’s third party
administrator to the broker; (iii) all proceeds from the sale shall be paid to the Company, for application to the Company’s
payroll tax withholding liability in connection with the newly Vested Shares; (iv) the Recipient shall not take any action that
would have the effect of changing the Recipient’s withholding amounts without the prior consent of the Company, including
without limitation submitting a new or amended Form W-4 that changes the amount of tax to be withheld from the Recipient’s
wages; (v) the Recipient shall not take any action that would interfere or delay the determination of the Recipient’s withholding
amount or the communication of such amount to the Company’s broker, or any other way accelerate or delay the date on which
such shares would ordinarily be sold; (vi) the Recipient shall not enter any hedging transaction in relation to the Company’s
securities, including any put, call, short sale or margin transaction; and (vii) the Recipient may not revoke or amend the Company’s
authority granted pursuant to this Section 8(d) without consent of the Company.


 


 


 






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9.               
Amendment, Modification & Assignment; Non-Transferability. This Agreement may only be modified or
amended in a writing signed by the parties hereto. No promises, assurances, commitments, agreements, undertakings or representations,
whether oral, written, electronic or otherwise, and whether express or implied, with respect to the subject matter hereof, have
been made by either party which are not set forth expressly in this Agreement. Unless otherwise consented to in writing by the
Company, in its sole discretion, this Agreement (and Recipient’s rights hereunder) may not be assigned, and the obligations
of Recipient hereunder may not be delegated, in whole or in part. The rights and obligations created hereunder shall be binding
on the Recipient and his heirs and legal representatives and on the successors and assigns of the Company.


 


10.            
Complete Agreement. This Agreement (together with those agreements and documents expressly referred to herein,
for the purposes referred to herein) embody the complete and entire agreement and understanding between the parties with respect
to the subject matter hereof, and supersede any and all prior promises, assurances, commitments, agreements, undertakings or representations,
whether oral, written, electronic or otherwise, and whether express or implied, which may relate to the subject matter hereof in
any way.


 


11.            
Miscellaneous.


 


(a)             
No Right to (Continued) Employment or Service. This Agreement and the grant of Restricted Stock hereunder
shall not shall confer, or be construed to confer, upon the Recipient any right to employment or service, or continued employment
or service, with the Company or any Related Entity.


 


(b)            
No Limit on Other Compensation Arrangements. Nothing contained in this Agreement shall preclude the Company
or any Related Entity from adopting or continuing in effect other or additional compensation plans, agreements or arrangements,
and any such plans, agreements and arrangements may be either generally applicable or applicable only in specific cases or to specific
persons.


 


(c)             
Severability. If any term or provision of this Agreement is or becomes or is deemed to be invalid, illegal
or unenforceable in any jurisdiction or under any applicable law, rule or regulation, then such provision shall be construed or
deemed amended to conform to applicable law (or if such provision cannot be so construed or deemed amended without materially altering
the purpose or intent of this Agreement and the grant of Restricted Stock hereunder, such provision shall be stricken as to such
jurisdiction and the remainder of this Agreement and the award hereunder shall remain in full force and effect).


 


(d)            
No Trust or Fund Created. Neither this Agreement nor the grant of Restricted Stock hereunder shall create
or be construed to create a trust or separate fund of any kind or a fiduciary relationship between the Company or any Related Entity
and the Recipient or any other person. To the extent that the Recipient or any other person acquires a right to receive payments
from the Company or any Related Entity pursuant to this Agreement, such right shall be no greater than the right of any unsecured
general creditor of the Company.


 


(e)             
Law Governing. This Agreement shall be governed by and construed and enforced in accordance with the internal
laws of the State of Nevada (without reference to the conflict of laws rules or principles thereof).


 


(f)             
Interpretation. The Recipient accepts the Restricted Stock subject to all of the terms, provisions and restrictions
of this Agreement. The undersigned Recipient hereby accepts as binding, conclusive and final all decisions or interpretations of
the Board upon any questions arising under this Agreement.


 


(g)            
Headings. Section, paragraph and other headings and captions are provided solely as a convenience to facilitate
reference. Such headings and captions shall not be deemed in any way material or relevant to the construction, meaning or interpretation
of this Agreement or any term or provision hereof.


 


(h)            
Notices. Any notice under this Agreement shall be in writing and shall be deemed to have been duly given when
delivered personally or when deposited in the United States mail, registered, postage prepaid, and addressed, in the case of the
Company, to the Company’s Chief Executive Officer at 1700 W. Horizon Parkway, Henderson, Nevada 89012, or if the Company
should move its principal office, to such principal office, and, in the case of the Recipient, to the Recipient’s last permanent
address as shown on the Company’s records, subject to the right of either party to designate some other address at any time
hereafter in a notice satisfying the requirements of this Section.


 


 


 






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(i)              
Section 409A.


 


		i.	It is intended that the Restricted Stock awarded pursuant to this Agreement be exempt from Section 409A of the Code (“Section
409A”) because it is believed that the Agreement does not provide for a deferral of compensation and accordingly that
the Agreement does not constitute a nonqualified deferred compensation plan within the meaning of Section 409A. The provisions
of this Agreement shall be interpreted in a manner consistent with this intention, and the provisions of this Agreement may not
be amended, adjusted, assumed or substituted for, converted or otherwise modified without the Recipient’s prior written consent
if and to the extent that the Company believes or reasonably should believe that such amendment, adjustment, assumption or substitution,
conversion or modification would cause the award to violate the requirements of Section 409A.



 


		ii.	In the event that either the Company or the Recipient believes, at any time, that any benefit or right under this Agreement
is subject to Section 409A, and does not comply with the requirements of Section 409A, it shall promptly advise the other
and the Company and the Recipient shall negotiate reasonably and in good faith to amend the terms of such benefits and rights,
if such an amendment may be made in a commercially reasonable manner, such that they comply with Section 409A with the most
limited possible economic effect on the Recipient and on the Company.



 


		iii.	Notwithstanding the foregoing, the Company does not make any representation to the Recipient that the shares of Restricted
Stock awarded pursuant to this Agreement are exempt from, or satisfies, the requirements of Section 409A, and the Company
shall have no liability or other obligation to indemnify or hold harmless the Recipient or any Beneficiary for any tax, additional
tax, interest or penalties that the Recipient or any Beneficiary may incur in the event that any provision of this Agreement, or
any amendment or modification thereof or any other action taken with respect thereto that either is consented to by the Recipient
or that the Company reasonably believes should not result in a violation of Section 409A, is deemed to violate any of the
requirements of Section 409A.



 


(j)              
Non-Waiver of Breach. The waiver by any party hereto of the other party’s prompt and complete performance,
or breach or violation, of any term or provision of this Agreement shall be effected solely in a writing signed by such party,
and shall not operate nor be construed as a waiver of any subsequent breach or violation, and the waiver by any party hereto to
exercise any right or remedy which he or it may possess shall not operate nor be construed as the waiver of such right or remedy
by such party, or as a bar to the exercise of such right or remedy by such party, upon the occurrence of any subsequent breach
or violation.


 


(k)            
Interpretation / Provisions of Plan Control. This Agreement is subject to all the terms, conditions
and provisions of the Plan, including, without limitation, the amendment provisions thereof, and to such rules, regulations and
interpretations relating to the Plan adopted by the Committee as may be in effect from time to time. If and to the extent that
this Agreement conflicts or is inconsistent with the terms, conditions and provisions of the Plan, the Plan shall control, and
this Agreement shall be deemed to be modified accordingly. The Recipient accepts the Award subject to all of the terms and provisions
of the Plan and this Agreement. The undersigned Recipient hereby accepts as binding, conclusive and final all decisions or interpretations
of the Committee upon any questions arising under the Plan and this Agreement, unless shown to have been made in an arbitrary and
capricious manner.


 


(l)              
Counterparts. This Agreement may be executed in two or more separate counterparts, each of which shall be
an original, and all of which together shall constitute one and the same agreement.


 


IN WITNESS WHEREOF, the parties
hereto, agree to the terms of this Agreement and acknowledge receipt as dated below.


 


	PAYSIGN, Inc., a Nevada corporation
	 	 
	By:	 	 
	
        Name:

        Title:

        
	 	 


 


 


 


 






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Agreed and Acknowledged Receipt of Agreement:


 


Dated: ____________________________


 


RECIPIENT:


 


	 	 	 
	 
	 	 
	By:	 	 
	 	 	[Insert name of Recipient]


 


 


 


 


 


 


 


 


 


 


 


 






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