Exhibit
10.2


 


Option
Number XXX


 


U.S.
ENERGY CORP.


 


2021
EQUITY INCENTIVE PLAN


 


STOCK
OPTION AGREEMENT


 


Unless
otherwise defined herein, the terms in the Stock Option Agreement (the “Option Agreement”) have the same meanings
as defined in the U.S. Energy Corp. 2021 (the “Company”) Equity Incentive Plan (as amended from time to time)(the
“Plan”).


 


		I.	NOTICE
                                            OF STOCK OPTION GRANT



 


Optionee:
________________


 


Address:
___________________________________


 


You
have been granted an Option to purchase common stock (the “Common Stock”) of the Company (the “Option”
and the “Shares”), subject to the terms and conditions of the Plan and this Option Agreement, as follows:


 


Grant
Date: ________________


 


Vesting
Commencement Date: ________________


 


Exercise
Price per Share: $________________


 


Total
Number of Shares Granted: ________________


 


Total
Exercise Price: $________________


 


Type
of Option1: Incentive ☐ OR Non-Qualified ☐


 


Expiration
Date: ________________


 


Vesting
Schedule: ________________.


 


To
the extent vested, this Option will be exercisable for three (3) months following the Termination of Service of Optionee, unless termination
is due to Optionee’s death or Disability, in which case this Option will be exercisable for twelve (12) months following the Termination
of Service of Optionee. In the event of termination due to Optionee’s death, the Company shall use commercially reasonable efforts
to notify Optionee’s estate of the exercisability of the Option following Optionee’s death. Notwithstanding the foregoing
sentence, in no event may this Option be exercised following the Termination of Service of Optionee as determined by the Company’s
Board to be for Cause or after the Expiration Date as provided above and this Option may be subject to earlier termination as provided
in the Plan.


 


 







1
Incentive Stock Options (ISOs) are only eligible to be granted to employees. For each employee, in the event that the aggregate
fair market value (determined as of the grant date) of ISOs that become exercisable for the first time in any calendar year exceed $100,000,
such stock options exceeding such $100,000 limit shall automatically be treated as non-qualified stock options regardless of the designation
above.


 



    	 



     


    

 


“Cause”
has the meaning ascribed to such term or words of similar import in Optionee’s written employment or service contract with the
Company or its parent or any subsidiary and, in the absence of such agreement or definition, means Optionee’s (i) conviction of,
or plea of nolo contendere to, a felony or any other crime involving moral turpitude; (ii) fraud on or misappropriation of any funds
or property of the Company or its subsidiaries, or any affiliate, customer or vendor; (iii) personal dishonesty, incompetence, willful
misconduct, willful violation of any law, rule or regulation (other than minor traffic violations or similar offenses), or breach of
fiduciary duty which involves personal profit; (iv) willful misconduct in connection with Optionee’s duties or willful failure
to perform Optionee’s responsibilities in the best interests of the Company or its subsidiaries; (v) illegal use or distribution
of drugs; (vi) violation of any material rule, regulation, procedure or policy of the Company or its subsidiaries, the violation of which
could have a material detriment to the Company; or (vii) material breach of any provision of any employment, non-disclosure, non-competition,
non-solicitation or other similar agreement executed by Optionee for the benefit of the Company or its subsidiaries, all as reasonably
determined by the Company’s Board of Directors, which determination will be conclusive.


 


Legends.


 


(a)
All certificates representing the Shares issued upon exercise of this Option shall, prior to such date as the Plan and Common Stock hereunder
are covered by a valid Form S-8 or similar U.S. federal registration statement, where applicable, have endorsed thereon the following
legend:


 


THE
SECURITIES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED OR QUALIFIED UNDER THE U.S. SECURITIES ACT OF 1933, AS AMENDED, OR
THE SECURITIES LAWS OF ANY STATE OR OTHER JURISDICTION, AND MAY BE OFFERED AND SOLD ONLY IF REGISTERED AND QUALIFIED PURSUANT TO THE
RELEVANT PROVISIONS OF U.S. FEDERAL, STATE AND FOREIGN SECURITIES LAWS OR IF THE COMPANY IS PROVIDED AN OPINION OF COUNSEL SATISFACTORY
TO THE COMPANY THAT REGISTRATION AND QUALIFICATION UNDER U.S. FEDERAL, STATE AND FOREIGN SECURITIES LAWS IS NOT REQUIRED.


 






    	2021 Stock Option Agreement
	Option Number XXXXXX
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(b)
If the Option is an incentive stock option (ISO), then the following legend will be included:


 


THE
SHARES REPRESENTED BY THIS CERTIFICATE WERE ISSUED UPON EXERCISE OF AN INCENTIVE STOCK OPTION, AND THE COMPANY MUST BE NOTIFIED IF THE
SHARES SHALL BE TRANSFERRED BEFORE THE LATER OF THE TWO (2) YEAR ANNIVERSARY OF THE DATE OF GRANT OF THE OPTION OR THE ONE (1) YEAR ANNIVERSARY
OF THE DATE ON WHICH THE OPTION WAS EXERCISED. THE REGISTERED HOLDER MAY RECOGNIZE ORDINARY INCOME IF THE SHARES ARE TRANSFERRED BEFORE
SUCH DATE.


 





		II.	AGREEMENT





 


1.
Grant of Option. The Administrator grants to the Optionee named in the Notice of Stock Option Grant in Part I of this Option
Agreement, an Option to purchase the number of Shares set forth in the Notice of Stock Option Grant, at the exercise price per Share
set forth in the Notice of Stock Option Grant (the “Exercise Price”), and subject to the terms and conditions
of the Plan, which is incorporated herein by reference. In the event of a conflict between the terms and conditions of the Plan and this
Option Agreement, the terms and conditions of the Plan prevail.


 


If
designated in the Notice of Stock Option Grant as an Incentive Stock Option, this Option is intended to qualify as an Incentive Stock
Option as defined in Code section 422. Nevertheless, to the extent that it exceeds the $100,000 rule of Code section 422(d), this Option
will be treated as a Nonstatutory/Non-Qualified Stock Option.


 


2.
Exercise of Option.


 


(a)
Right to Exercise. This Option is exercisable during its term in accordance with the Vesting Schedule set out in the Notice of
Stock Option Grant and with the applicable provisions of the Plan and this Option Agreement.


 


(b)
Method of Exercise. This Option is exercisable by (i) delivery of an exercise notice in the form attached as Exhibit A
(the “Exercise Notice”) or in a manner and pursuant to procedures as the Administrator may determine, which
will state the election to exercise the Option, the number of Shares with respect to which the Option is being exercised, and other representations
and agreements as may be required by the Company and (ii) paying the Company in full the aggregate Exercise Price as to all Shares being
acquired, together with any applicable tax withholding.


 


This
Option will be deemed to be exercised upon receipt by the Company of a fully executed Exercise Notice accompanied by the aggregate Exercise
Price, together with any applicable tax withholding.


 






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	Option Number XXXXXX
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No
Shares will be issued pursuant to the exercise of an Option unless the issuance and exercise of Shares complies with applicable state
and federal laws (“Applicable Laws”). Assuming compliance, for income tax purposes the Shares will be considered
transferred to the Optionee on the date on which the Option is exercised with respect to the Shares.


 


3.
Method of Payment. The aggregate Exercise Price may be paid by any of the following, or a combination thereof, at the election
of the Optionee:


 


(a)
cash;


 


(b)
check;


 


(c)
to the extent not prohibited by Section 402 of the Sarbanes-Oxley Act of 2002, a promissory note;


 


(d)
other shares of Common Stock, provided Shares have a Fair Market Value on the date of surrender equal to the aggregate exercise price
of the Shares as to which said Option will be exercised;


 


(e)
by asking the Company to withhold Shares from the total Shares to be delivered upon exercise equal to the number of Shares having a value
equal to the aggregate Exercise Price of the Shares being acquired;


 


(f)
any combination of the foregoing methods of payment; or


 


(g)
such other consideration and method of payment for the issuance of Shares to the extent permitted by Applicable Laws.


 


4.
Restrictions on Exercise. This Option may not be exercised if the issuance of such Shares upon such exercise or the method of
payment of consideration for such shares would constitute a violation of any Applicable Laws. The Company will be relieved of any liability
with respect to any delayed issuance of shares or its failure to issue shares if such delay or failure is necessary to comply with Applicable
Laws.


 


5.
Non-Transferability of Option. This Option may not be transferred in any manner otherwise than by will or by the laws of descent
or distribution and may be exercised during the lifetime of Optionee only by Optionee. The terms of the Plan and this Option Agreement
are binding upon the executors, administrators, heirs, successors and assigns of the Optionee.


 


6.
Term of Option. This Option may be exercised only within the term set out in the Notice of Stock Option Grant, and may be exercised
during the term only in accordance with the Plan and the terms of this Option.


 






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	Option Number XXXXXX
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7.
Tax Obligations.


 


(a)
Withholding Taxes. Optionee agrees to arrange for the satisfaction of all Federal, state, local and foreign income and employment
tax withholding requirements applicable to the Option exercise. Optionee acknowledges and agrees that the Company may refuse to honor
the exercise and refuse to deliver the Shares if withholding amounts are not delivered at the time of exercise.


 


(b)
Notice of Disqualifying Disposition of ISO Shares. If the Option granted to Optionee is an Incentive Stock Option (“ISO”),
and if Optionee sells or otherwise disposes of any of the Shares acquired pursuant to the ISO on or before the later of (i) the date
two (2) years after the Grant Date, or (ii) the date one (1) year after the date of exercise, the Optionee must immediately notify the
Company of the disposition in writing. Optionee agrees that Optionee may be subject to income tax withholding by the Company on the compensation
income recognized by the Optionee.


 


(c)
Code Section 409A. Under Code section 409A, an Option that was granted with a per Share exercise price that is determined by the
Internal Revenue Service (the “IRS”) to be less than the Fair Market Value of a Share on the Grant Date (a
“discount option”) may be considered deferred compensation. An Option that is a discount option may result
in (i) income recognition by the Optionee prior to the exercise of the Option, (ii) an additional twenty percent (20%) tax, and (iii)
potential penalty and interest charges. Optionee acknowledges that the Company cannot and has not guaranteed that the IRS will agree
that the per Share Exercise Price of this Option equals or exceeds Fair Market Value of a Share on the Grant Date in a later examination.
Optionee agrees that if the IRS determines that the Option was granted with a per Share exercise price that was less than the Fair Market
Value of a Share on the Grant Date, Optionee will be solely responsible for any and all resulting tax consequences.


 


8.
No Guarantee of Continued Service. OPTIONEE ACKNOWLEDGES AND AGREES THAT THE VESTING OF SHARES PURSUANT TO THE VESTING SCHEDULE
HEREOF IS EARNED ONLY BY CONTINUING AS AN EMPLOYEE AND/OR DIRECTOR (AS APPLICABLE) AT THE WILL OF THE COMPANY (OR THE PARENT OR SUBSIDIARY
EMPLOYING OR RETAINING OPTIONEE) AND NOT THROUGH THE ACT OF BEING HIRED, BEING GRANTED THIS OPTION OR ACQUIRING SHARES HEREUNDER. OPTIONEE
FURTHER ACKNOWLEDGES AND AGREES THAT THIS OPTION AGREEMENT, THE TRANSACTIONS CONTEMPLATED HEREUNDER AND THE VESTING SCHEDULE SET FORTH
HEREIN DO NOT CONSTITUTE AN EXPRESS OR IMPLIED PROMISE OF CONTINUED ENGAGEMENT AS AN EMPLOYEE AND/OR DIRECTOR (AS APPLICABLE) FOR THE
VESTING PERIOD, FOR ANY PERIOD, OR AT ALL, AND WILL NOT INTERFERE IN ANY WAY WITH OPTIONEE’S RIGHT OR THE RIGHT OF THE COMPANY
(OR THE PARENT OR SUBSIDIARY EMPLOYING OR RETAINING OPTIONEE) TO TERMINATE OPTIONEE’S RELATIONSHIP AS AN EMPLOYEE OR DIRECTOR AT
ANY TIME, WITH OR WITHOUT CAUSE.


 






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	Option Number XXXXXX
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9.
Notices. All notices or other communications which are required or permitted hereunder will be in writing and sufficient if (i)
personally delivered or sent by telecopy, (ii) sent by nationally-recognized overnight courier or (iii) sent by registered or certified
mail, postage prepaid, return receipt requested, addressed as follows:


 


(a)
if to the Optionee, to the address (or telecopy number) set forth on the Notice of Stock Option Grant; and


 


(b)
if to the Company, to its principal executive office as specified in any report filed by the Company with the Securities and Exchange
Commission or to such address as the Company may have specified to the Optionee in writing, Attention: Corporate Secretary;


 


or
to any other address as the party to whom notice is to be given may have furnished to the other party in writing in accordance herewith.
Any communication will be deemed to have been given (i) when delivered, if personally delivered, or when telecopied, if telecopied, (ii)
on the first Business Day (as hereinafter defined) after dispatch, if sent by nationally-recognized overnight courier and (iii) on the
fourth Business Day following the date on which the piece of mail containing the communication is posted, if sent by mail. As used herein,
“Business Day” means a day that is not a Saturday, Sunday or a day on which banking institutions in the city
to which the notice or communication is to be sent are not required to be open.


 


10.
Specific Performance. Optionee expressly agrees that the Company will be irreparably damaged if the provisions of this Option
Agreement and the Plan are not specifically enforced. Upon a breach or threatened breach of the terms, covenants and/or conditions of
this Option Agreement or the Plan by the Optionee, the Company will, in addition to all other remedies, be entitled to a temporary or
permanent injunction, without showing any actual damage, and/or decree for specific performance, in accordance with the provisions hereof
and thereof. The Administrator has the power to determine what constitutes a breach or threatened breach of this Option Agreement or
the Plan. The Administrator’s determinations will be final and conclusive and binding upon the Optionee.


 


11.
No Waiver. No waiver of any breach or condition of this Option Agreement will be deemed to be a waiver of any other or subsequent
breach or condition, whether of like or different nature.


 


12.
Optionee Undertaking. The Optionee agrees to take whatever additional actions and execute whatever additional documents the Company
may in its reasonable judgment deem necessary or advisable in order to carry out or effect one or more of the obligations or restrictions
imposed on the Optionee pursuant to the express provisions of this Option Agreement.


 


13.
Modification of Rights. The rights of the Optionee are subject to modification and termination in certain events as provided in
this Option Agreement and the Plan.


 






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	Option Number XXXXXX
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14.
Governing Law. This Agreement is governed by, and construed in accordance with, the laws of the State of Wyoming, without giving
effect to its conflict or choice of law principles that might otherwise refer construction or interpretation of this Agreement to the
substantive law of another jurisdiction.


 


15.
Counterparts; Facsimile Execution. This Option Agreement may be executed in one or more counterparts, each of which will be deemed
to be an original, but all of which together constitute one and the same instrument. Facsimile execution and delivery of this Option
Agreement is legal, valid and binding execution and delivery for all purposes.


 


16.
Entire Agreement. The Plan, this Option Agreement, and upon execution, the Exercise Notice, constitute the entire agreement of
the parties with respect to the subject matter hereof and supersede in their entirety all prior undertakings and agreements of the Company
and Optionee with respect to the subject matter hereof, and may not be modified adversely to the Optionee’s interest except by
means of a writing signed by the Company and Optionee.


 


17.
Severability. In the event one or more of the provisions of this Option Agreement should, for any reason, be held to be invalid,
illegal or unenforceable in any respect, such invalidity, illegality or unenforceability will not affect any other provisions of this
Option Agreement, and this Option Agreement will be construed as if such invalid, illegal or unenforceable provision had never been contained
herein.


 


18.
Language. You acknowledge that you are proficient in the English language, or have consulted with an advisor who is proficient
in the English language, so as to enable you to understand the provisions of this Agreement and the Plan. If you have received this Agreement
or any other document related to the Plan translated into a language other than English and if the meaning of the translated version
is different than the English version, the English version will control.


 


19.
Electronic Delivery and Participation. The Company may, in its sole discretion, decide to deliver any documents related to current
or future participation in the Plan by electronic means. You hereby consent to receive such documents by electronic delivery and agree
to participate in the Plan through an online or electronic system established and maintained by the Company or a third party designated
by the Company.


 


20.
Imposition of Other Requirement. The Company reserves the right to impose other requirements on your participation in the Plan,
on the Option and on any shares of Common Stock acquired under the Plan, to the extent the Company determines it is necessary or advisable
for legal or administrative reasons, and to require you to sign any additional agreements or undertakings that may be necessary to accomplish
the foregoing.


 


21.
No Advice Regarding Grant. The Company is not providing any tax, legal or financial advice, nor is the Company making any recommendations
regarding your participation in the Plan, or your acquisition or sale of the underlying shares of Common Stock. You should consult with
your own personal tax, legal and financial advisors regarding your participation in the Plan before taking any action related to the
Plan.


 


22.
Other Documents. You hereby acknowledge receipt of or the right to receive a document providing the information required by Rule
428(b)(1) promulgated under the Securities Act, which includes the document containing the Plan information specified in Section 10(a)
of the Securities Act (“Prospectus”).


 


23.
WAIVER OF JURY TRIAL. THE OPTIONEE EXPRESSLY, IRREVOCABLY AND UNCONDITIONALLY WAIVES TRIAL BY JURY IN ANY LEGAL ACTION OR PROCEEDING
RELATING TO THIS OPTION AGREEMENT AND FOR ANY COUNTERCLAIM THEREIN.


 


[Remainder
of page left intentionally blank.]


 




    	2021 Stock Option Agreement
	Option Number XXXXXX
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Optionee
acknowledges receipt of a copy of the Plan and represents that he or she is familiar with the terms and provisions thereof, and accepts
this Option subject to all of the terms and provisions thereof. Optionee has reviewed the Plan and this Option in their entirety, has
had an opportunity to obtain the advice of counsel prior to executing this Option and fully understands all provisions of the Option.
Optionee agrees to accept as binding, conclusive and final all decisions or interpretations of the Administrator upon any questions arising
under the Plan or this Option. Optionee further agrees to notify the Company upon any change in the residence address indicated below.


 


	OPTIONEE
    	 	U.S.
    ENERGY CORP.
	 	 	 
	Signature	

    
	 	By:	

    

	 	 	 
	Print
    Name:		 	Print
    Name:	

	 	 	 
	Address:	
	 	Address:	

    

    

	 	 	 	 	 
	 	 	 
	Date
    Signed: 	
	 	Date
    Signed:	



 




    	2021 Stock Option Agreement
	Option Number XXXXXX
	Page 8 of 12



     


    

 


EXHIBIT
A


 


2021
EQUITY INCENTIVE PLAN


 


EXERCISE
NOTICE


 


U.S.
Energy Corp.


675
Bering Drive


Suite
100


Houston,
Texas 77057


 


Attention:
U.S. Energy Corp., Corporate Secretary


 


1.
Exercise of Option. Effective as of today, _____________, _____, the undersigned (“Optionee”) elects
to exercise Optionee’s option to purchase ___________ shares of the Common Stock (the “Shares”) of U.S.
Energy Corp. (the “Company”) under and pursuant to the U.S. Energy Corp. 2021 Equity Incentive Plan (as amended
from time to time, the “Plan”) and the Stock Option Agreement effective ______________ (the “Option
Agreement”).


 


2.
Delivery of Payment. Optionee herewith delivers to the Company the full purchase price of the Shares, as set forth in the Option
Agreement, and any and all withholding taxes due in connection with the exercise of the Option.


 


3.
Representations of Optionee. Optionee acknowledges that Optionee has received, read and understood the Plan and the Option Agreement
and agrees to abide by and be bound by their terms and conditions.


 


4.
Rights as Stockholder. Until the issuance of the Shares (as evidenced by the appropriate entry on the books of the Company or
of a duly authorized transfer agent of the Company), no right to vote or receive dividends or any other rights as a stockholder exists
with respect to the Shares, notwithstanding the exercise of the Option. Subject to the requirements of Section 6 below, the Shares
will be issued to the Optionee as soon as practicable after the Option is exercised in accordance with the Option Agreement. No adjustment
will be made for a dividend or other right for which the record date is prior to the date of issuance except as provided in the Plan.


 


5.
Tax Consultation. Optionee understands that Optionee may suffer adverse tax consequences as a result of Optionee’s purchase
or disposition of the Shares. Optionee represents that Optionee has consulted with any tax consultants Optionee deems advisable in connection
with the purchase or disposition of the Shares and that Optionee is not relying on the Company for any tax advice.


 


6.
Refusal to Transfer. The Company will not (i) transfer on its books any Shares that have been sold or otherwise transferred in
violation of any of the provisions of this Exercise Notice, or (ii) be required to treat as owner of such Shares or to accord the right
to vote or pay dividends to any purchaser or other transferee to whom such Shares have been so transferred.


 






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	Option Number XXXXXX
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7.
Successors and Assigns. The Company may assign any of its rights under this Exercise Notice to single or multiple assignees, and
this Exercise Notice inures to the benefit of the successors and assigns of the Company. Subject to the restrictions on transfer herein
set forth, this Exercise Notice is binding upon Optionee and his or her heirs, executors, administrators, successors and assigns.


 


8.
Interpretation. Any dispute regarding the interpretation of this Exercise Notice will be submitted by Optionee or by the Company
forthwith to the Administrator for review at its next regular meeting. The resolution of disputes by the Administrator will be final
and binding on all parties.


 


9.
Governing Law; Severability. This Exercise Notice is governed by, and construed in accordance with, the laws of the State of Wyoming,
without giving effect to its conflict or choice of law principles that might otherwise refer construction or interpretation of this Exercise
to the substantive law of another jurisdiction. In the event that any provision hereof becomes or is declared by a court of competent
jurisdiction to be illegal, unenforceable or void, this Exercise Notice will continue in full force and effect.


 


 10. Optionee Representations.




 


(a)
With respect to a transaction occurring prior to such date as the Plan and Common Stock thereunder are covered by a valid Form S-8 or
similar U.S. federal registration statement, Optionee agrees that in no event shall Optionee make a disposition of any of the Common
Stock, unless and until: (i) Optionee shall have notified the Company of the proposed disposition and shall have furnished the Company
with a statement of the circumstances surrounding the proposed disposition; and (ii) Optionee shall have furnished the Company with an
opinion of counsel satisfactory to the Company to the effect that (A) such disposition will not require registration or qualification
of such Common Stock under applicable U.S. federal, state or foreign securities laws or (B) appropriate action necessary for compliance
with the U.S. federal, state or foreign securities laws has been taken; or (iii) the Company shall have waived, expressly and in writing,
its rights under clauses (i) and (ii) of this Subsection.


 


(b)
Optionee understands that if a registration statement covering the Common Stock under the Securities Act is not in effect when Optionee
desires to sell the Common Stock, Optionee may be required to hold the Common Stock for an indeterminate period. Optionee also acknowledges
that Optionee understands that any sale of the Common Stock which might be made by Optionee in reliance upon Rule 144 under the Securities
Act may be made only in limited amounts in accordance with the terms and conditions of that Rule.


 






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	Option Number XXXXXX
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11.
Other Documents. Optionee hereby acknowledges receipt or the right to receive a document providing the information required by
Rule 428(b)(1) promulgated under the Securities Act of 1933, as amended, including, but not limited to, the information required by Part
I of Form S-8, if applicable.


 


12.
Notices. Any notice required or permitted hereunder will be provided in writing and deemed effective if provided in the manner
specified in the Option Agreement.


 


13.
Further Instruments. The parties agree to execute any further instruments and to take any further action as may be reasonably
necessary to carry out the purposes and intent of the Option Agreement and this Exercise Notice.


 


14.
No Advice Regarding Exercise. The Company is not providing any tax, legal or financial advice, nor is the Company making any recommendations
regarding your exercise of the options set forth in the Option Agreement, or your acquisition or sale of the underlying shares of Common
Stock. You should consult with your own personal tax, legal and financial advisors regarding your exercise of the options, before taking
any action related to the Shares or the Plan.


 


15.
Entire Agreement. The Plan and Option Agreement are incorporated herein by reference. This Exercise Notice, the Plan, and the
Option Agreement constitute the entire agreement of the parties with respect to the subject matter hereof and supersede in their entirety
all prior undertakings and agreements of the Company and Optionee with respect to the subject matter hereof, and may not be modified
adversely to the Optionee’s interest except by means of a writing signed by the Company and Optionee.


 


[Signature
page follows.]


 




    	2021 Stock Option Agreement
	Option Number XXXXXX
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	Submitted by:	 	Accepted by:



	 	 	 	 	 
	OPTIONEE	 	U.S. ENERGY CORP.
	 	 	 	 	 
	Signature

    
	 	 	By:

    
	 
	 	 	 	 	 
	Print
Name:

    
	 	 	Print
                                            Name: 

    
	 
	 	 	 	 	 
	Address:
                                            

    
	 	 	 	 
	 	 	 	 	 
	 	 	 	Date
                                            Received: 

    
	 


 






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	Option Number XXXXXX
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