# EDGAR Filing Document

**Accession Number:** 0001513525
**File Stem:** 0001213900-26-042057
**Filing Date:** 2026-4
**Character Count:** 26870
**Document Hash:** c6c3e54c2030059d596fecf42025db2d
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001213900-26-042057.hdr.sgml**: 20260409

**ACCESSION NUMBER**: 0001213900-26-042057

**CONFORMED SUBMISSION TYPE**: 8-K

**PUBLIC DOCUMENT COUNT**: 12

**CONFORMED PERIOD OF REPORT**: 20260407

**ITEM INFORMATION**: Departure of Directors or Certain Officers; Election of Directors; Appointment of Certain Officers: Compensatory Arrangements of Certain Officers

**ITEM INFORMATION**: Financial Statements and Exhibits

**FILED AS OF DATE**: 20260409

**DATE AS OF CHANGE**: 20260409

**FILER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** ADIAL PHARMACEUTICALS, INC.
- **CENTRAL INDEX KEY:** 0001513525
- **STANDARD INDUSTRIAL CLASSIFICATION:** PHARMACEUTICAL PREPARATIONS [2834]
- **ORGANIZATION NAME:** 03 Life Sciences
- **EIN:** 800667150
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 8-K
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-38323
- **FILM NUMBER:** 26852345

**BUSINESS ADDRESS:**
- **STREET 1:** 1180 SEMINOLE TRAIL
- **STREET 2:** SUITE 495
- **CITY:** CHARLOTTESVILLE
- **STATE:** VA
- **ZIP:** 22901
- **BUSINESS PHONE:** 434-422-9800

**MAIL ADDRESS:**
- **STREET 1:** 1180 SEMINOLE TRAIL
- **STREET 2:** SUITE 495
- **CITY:** CHARLOTTESVILLE
- **STATE:** VA
- **ZIP:** 22901

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** ADial Pharmaceuticals, L.L.C.
- **DATE OF NAME CHANGE:** 20170515

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Adial Pharmaceuticals, L.L.C.
- **DATE OF NAME CHANGE:** 20110218

?xml version='1.0' encoding='ASCII'?

**UNITED STATES**

**SECURITIES AND EXCHANGE COMMISSION**

**WASHINGTON, D.C. 20549**

**FORM 8-K**

**CURRENT REPORT**

**Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934**

Date of Report (date of earliest event reported): **April 7, 2026**

**Adial Pharmaceuticals, Inc.**

*(Exact name of registrant as specified in charter)*

**Delaware**

*(State or other jurisdiction of incorporation)*

---

| | |
|:---|:---|
| **001-38323** | **82-3074668** |
| *(Commission File Number)* | *(IRS Employer Identification No.)* |

---

**4870 Sadler Road, Ste 300**

**Glen Allen, VA 23060**

*(Address of principal executive offices and zip code)*

**(804) 487-8196**

*(Registrant's telephone number including area code)*

 

*(Former Name and Former Address)*

Check the appropriate box below if the Form 8-K filing is intended to simultaneously satisfy the filing obligation of registrant under any of the following provisions:

☐ Written communications pursuant to Rule 425 under the Securities Act (17 CFR 230.425)

☐ Soliciting material pursuant to Rule 14a-12(b) under the Exchange Act (17 CFR 240.14a-12)

☐ Pre-commencement communications pursuant to Rule 14d-2(b) under the Exchange Act (17 CFR 240.14d-2(b))

☐ Pre-commencement communications pursuant to Rule 13e-4(c) under the Exchange Act (17 CFR 240.13e-4(c))

Securities registered pursuant to Section 12(b) of the Act:

---

| | | |
|:---|:---|:---|
| **Title of each class** | **Trading Symbols** | **Name of each exchange on which registered** |
| Common Stock | ADIL | The Nasdaq Stock Market LLC<br> ((Nasdaq Capital Market) |

---

Indicate by check mark whether the registrant is an emerging growth company as defined in in Rule 405 of the Securities Act of 1933 (§230.405 of this chapter) or Rule 12b-2 of the Securities Exchange Act of 1934 (§240.12b-2 of this chapter).

Emerging growth company ☐

If an emerging growth company, indicate by checkmark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ☐

**Item 5.02** **Departure of Directors or Certain Officers; Election of Directors; Appointment of Certain Officers; Compensatory Arrangements of Certain Officers.** 

On April 7, 2026, the Compensation Committee of the Board of Directors (the "Board") of Adial Pharmaceuticals, Inc., a Delaware corporation (the "Company"), approved the grant of restricted stock awards (collectively, the "RSAs") to the Company's named executive officers, as follows:

● 37,985 RSAs to Cary Claiborne, the Company's Chief Executive Officer and a Director, 28,800 of which were issued to him for his role as Chief Executive Officer and 9,185 of which were issued to him for his role as a Director of the Company;

● 17,325 RSAs to Vinay Shah, the Company's Chief Financial Officer, all of which were issued to him for his role as Chief Financial Officer; and

● 26,510 RSAs to Tony Goodman, the Company's Chief Operating Officer and a Director, 17,325 of which were issued to him for his role as Chief Operating Officer and 9,185 of which were issued to him for his role as a Director of the Company.

In addition to the foregoing, the Compensation Committee approved the grant of (i) 9,185 RSAs to each of Kevin Schuyler and Robertson H. Gilliland and (ii) options to purchase 9,185 shares of Company common stock, at an exercise price of $1.64 per share, to Kermit Anderson, in each case as compensation for their service as Directors of the Company, which additional RSAs and options are subject to the same vesting terms as those set forth above.

The RSAs vest in full on the earlier of (i) the one-year anniversary of the grant date and (ii) upon the occurrence of a Change of Control (as defined in the Company's 2017 Equity Incentive Plan, as amended (the "2017 Plan")).

On April 7, 2026, the Board approved a form of Restricted Stock Award Agreement to be used for the grant of restricted stock awards under the 2017 Plan, including for the grant of the RSAs made to named executive officers described above. The form of Restricted Stock Award Agreement is attached hereto as Exhibit 10.1 and is incorporated herein by reference.

**Item 9.01. Financial Statements and Exhibits**.

(d) Exhibits.

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| | |
|:---|:---|
| **Exhibit No.** | **Description** |
| 10.1 | [Form of Restricted Stock Award Agreement under 2017 Equity Incentive Plan](ea028577201ex10-1.htm) |
| 104 | Cover Page Interactive Data File (embedded within the Inline XBRL document) |

---

**SIGNATURES**

Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned hereunto duly authorized.

---

| | | |
|:---|:---|:---|
| Dated: April 9, 2026 | **ADIAL PHARMACEUTICALS, INC.** | **ADIAL PHARMACEUTICALS, INC.** |
|  | By: | /s/ Cary J. Claiborne |
|  | Name: | Cary J. Claiborne |
|  | Title: | President and Chief Executive Officer |

---

## Exhibit 10.1

**Exhibit 10.1**

**FORM OF**

**ADIAL PHARMACEUTICALS, INC.**

**RESTRICTED STOCK AWARD AGREEMENT**

This Restricted Stock Award Agreement (this "<u>Agreement</u>"), dated as of the "Award Date" set forth in the attached <u>Exhibit A</u>, is entered into between Adial Pharmaceuticals, Inc., a Delaware corporation (the "<u>Company</u>"), and the individual identified in <u>Exhibit A</u> (the "<u>Awardee</u>"). Capitalized terms that are not otherwise defined in this Agreement shall have the meanings given to such terms in the Adial Pharmaceuticals, Inc. 2017 Equity Incentive Plan, as amended (the "<u>Plan</u>").

WHEREAS, the Company desires to provide the Awardee an incentive to participate in the success and growth of the Company through the holding of a proprietatry interest in the Company; and

WHEREAS, to give effect to the foregoing intentions, the Company desires to grant the Awardee a restricted stock award of shares of the Company's common stock, $0.001 par value per share (the "<u>Common Stock</u>") pursuant to the Plan;

NOW, THEREFORE, in consideration of the mutual covenants hereinafter set forth and for other good and valuable consideration, the parties hereto agree as follows:

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1. <u>Grant</u>. The Company hereby grants the Awardee a restricted stock award (the "<u>Award</u>") with respect to the number of shares of Common Stock set forth in <u>Exhibit A</u> (such shares being referred to herein as the "<u>Restricted Shares</u>"). The Award and the Restricted Shares shall be subject to the terms and conditions set forth in this Agreement and the provisions of the Plan, the terms of which are incorporated herein by reference. Capitalized terms used but not otherwise defined herein shall have the meanings as set forth in the Plan.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;2. <u>Lapsing Forfeiture Provisions</u>. Subject to the terms of this Agreement, the Plan and the terms of any employment agreement between the Company and Awardee, the Awardee shall forfeit the Restricted Shares, to the extent that the transfer restrictions set forth in Section 3 have not previously lapsed, immediately upon Awardee's cessation of employment by, or service to, the Company or a Subsidiary (as defined in the Plan), as applicable. Restricted Shares, to the extent forfeited, shall be immediately returned to the Company.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3. <u>Transfer Restrictions</u>. The Restricted Shares may not be sold, assigned, pledged or otherwise transferred (voluntarily or involuntarily) or otherwise be the subject of any disposition unless and until the Restricted Shares become vested and such transfer restrictions lapse in accordance with <u>Exhibit A</u>. Upon satisfaction of the vesting conditions set forth in <u>Exhibit A</u> with respect to Restricted Shares, the transfer restrictions set forth in this Section shall lapse.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;4. <u>Adjustment of Shares</u>. Notwithstanding anything contained herein to the contrary, in the event of any change in the Company's Common Stock resulting from a corporate transaction including, but not limited to, a dividend or other distribution (whether in the form of cash, Company stock, or other property), recapitalization, stock split, reorganization, reclassification, merger, consolidation, spin-off, combination, repurchase, share exchange, liquidation, dissolution or other similar corporate transaction, the Restricted Shares shall be treated in the same manner in any such transaction as other Common Stock. Any Common Stock or other securities received by the Awardee as a result of such transaction with respect to the Restricted Shares shall be subject to the restrictions and conditions set forth herein and in the attached <u>Exhibit A</u>.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;5. <u>Rights as Stockholder</u>. Except as provided by Section 3 hereof, the Awardee shall be entitled to all of the rights of a stockholder with respect to the Restricted Shares as of the Award Date, including, but not limited to, the right to vote such shares and receive dividends and other distributions payable with respect to same.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;6. <u>Legend</u>. The stock certificates or electronic book entry statements, as applicable, representing the Restricted Shares shall bear the following legend:

THE SHARES OF STOCK REPRESENTED HEREBY ARE SUBJECT TO THE TERMS AND CONDITIONS (INCLUDING FORFEITURE CONDITIONS AND TRANSFER RESTRICTIONS) CONTAINED IN A RESTRICTED STOCK AWARD AGREEMENT BETWEEN ADIAL PHARMACEUTICALS, INC. AND THE HOLDER AND THE TERMS OF THE ADIAL PHARMACEUTICALS, INC. 2017 EQUITY INCENTIVE PLAN, AS AMENDED (THE "PLAN"), AS EACH MAY BE AMENDED FROM TIME TO TIME. A COPY OF SUCH AGREEMENT AND PLAN IS ON FILE IN THE OFFICE OF THE SECRETARY OF ADIAL PHARMACEUTICALS, INC.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;7. <u>Section 83(b) Election</u>. The Awardee hereby acknowledges that the Awardee has been informed that, with respect to the Restricted Shares, the Awardee may file an election with the Internal Revenue Service, within 30 days of the execution of this Agreement, electing pursuant to Section 83(b) of the Internal Revenue Code of 1986, as amended, (the "<u>Code</u>") to be taxed currently on any difference between the purchase price of the Restricted Shares and their fair market value on the date of purchase. Absent such an election, taxable income will be measured and recognized by the Awardee at the time or times at which the forfeiture restrictions on the Restricted Shares lapse. The Awardee is strongly encouraged to seek the advice of his own tax consultants in connection with the issuance of the Restricted Shares and the advisability of filing an election under Section 83(b) of the Code. A form of Election under Section 83(b) is attached hereto as <u>Exhibit B</u> for reference.

THE AWARDEE ACKNOWLEDGES THAT IT IS NOT THE COMPANY'S, BUT RATHER THE AWARDEE'S SOLE RESPONSIBILITY TO FILE THE ELECTION UNDER SECTION 83(b) TIMELY.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;8. <u>Government Regulations</u>. Notwithstanding anything contained herein to the contrary, the Company's obligation to issue or deliver certificates or book entry statements evidencing the Restricted Shares shall be subject to the terms of all applicable laws, rules and regulations and to such approvals by any governmental agencies or national securities exchanges as may be required.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;9. <u>Withholding Taxes</u>. The Company shall have the right to require the Awardee to remit to the Company, or to withhold from amounts payable to the Awardee, as compensation or otherwise, an amount sufficient to satisfy all federal, state and local withholding tax requirements (including, without limitation, any tax resulting from (i) the expiration of restrictions set forth hereunder that are applicable to any particular Restricted Shares or (ii) an election made by the Awardee under Section 83(b) of the Code).

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;10. <u>Tax Consequences</u>. Awardee hereby agrees that the Company does not have a duty to design or administer the Plan or its other compensation programs in a manner that minimizes Awardee's tax liabilities. Awardee shall not make any claim against the Company, or any of its officers, directors, employees or affiliates, related to tax liabilities arising from the grant of the Restricted Shares to Awardee or Awardee's other compensation.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;11. <u>Investment Purpose</u>. The Awardee represents and warrants that unless the Restricted Shares are registered under the Securities Act of 1933, as amended (the "<u>Securities Act</u>"), any and all shares of Common Stock acquired by the Awardee under this Agreement will be acquired for investment for the Awardee's own account and not with a view to, for resale in connection with, or with an intent of participating directly or indirectly in, any distribution of such shares of Common Stock within the meaning of the Securities Act. The Awardee agrees not to sell, transfer or otherwise dispose of such shares (i) until the transfer restrictions set forth in Section 3 have lapsed and (ii) unless the Restricted Shares are either (a) registered under the Securities Act and all applicable state securities laws, or (b) exempt from such registration in the opinion of Company counsel.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;12. <u>Securities Law Restrictions</u>. Regardless of whether the offering and sale of shares of Restricted Shares pursuant to this Agreement and the Plan have been registered under the Securities Act, or have been registered or qualified under the securities laws of any state, the Company at its discretion may impose restrictions upon the sale, pledge or other transfer of such shares of Common Stock (including the placement of appropriate legends on stock certificates or the imposition of stop-transfer instructions) if, in the judgment of the Company, such restrictions are necessary in order to achieve compliance with the Securities Act or the securities laws of any state or any other law.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;13. <u>Awardee Representations</u>. The Awardee has reviewed with his own tax advisors the federal, state, local and foreign tax consequences of the transactions contemplated by this Agreement. The Awardee is relying solely on such advisors and not on any statements or representations of the Company or any of its agents, if any, made to the Awardee. The Awardee understands that the Awardee (and not the Company) shall be responsible for the Awardee's own tax liability arising as a result of the transactions contemplated by this Agreement.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;14. <u>No Guarantee of Continued Service</u>. The Awardee acknowledges and agrees that (i) nothing in this Agreement or the Plan confers on the Awardee any right to continue in an employment, service or consulting relationship with the Company, nor shall it affect in any way the Awardee's right or the Company's right to terminate the Awardee's employment, service, or consulting relationship at any time, with or without cause, subject to any employment or service agreement that may have been entered into by the Company and the Awardee; and (ii) the Company would not have granted this Award to the Awardee but for these acknowledgements and agreements.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;15. <u>Notices</u>. Any notices provided for in this Agreement or the Plan shall be given in writing and shall be deemed effectively given upon receipt or, in the case of notices delivered by mail by the Company to Awardee, five (5) days after deposit in the United States mail, postage prepaid, addressed to Awardee at the last address Awardee provided to the Company.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;16. <u>Governing Plan Document</u>. The Award is subject to all the provisions of the Plan, the provisions of which are hereby made a part of of this Agreement, and is further subject to all interpretations, amendments, rules and regulations, which may from time to time be promulgated and adopted pursuant to the Plan. In the event of any conflict between the provisions of this Agreement and those of the Plan, the provisions of the Plan shall control.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;17. <u>Governing Law</u>. This Agreement shall be governed by, construed and enforced in accordance with the laws of the State of Delaware without giving effect to its principles governing conflicts of law.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;18. <u>Entire Agreement</u>. This Agreement, together with the the terms of the Plan and the terms of any employment agreement between the Company and Awardee, constitutes the entire agreement between the parties hereto with respect to the subject matter hereof, and supersedes all prior agreements and understandings relating to the subject matter of this Agreement.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;19. <u>Opportunity for Review</u>. Awardee and the Company agree that this Award is granted under and governed by the terms and conditions of the Plan and this Agreement. The Awardee has reviewed the Plan and this Agreement in their entirety, has had an opportunity to obtain the advice of counsel prior to accepting this Agreement and fully understands all provisions of the Plan and this Agreement. The Awardee hereby agrees to accept as binding, conclusive and final all decisions or interpretations of the Committee upon any questions relating to the Plan and this Agreement. The Awardee further agrees to notify the Company upon any change in Awardee's residence address.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;20. <u>Binding Effect</u>. This Agreement shall be binding upon and inure to the benefit of the Company and the Awardee and their respective permitted successors, assigns, heirs, beneficiaries and representatives. This Agreement is personal to the Awardee and may not be assigned by the Awardee without the prior consent of the Company. Any attempted assignment in violation of this Section shall be null and void.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;21. <u>Amendment</u>. This Agreement may be amended or modified only by a written instrument executed by both the Company and the Awardee; <u>provided</u>, <u>however</u>, that to the extent that this Agreement and the award of Restricted Shares hereunder are or become subject to the provisions of Section 409A of the Code, the Company and the Awardee agree that this Agreement may be amended or modified by the Company, in its sole discretion and without the Awardee's consent, as appropriate to maintain compliance with the provisions of Section 409A of the Code.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;22. <u>Severability</u>. In the event that any one or more of the provisions or portion thereof contained in this Agreement shall for any reason be held to be invalid, illegal, or unenforceable in any respect, the same shall not invalidate or otherwise affect any other provisions of this Agreement, and this Agreement shall be construed as if the invalid, illegal or unenforceable provision or portion thereof had never been contained herein.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;23. <u>Recoupment</u>. Any amounts paid hereunder shall be subject to recoupment in accordance with The Dodd–Frank Wall Street Reform and Consumer Protection Act and any implementing regulations thereunder, any clawback policy adopted by the Company or as is otherwise required by applicable law or stock exchange listing conditions.

**IN WITNESS WHEREOF**, the parties hereto have executed this Agreement or caused their duly authorized officer to execute this Agreement as of the date first written above. By signing below, the Awardee accepts the Award, acknowledges receipt of a copy of the Plan and this Agreement, and agrees to the terms thereof.

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| |
|:---|
| **ADIAL PHARMACEUTICALS, INC.** |
| By: |
| Name: |
| Title: |
| **AWARDEE** |
| Name: |

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**EXHIBIT A**

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| | | |
|:---|:---|:---|
| 1. | (a). | **Awardee's Name**: **<u>_____________</u>** |
|  | (b). | **Award Date: <u>_________________</u>** |
|  | (c). | **Number of Restricted Shares Granted**: **<u>_______________</u>** |

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| | |
|:---|:---|
| (d). | **Vesting Requirements**: Subject to the following terms, the Restricted Shares shall become vested, and the restrictions applicable to Restricted Shares as set forth in Section 3 of the Award Agreement to which this <u>Exhibit A</u> relates shall lapse, as follows: 100% of the Restricted Shares shall vest on the earlier of (i) the first anniversary of the Award Date and (ii) upon the occurrence of a Change in Control. |

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**Exhibit** **B**

**ELECTION UNDER SECTION 83(b)**

**OF THE INTERNAL REVENUE CODE OF 1986**

The undersigned taxpayer hereby elects, pursuant to § 83(b) of the Internal Revenue Code of 1986, as amended, to include in gross income as compensation for services the excess (if any) of the fair market value of the shares described below over the amount paid for those shares.

&nbsp;&nbsp;&nbsp;&nbsp;1. The
 name, taxpayer identification number, address of the undersigned, and the taxable year for
 which this election is being made are:

Name: ____________________ <br> Address: __________________ <br> __________________

Social Security Number: ____________

Taxable Year: __________

&nbsp;&nbsp;&nbsp;&nbsp;2. The
 property which is the subject of this election is _______ shares of common stock of (the
 "Stock") of Adial Pharmaceuticals, Inc., a Delaware corporation (the "Company").

&nbsp;&nbsp;&nbsp;&nbsp;3. The
 property was transferred to the undersigned on _____________ **.** 

&nbsp;&nbsp;&nbsp;&nbsp;4. The
 property is subject to the following restrictions:

The above-mentioned 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 contained in such agreement.

&nbsp;&nbsp;&nbsp;&nbsp;5. The
 fair market value of the property at the time of transfer (determined without regard to any
 restriction other than a nonlapse restriction as defined in § 1.83-3(h) of the Income
 Tax Regulations) is: $______per share x _______ shares = $_______.

&nbsp;&nbsp;&nbsp;&nbsp;6. For
 the property transferred, the undersigned did not pay any amount for the stock. Therefore,
 $______ (the full fair market value of the shares stated above) is includible in the undersigned's
 gross income as compensation for services.

&nbsp;&nbsp;&nbsp;&nbsp;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 or her 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. The undersigned is the person performing the services in connection with which the property was transferred.

Dated: ________________ ___________________________ <br> Taxpayer signature

**INSTRUCTIONS FOR FILING SECTION 83(B) ELECTION**

Attached is a form of election under section 83(b) of the Internal Revenue Code. If you wish to make such an election, you should complete, sign and date the election and then proceed as follows:

1. Execute three counterparts of your completed election (plus one extra counterpart for each person other than you, if any who receives property that is the subject of your election), retaining at least one photocopy for your records.

2. Send one counterpart to the Internal Revenue Service Center with which you will file your Federal income tax return for the current year via certified mail, return receipt requested. THE ELECTION SHOULD BE SENT IMMEDIATELY, AS YOU ONLY HAVE 30 DAYS FROM THE ISSUANCE/PURCHASE/GRANT DATE WITHIN WHICH TO MAKE THE ELECTION – NO WAIVERS, LATE FILINGS OR EXTENSIONS ARE PERMITTED.

3. Deliver one counterpart of the completed election to the Company for its files.

4. If anyone other than you (e.g., one of your family members) will receive property that is the subject of your election, deliver one counterpart of the completed election to each such person.