Document:

exv10w19

 

Exhibit 10.19

Summary of Compensation for 

Non-Employee Directors and Named Executive Officers

Non-Employee Director Compensation Summary

Annual Retainer

$20,000

Additional $5,000 for serving as chair of the audit committee

Retainers are payable in cash in equal, quarterly installments in arrears

Board and Committee Meeting Fees

$2,000 per meeting for each Board of Directors meeting attended

$1,000 per meeting for each Board committee meeting attended

Annual Equity Award

1,000 shares of restricted stock are awarded to all non-employee directors (other than Gerald J.
Ford and Donald J. Edwards) pursuant to the 2002 Long Term Incentive Plan of First Acceptance
Corporation (the “Company”), on the date of each annual meeting of the Company’s stockholders.

Named Executive Officer Compensation Summary

Current salaries for named executive officers:

	 	 	 	 	 	 	 
	Name	 	Title	 	Salary
	Stephen J. Harrison

	 	President and Chief Executive Officer
	 	$	500,000	 
	 
	 	 	 	 	 	 
	Thomas M. Harrison, Jr.

	 	Executive Vice President and Secretary
	 	$	300,000	 
	 
	 	 	 	 	 	 
	William R. Pentecost

	 	Chief Information Officer
	 	$	191,650	 
	 
	 	 	 	 	 	 
	Randy L. Reed

	 	Senior Vice President — Sales and Marketing
	 	$	175,000	 
	 
	 	 	 	 	 	 
	Michael J. Bodayle

	 	Chief Financial Officer - Insurance
Company Operations
	 	$	164,300	 

Under the terms of their respective employment agreements, Stephen J. Harrison is entitled to
receive an annual bonus equal to up to 100% of his base salary and Thomas M. Harrison, Jr. is
entitled to receive an annual bonus equal to up to 50% of his base salary, based upon such
executives’ attainment of performance-based objectives set forth in their respective employment
agreements for the calendar year ending December 31, 2004, and for each calendar year thereafter as
established by the Company’s Board of Directors. On November 10, 2005, the

 

 

Compensation Committee
(the “Compensation Committee”) of the Board of Directors of the Company approved bonus targets for
the period from July 1, 2005 through June 30, 2006 for
Stephen J. Harrison and Thomas M. Harrison, Jr. pursuant to the terms of their respective
employment agreements. The Compensation Committee determined that bonuses for Stephen J. Harrison
and Thomas M. Harrison, Jr. during this twelve-month period would be based 50% upon the attainment
of certain targets for income before income taxes by USAuto Holdings, Inc. and its subsidiaries
(which constitutes the Company’s insurance operations) and 50% based upon qualitative factors to be
considered by the Compensation Committee.

The other named executive officers of the Company receive bonuses as determined in the discretion
of the Compensation Committee.

The named executive officers may also receive stock options pursuant to the Company’s
stockholder-approved 2002 Long Term Incentive Plan as determined in the discretion of the
Compensation Committee.

Additional Information

The foregoing information is summary in nature. Additional information regarding director and
named executive officer compensation will be provided in the Company’s Proxy Statement to be filed
in connection with the Company’s Annual Meeting of Stockholders to be held on November 9,
2006.EX-10.4

 

EXHIBIT 10.4

PARK
VIEW FEDERAL SAVINGS BANK
SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN

Amended and Restated February 2006

1

 

PARK VIEW FEDERAL SAVINGS BANK

SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN

Article 1

Definitions

	 	 	 
	Section 1.1

	 	Administrator. The Administrator of the Plan shall be the Compensation Committee.
	 
	 	 
	Section 1.2

	 	Actuarial Equivalent. At any date, with respect to any Plan Benefit hereunder, a payment or payments equal in the
aggregate to the value at such date of such. Plan Benefit determined actuarially on the basis of the current
Pension Benefit Guarantee Corporation (“PBGC”) interest rate and the mortality table currently used by the PBGC at
such date.
	 
	 	 
	Section 1.3

	 	Bank. Park View Federal Savings Bank, a federally chartered savings association, or any successor thereto as
provided in Section 10.12 herein.
	 
	 	 
	Section 1.4

	 	Board. The Board of Directors of Park View Federal Savings Bank.
	 
	 	 
	Section 1.5

	 	Compensation Committee. The Compensation Committee of the Board of Directors of Park View Federal Savings Bank.
	 
	 	 
	Section 1.6

	 	Code. The Internal Revenue Code of 1986, as amended, or as it may be amended from time to time.
	 
	 	 
	Section 1.7

	 	Company. PVF Capital Corporation, an Ohio corporation, or any successor thereto as provided in Section 10.12
herein, or any subsidiary thereof.
	 
	 	 
	Section 1.8

	 	Effective Date. The effective date of the Plan shall be July 1, 1998,
	 
	 	 
	Section 1.9

	 	Plan. The Park View Federal Savings Bank Supplemental Executive Retirement Plan.
	 
	 	 
	Section 1.10

	 	Plan Benefit. Retirement benefits payable under the Park View Federal Savings Bank Supplemental Executive
Retirement Plan.
	 
	 	 
	Section 1.11

	 	Participant. An employee who is eligible to participate in the Park View Federal Savings Bank Supplemental
Executive Retirement Plan.
	 
	 	 
	Section 1.12

	 	Retirement Date. The first day of any calendar month following the Participant’s sixty fifth (65th) birthday on
which the Participant elects to retire, or such earlier date as the Board, by resolution, may agree to grant the
Participant early retirement.

2

 

Article 2

Purpose of Plan

	 	 	 
	Section 2.1

	 	Purpose. The Plan is designed to provide retirement benefits payable out of the general
assets of the Bank as provided in Article 4.

Article 3

Eligibility

	 	 	 
	Section 3.1

	 	Eligibility. Eligibility to participate in the Plan is limited to Employees of the Bank
who are designated by the Compensation Committee of the Board of Directors of the Bank.

Article 4

Benefits

	 	 	 
	Section 4.1

	 	Amount of Benefits. The annual amount of benefits payable to
each Participant under the Plan shall be equal to sixty
percent (60%) of the Participant’s Final Pay, reduced by the
Actuarial Equivalent of the annual benefits payable to the
Participant under the Bank’s Qualified Retirement Plans
consistent with the form of benefits paid under Section 4.2.
For purposes of this Section, the reduction for benefits
payable under Qualified Retirement Plans shall not include
elective deferrals made by the employee and earnings thereon.
For purposes of this Section, Final Pay shall be defined as
the highest year’s combined salary and target bonus (as
defined in the Bank’s Management Incentive Compensation Plan
established July 1, 1997) during the last five years of the
Participant’s employment with the Bank. The determination of
combined salary and target bonus shall include any amounts
electively deferred by the Participant to any of the Bank’s
qualified or nonqualified employee benefit plans.
	 
	 	 
	Section 4.2

	 	Form of Benefit Payments. The benefits payable to or on behalf
of a Participant as determined under Section 4.1 shall be paid
in the form of a lump sum distribution, single life annuity or
converted to the Actuarial Equivalent joint and survivor
annuity.
	 
	 	 
	Section 4.3

	 	Time of Benefit Payments. Payment of benefits (annuity
payments or the lump sum equivalent of the annuity payments)
due under the Plan to the Participant shall commence on the
Participant’s Normal Retirement Date or, such earlier date as
otherwise provided in this Agreement or as the Compensation
Committee of the Board may, by resolution, otherwise

3

 

	 	 	 
	 

	 	determine. Subsequent annual payments of benefits shall be paid to the Participant
each year, thereafter, on the anniversary date of the initial payment described in
the previous sentence. Annuity payments shall continue for the lifetime of the
Participant, or for the joint lives of the Participant and his or her spouse if
actuarially converted pursuant to Section 4.2. In the event the Participant dies
prior to commencement of benefit payments, the benefits payable shall be paid in a
lump sum Actuarial Equivalent to the named beneficiary under Article 7 herein
within one year from the date of death of the Participant.
	 
	 	 
	Section 4.4

	 	Distribution Election. Each Participant shall elect on a Distribution Election Form
(in the form attached hereto) the distribution form for Benefit Amount described in Section
4.1. If any Participant fails to make an election on a Distribution Election Form with
respect to the Plan the distribution form shall be a single life annuity or converted to the
Actuarial Equivalent joint and survivor annuity. Payment of the Benefit within 30 days upon
the occurrence of normal retirement, disability, death, early retirement or change of control,
as described in Article 5 .

Article 5

Vesting

	 	 	 
	Section 5.1

	 	Pro Rata Vesting. Provided that the Participant has remained
continuously in the employ of the Bank (except for normal vacation
time and such other leaves of absence as may be approved by the
Board), the Participant shall vest in the Plan Benefits described
in Article 4 of this Agreement each year, on a pro rata basis,
beginning with the one year anniversary date of the effective date
that the Participant becomes eligible to participate in the Plan
and continuing with each succeeding annual anniversary date
thereafter until the Participant’s attainment of age sixty-five
(65). Upon the Participant’s attainment of age sixty-five (65) and
provided the Participant has remained continuously in the employ
of the Bank, the Participant shall be fully vested in the Plan
Benefits described in Article 4 of this Agreement.
	 
	 	 
	Section 5.2

	 	Example. A Participant is age forty-five (45) at the effective
date of this Agreement. Assuming the Participant remains in the
employ of the Bank for another fifteen (15) years until he is age
sixty (60), he will be entitled to an annual benefit under Article
4 and Section 5.1 of this Agreement that is equal to forty-five
percent (45%) of the Participant’s highest combined salary and
target bonus during the last five years of his employment
determined as follows:

4

 

	 	 	 
	 

	 	15 years Credited service x 60% Final Pay = 45% Final Pay at

20 year vesting period   age sixty-five (65)1
	 
	 	 
	 

	 	1 If payments begin earlier than age sixty-five (65), the benefit
will be actuarially reduced. If requested by the Participant and approved by the
Compensation Committee, the actuarially reduced lump sum equivalent may be paid in
lieu of annual benefits.
	 
	 	 
	 

	 	Years of credited service shall be equal to the number of years the
Participant remains in the employ of the Bank after becoming an eligible
Participant of the Plan as determined by the Board
	 
	 	 
	 

	 	Vesting period shall be equal to the difference between sixty-five (65) and the
Participant’s age at the time he becomes a Participant in the Plan.
	 
	 	 
	Section 5.3

	 	Death or Disability. In the event that the Participant dies or becomes permanently and
totally disabled while in the employ of the Bank and prior to age sixty-five (65), the
Participant shall become fully vested in the Plan Benefits described in Article 4 of this
Agreement.
	 
	 	 
	 

	 	For purposes of this Agreement, disability shall mean a condition in which the
Participant is: (a) unable to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment that can be expected to
result in death, or last for a continuous period of not less than twelve (12)
months; or (b) by reason of any medically determinable physical or mental
impairment that can be expected to result in death, or last for a continuous period
of not less than twelve (12) months, is receiving income replacement benefits for a
period of not less than three (3) months under an accident and health plan covering
participants of Bank.
	 
	 	 
	Section 5.4

	 	Early Retirement. In the event the Participant wishes to
retire prior to age sixty-five (65), the Compensation
Committee of the Board may agree, by resolution, to fully vest
the Participant in the entire Plan Benefit described in
Article 4. The Compensation Committee of the Board may also
agree, by resolution, and with the approval of the
Participant, to begin payment of the Participant’s Plan
Benefits prior to the Participant’s attainment of age
sixty-five (65), Benefits commencing earlier than the
Participant’s age 65 will be actuarially reduced for the
Participant’s age at commencement.

5

 

	 	 	 
	Section 5.5

	 	Change in Control.

	 	(a)	 	In the event of a change in control of the Company, the
entire Plan Benefit described in Article 4 shall become fully vested and be
immediately payable to the Participant in full.
	 
	 	(b)	 	For purposes of this Agreement, a change in control shall mean:

	 	(i)	 	The acquisition by a person or persons
acting in concert of the power to vote twenty-five percent (25%) or
more of a class of the Company’s voting securities, or the
acquisition by a person of the power to direct the Company’s
management or policies, if the Board of Directors or the Office of
Thrift Supervision (the “OTS”) or successor regulatory agency has
made a determination that such acquisition constitutes or will
constitute an acquisition of control of the Company for the purposes
of the Savings and Loan Holding Company Act or the Change in Bank
Cant-Tot Act and the regulations thereunder (12 CFR Part 574 or any
successor provision);
	 
	 	(ii)	 	during the period of two (2) consecutive
years during the term of this Agreement, individuals who at the
beginning of such period constitute the Board of Directors of the
Company cease for any reason to constitute at least a majority
thereof, unless the election of each director who was not a director
at the beginning of such period has been approved in advance by
directors representing at least two thirds (2/3) of the directors
then in office who were directors in office at the beginning of the
period;
	 
	 	(iii)	 	the Company shall have merged into or
consolidated with another company, or merged another company into the
Company, on a basis whereby less than fifty percent (50%) of the
total voting power of the surviving company is represented by shares
held by former shareholders of the Company prior to such merger or
consolidation; or
	 
	 	(iv)	 	The Company shall have sold (i)
substantially all of its assets; or, (ii) the Bank, to another
person. The term “person” refers to an individual, corporation,
partnership, trust, association, joint venture, pool, syndicate, sole
proprietorship, unincorporated organization or other entity.

6

 

Article 6

Termination for Cause

	 	 	 
	Section 6.1

	 	In the event of the termination of the Participant for Cause,
the Bank shall have no further obligations under this
Agreement other than payment to the Participant at the
Retirement Date of any vested portion of the Plan Benefit.
For purposes of this Agreement, Cause shall be defined as
termination as a result of the Participant’s personal
dishonesty, incompetence, willful misconduct, breach of
fiduciary duty involving personal profit, intentional failure
to perform stated duties, willful violation of any law, rule
or regulation (other than traffic violations or similar
offenses) or final cease-and-desist order or material breach
of any provision of this Agreement.
	 
	 	 
	Sections 6.2

	 	If any events specified in Section 563.39(b) (2) through (5)
of the OTS Regulations (or any successor provision thereto)
shall occur, the Participant’s rights under this Agreement
shall be determined in accordance with the provisions of such
Sections.

Article 7

Beneficiary Designation

	 	 	 
	Section 7.1

	 	Beneficiary Designation. Each Participant shall have the
right, at any time, to designate any person or persons as his
Beneficiary or Beneficiaries (both primary and contingent) to
whom payment under this Plan shall be paid in the event of
death prior to complete distribution of the Participant’s Plan
Benefits under the Plan. Each Beneficiary Designation shall be
in a written form prescribed by the Administrator and will be
effective only when filed with the Administrator during the
Participant’s lifetime.
	 
	 	 
	Section 7.2

	 	Amendments. Any Beneficiary Designation may be changed by a
Participant without the consent of any designated Beneficiary
by the filing of a new Beneficiary Designation with the
Administrator. The filing of a new Beneficiary Designation
form will cancel all Beneficiary Designations previously
filed,
	 
	 	 
	Section 7.3

	 	No Beneficiary Designation. If any Participant fails to
designate a Beneficiary in the manner provided above, or if
the Beneficiary designated by a deceased Participant
predeceases the Participant, the Administrator shall direct
the Bank to distribute such Participant’s remaining benefits
under the Plan as follows:

7

 

	 	a.	 	To the Participant’s surviving spouse, if any; or
	 
	 	b.	 	If the Participant has no surviving spouse, then to the
Participant’s children in equal shares by right of representation; or
	 
	 	c.	 	If the Participant shall have no surviving spouse or
children, then to the Participant’s estate; or
	 
	 	d.	 	In the absence of a will, in accordance with the intestate
statute of the Participant’s domicile.

	 	 	 
	Section 7.4

	 	Effect of Payment. Payment to the Beneficiary or as provided
in Section 4.3 above shall completely discharge the Bank’s
obligations under this Plan.
	 
	 	 
	Section 7.5

	 	Death of Beneficiary. Following commencement of payment of
benefits under the Plan, if the Beneficiary designated by the
deceased Participant dies before receiving complete
distribution of such benefits any remaining benefits shall be
paid:

	 	a.	 	As designated by the Beneficiary in a written form prescribed
by the Administrator which is effective only when fled with the Administrator
during the Beneficiary’s lifetime; or
	 
	 	b.	 	If the Beneficiary shall not have made such designation, then
to the Beneficiary’s estate.

Article 8

Claims Procedure

	 	 	 
	Section 8.1

	 	Claim. Any person claiming a benefit under the Plan,
requesting an interpretation or ruling under the Plan, or
requesting information under the Plan shall present the
request in writing to the Administrator who shall respond in
writing as soon as practicable, and in no event later than
ninety (90) days after the date of the written request.
	 
	 	 
	Section 8.2

	 	Denial of Claim. If the claim or request is denied, the
written notice of denial shall be made within ninety (90) days
of the date of receipt of such claim or request by the
Administrator and shall state:

	 	a.	 	The reason for denial, with specific reference to the Plan
provision on which the denial is based.
	 
	 	b.	 	A description of any additional material or information
required and an explanation of why it is necessary.

8

 

	 	c.	 	An explanation of the Plan’s claim review procedure.

	 	 	 
	Section 8.3

	 	Review of Claim. Any person whose claim or request is denied
or who has not received a response within ninety (90) days may
request review by notice given in writing to the Administrator
within (60) days of receiving a response or one hundred fifty
(150) days from the date the claim was received by the
Administrator. The claim or request shall be reviewed by the
Administrator who may, but shall not be required to, grant the
claimant a hearing. On review, the claimant may have
representation, examine pertinent documents, and submit issues
and comments in writing.
	 
	 	 
	Section 8.4

	 	Final Decision. The decision on review shall normally be made
within sixty (60) days after the Administrator’s receipt of a
request for review. If an extension of time is required for a
hearing or other special circumstances, the claimant shall be
notified and the time limit shall be one hundred twenty (120)
days after the Administrator’s receipt of a request for
review. The decision shall be in writing and shall state the
reasons and relevant Plan provision. All decisions on review
shall be final and bind all parties concerned.

Article 9

Amendment of Plan

	 	 	 
	Section 9.1

	 	Amendment of Plan. The Board may, at any time, amend the Plan in whole or in part,
provided, however, that no amendment shall be effective to decrease or restrict any vested
Plan Benefits accrued under the Plan.

Article 10

Miscellaneous

	 	 	 
	Section 10.1

	 	Benefits Unfunded. The benefits payable under the Plan shall
be paid by the Bank each year out of its general assets.
	 
	 	 
	Section 10.2

	 	Unsecured General Creditor. Participants have the status of
unsecured general creditors of the Bank. The Bank’s
obligation under the Plan shall be merely that of an unfunded
and unsecured promise of the Bank to make benefit payments in
the future.
	 
	 	 
	Section 10.3

	 	Nonassignability. Neither a Participant nor any other person
shall have any right to alienate, commute, sell, assign,
transfer, pledge, anticipate, mortgage or otherwise encumber,
transfer, hypothecate or convey in

9

 

	 	 	 
	 

	 	advance of actual receipt the amounts, if any, payable hereunder, or any part
thereof, which are, and all rights which are, expressly declared to be unassignable
and nontransferable. No part of the amounts payable shall, prior to actual payment,
be subject to seizure or separation for the payment of any other person, nor be
transferable by operation of law in the event of a Participant’s or another
person’s bankruptcy or insolvency.
	 
	 	 
	Section 10.4

	 	Payment of Taxes. The Bank shall have the right to deduct
from all benefits paid hereunder any Federal, state or local
taxes required to be withheld with respect to such benefit
payments.
	 
	 	 
	Section 10.5

	 	Not a Contract of Employment. The terms and conditions of
this Plan shall not be deemed to constitute a contract of
employment between the Bank and the Participant, except as
may otherwise be specifically provided herein. Moreover,
nothing in this Plan shall be deemed to give the Participant
the right to be retained in the service of the Bank or to
interfere with the right of the Bank to discipline or
discharge the Participant at any time
	 
	 	 
	Section 10.6

	 	Participant Cooperation. A Participant will cooperate with
the Bank by furnishing any and all information requested by
the Bank in order to facilitate the payment of benefits
hereunder and such other action as may be requested by the
Bank.
	 
	 	 
	Section 10.7

	 	Terms. Whenever any words are used herein in the masculine,
they shall be construed as though they were used in the
feminine in all cases where they would so apply; and
wherever any words are used herein in the singular or in the
plural, they shall be construed as though they were used in
the plural or the singular, as the case may be, in all cases
where they would so apply.
	 
	 	 
	Section 10.8

	 	Caption. The captions of articles, sections, and paragraphs
of the Plan are for convenience only and shall not control
or affect the meaning or construction of any of its
provisions.
	 
	 	 
	Section 10.9

	 	Governing Law. This agreement shall, except to the extent
that Federal Laws (including a law, rule or regulation of
the OTS or Federal Deposit Insurance Corporation (FDIC))
shall be deemed to apply, be governed by and construed and
enforced in accordance with the laws of Ohio.
	 
	 	 
	Section 10.10

	 	Validity. In case any provision of this Plan shall be held
illegal or invalid for any reason, said illegality or
invalidity shall not affect the remaining parts hereof, but
this Plan shall be construed and enforced as if such illegal
and invalid provision had never been inserted herein.

10

 

	 	 	 
	Section 10.11

	 	Notice. All notices or other communications under this Plan
shall be made in writing and either hand delivered or sent
by registered or certified mail to the Administrator.
	 
	 	 
	Section 10.12

	 	Successors, All obligations of the Company and the Bank,
respectively, under the Plan shall be binding on any
successor to the Company and the Bank, respectively, whether
the existence of such successor is the result of a direct or
indirect purchase, merger, consolidation or otherwise, of
all or substantially all of the business and/or assets of
the Company or the Bank.

IN WITNESS WHEREOF, and pursuant to resolution of the Board of Directors of the undersigned, the
Bank has caused this instrument to be executed by its duly authorized
officer this
_______________ day of _________,
2006.

	 	 	 	 	 	 	 	 	 
	PVF CAPITAL CORPORATION	 	PARK VIEW FEDERAL SAVINGS BANK
	 
	 	 	 	 	 	 	 	 
	By:

	 	 	 	By:	 	 	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	John R. Male

Chairman of the Board 

of Directors
	 	 	 	Gerald A. Fallon 

Chairman of 

Compensation Committee	 	 
	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	PARK VIEW FEDERAL SAVINGS BANK	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	By:
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 
	 

	 	John R. Male 

Chairman of the Board 

of Directors	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 

	 	 	 	 	 
	STATE OF OHIO 

CUYAHOGA COUNTY

	 	)

)

)	 	 
	 
	 	 	 	 
	Sworn to before my by the aforesaid John R. Male and Gerald A. Fallon and subscribed in my presence
this ______ day of ____________, 2006.
	 

	 	 	 	 
	 

	 	________________________
	 

	 	NOTARY PUBLIC

11

 

PARK VIEW FEDERAL SAVINGS BANK

SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN

DISTRIBUTION ELECTION FORM

I, ____________, a Participant pursuant to the Park View Federal Savings Bank
Supplemental Executive Retirement Plan, hereby elect that, upon the occurrence of normal
retirement, disability, death, early retirement or change of control, as described in Article 5,
the amount of benefits payable, described in Article 4, shall be distributed to me as follows:

	 	 	 	___  Lump-sum payment within 30 days of event entitling me to such distribution.
	 
	 	 	 	___  Payment of Benefit annually as a straight life annuity or converted to the Actuarial
Equivalent joint and survivor annuity, commencing 30 days after event entitling me to
such distribution.

______________________________

[Participant Signature]

Date: __________________________

12

 

BENEFICIARY DESIGNATION

I direct that all amounts payable at my death under the terms of the Park View Federal Savings Bank
Supplemental Executive Retirement be paid as provided below. As used below “survive me” means
“survive me by more than 30 days.” (Fill in the blank(s) of only one of the following)

	 	1.	 	To _________, if such person survives me, otherwise in equal shares to my
children who survive me; but if any child of mine does not survive me and leaves a child or
children, then such child’s share equally to his or her children, who survive me. At this
time, my children are
___________________________________________________________________________

______________________________________________________________________________________________.
	 
	 	2.	 	To my children who survive me in equal shares but if any child of mine does not survive me
and leaves a child or children, then such child’s share equally to his or her children who
survive me. At this time my children are ___________________

_____________________________________________________________________________________________.
	 
	 	3.	 	To _________, trustee (or
any successor trustee) of a trust agreement of which I
am the grantor dated _______________.
	 
	 	4.	 	To:________________________________________________________________________________________________
	 
	 	 	 	___________________________________________________________________________________________________
	 
	 	 	 	___________________________________________________________________________________________________
	 
	 	 	 	___________________________________________________________________________________________________
	 
	 	 	 	DATED this
__________________ day of _______________.
	 
	 	 	 	______________________________

                     (signature)

13

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