Document:

Form of Warrants

 Exhibit 10.5 
 [FORM OF SERIES [A][B][C] WARRANT] 
 NEITHER THE ISSUANCE AND SALE OF
THE SECURITIES REPRESENTED BY THIS CERTIFICATE NOR THE SECURITIES INTO WHICH THESE SECURITIES ARE EXERCISABLE HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE STATE SECURITIES LAWS. THE SECURITIES MAY NOT BE OFFERED
FOR SALE, SOLD, TRANSFERRED OR ASSIGNED (I) IN THE ABSENCE OF (A) AN EFFECTIVE REGISTRATION STATEMENT FOR THE SECURITIES UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR (B) AN OPINION OF COUNSEL, IN A FORM REASONABLY ACCEPTABLE TO
THE COMPANY, THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT OR (II) UNLESS SOLD PURSUANT TO RULE 144 OR RULE 144A UNDER SAID ACT. NOTWITHSTANDING THE FOREGOING, THE SECURITIES MAY BE PLEDGED IN CONNECTION WITH A BONA FIDE MARGIN ACCOUNT OR OTHER
LOAN OR FINANCING ARRANGEMENT SECURED BY THE SECURITIES. 
 MARSHALL EDWARDS, INC. 

WARRANT TO PURCHASE COMMON STOCK 

Warrant No.:          

Number of Shares of Common Stock:         

Date of Issuance: May [    ], 2011 (“Issuance Date”) 

Marshall Edwards, Inc., a company organized under the laws of Delaware (the “Company”), hereby certifies
that, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, [HUDSON BAY MASTER FUND LTD.] [OTHER BUYERS], the registered holder hereof or its permitted assigns (the “Holder”), is
entitled, subject to the terms set forth below, to purchase from the Company, at the Exercise Price (as defined below) then in effect, upon surrender of this Warrant to Purchase Common Stock (including any Warrants to Purchase Common Stock issued in
exchange, transfer or replacement hereof, the “Warrant”), at any time or times on or after [SERIES A: the six month anniversary of the date hereof][SERIES B: the Series B Eligibility Date] [SERIES C: the First
Reset Date] (the “Initial Exercisability Date”), but not after 11:59 p.m., New York time, on the Expiration Date (as defined below),
            (            )1 fully paid nonassessable shares of Common Stock, par value $0.00000002 per share, subject to adjustment as provided
herein (the “Warrant Shares”). Except as otherwise defined herein, capitalized terms in this Warrant shall have the meanings set forth in Section 16. This Warrant is one of the Warrants to purchase Common Stock (the
“SPA Warrants”) issued pursuant to Section 1 of that certain Securities Purchase Agreement, dated as of May 2, 2011 (the “Subscription Date”), by and among the Company and the investors (the
“Buyers”) referred to therein (the “Securities Purchase Agreement”). 
  

	1 	 [SERIES A: Insert 1,125,282.] [SERIES B: Insert 1,082,767.] [SERIES C: Insert 8,000,000.] 

 1. EXERCISE OF WARRANT. 

(a) Mechanics of Exercise. Subject to the terms and conditions hereof (including, without
limitation, the limitations set forth in Section 1(f)), this Warrant may be exercised by the Holder on any time or times on or after the Initial Exercisability Date, in whole or in part, by (i) delivery of a written notice, in the form
attached hereto as Exhibit A (the “Exercise Notice”), of the Holder’s election to exercise this Warrant and (ii) [SERIES A: (A)] [SERIES A&B: payment to the Company of an amount equal to the
applicable Exercise Price multiplied by the number of Warrant Shares as to which this Warrant is being exercised (the “Aggregate Exercise Price”) in cash or by wire transfer of immediately available funds] [SERIES A: or
(B) by notifying the Company that this Warrant is being exercised pursuant to a Cashless Exercise (as defined in Section 1(d))] [SERIES C: deemed payment to the Company of an amount equal to the applicable Exercise Price multiplied
by the number of Warrant Shares as to which this Warrant is being exercised (the “Aggregate Exercise Price”) pursuant to a Cashless Exercise (as defined in Section 1(d).]. The Holder shall not be required to deliver the
original Warrant in order to effect an exercise hereunder. Execution and delivery of the Exercise Notice with respect to less than all of the Warrant Shares shall have the same effect as reducing the number of Warrant Shares on the face of this
Warrant to the remaining number of Warrant Shares underlying this Warrant. On or before the first (1st) Trading Day following the date on which the Company has received the Exercise Notice, the Company shall transmit by facsimile an acknowledgment of confirmation of receipt of the Exercise Notice to
the Holder and the Company’s transfer agent (the “Transfer Agent”). On or before the third
(3rd) Trading Day following the date on which the
Exercise Notice has been delivered to the Company (the “Share Delivery Date”) [SERIES A&B:(provided that if the Aggregate Exercise Price [SERIES A: (unless notice of Cashless Exercise was given in the Exercise
Notice)] has not been delivered by such date, the Share Delivery Date shall be one Trading Day after the Aggregate Exercise Price is delivered)], the Company shall (X) provided that the Transfer Agent is participating in The Depository Trust
Company (“DTC”) Fast Automated Securities Transfer Program, credit such aggregate number of Warrant Shares to which the Holder is entitled pursuant to such exercise to the Holder’s or its designee’s balance account with
DTC through its Deposit / Withdrawal At Custodian system, or (Y) if the Transfer Agent is not participating in the DTC Fast Automated Securities Transfer Program or upon the request of the Holder, issue and dispatch by overnight courier to the
address as specified in the Exercise Notice, a certificate, registered in the Company’s share register in the name of the Holder or its designee, for the number of shares of Common Stock to which the Holder is entitled pursuant to such
exercise. The Company shall be responsible for all fees and expenses of the Transfer Agent and all fees and expenses with respect to the issuance of Warrant Shares via DTC, if any. Upon proper delivery of the Exercise Notice [SERIES A&B:
(provided that payment of the Aggregate Exercise Price [SERIES A: or notice of Cashless Exercise] is delivered in accordance herewith, as applicable)], the Holder shall be deemed for all corporate purposes to have become the holder of record
of the Warrant Shares with respect to which this Warrant has been exercised, irrespective of the date such Warrant Shares are credited to the Holder’s DTC account or the date of delivery of the certificates evidencing such Warrant Shares, as
the case may be. If this Warrant is submitted in connection with any exercise pursuant to this Section 1(a) and the number of Warrant Shares represented by this Warrant submitted for exercise is greater than the number of Warrant Shares being
acquired upon an exercise, then the Company shall as soon as practicable and in no event later than three (3) Trading Days after any exercise and at its own expense, issue a new Warrant (in accordance

  
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with Section 7(d)) representing the right to purchase the number of Warrant Shares issuable immediately prior to such exercise under this Warrant, less the number of Warrant Shares with
respect to which this Warrant is exercised. No fractional shares of Common Stock are to be issued upon the exercise of this Warrant, but rather the number of shares of Common Stock to be issued shall be rounded up to the nearest whole number. The
Company shall pay any and all taxes which may be payable with respect to the issuance and delivery of Warrant Shares upon exercise of this Warrant.] [SERIES A & C: NOTWITHSTANDING ANY PROVISION OF THIS WARRANT TO THE CONTRARY, NO MORE
THAN THE MAXIMUM ELIGIBILITY NUMBER OF WARRANT SHARES SHALL BE EXERCISABLE HEREUNDER.] 
 (b) Exercise
Price. For purposes of this Warrant, “Exercise Price” means [SERIES A: $1.57, subject to adjustment as provided herein][SERIES B: the lowest of (i) $1.333, subject to adjustment as provided herein,
(ii) (A) if with respect to a forced exercise pursuant to Section 4A, eighty five percent (85%) of the arithmetic average of the lowest eight (8) Weighted Average Prices of the Common Stock during the twenty
(20) consecutive Trading Day period immediately following the fifth (5th) Trading Day following the Forced Exercise Notice Date or (B) if with respect to an exercise by the Holder pursuant to Section 1(a), eighty five percent
(85%) of the arithmetic average of the lowest eight (8) Weighted Average Prices of the Common Stock during the twenty (20) consecutive Trading Day period ending on the Trading Day immediately preceding the date of delivery of the
Exercise Notice and (iii) the lowest deemed consideration per share of Common Stock (as determined in accordance with the provisions of Section 2(a) of the Series A Warrants (as defined in the Securities Purchase Agreement)) issued in any
Allowed Subsequent Placement (as defined in the Securities Purchase Agreement).] [SERIES C: $0.00000002, subject to the adjustment as provided herein.] 
 (c) Company’s Failure to Timely Deliver Securities. If the Company shall fail for any reason or for no reason to issue to the Holder on or before the Share Delivery Date, a certificate for the
number of shares of Common Stock to which the Holder is entitled and register such shares of Common Stock on the Company’s share register or to credit the Holder’s balance account with DTC for such number of shares of Common Stock to which
the Holder is entitled upon the Holder’s exercise of this Warrant, then, in addition to all other remedies available to the Holder, the Company shall pay in cash to the Holder on each day after such Share Delivery Date that the issuance of such
shares of Common Stock is not timely effected an amount equal to 1.5% of the product of (A) the sum of the number of shares of Common Stock not issued to the Holder on a timely basis and to which the Holder is entitled and (B) the Closing
Sale Price of the Common Stock on the Trading Day immediately preceding the last possible date which the Company could have issued such shares of Common Stock to the Holder without violating Section 1(a). In addition to the foregoing, if on or
prior to the Share Delivery Date the Company shall fail to issue and deliver a certificate to the Holder and register such shares of Common Stock on the Company’s share register or credit the Holder’s balance account with DTC for the
number of shares of Common Stock to which the Holder is entitled upon the Holder’s exercise hereunder or pursuant to the Company’s obligation pursuant to clause (ii) below, and if on or after such Trading Day the Holder purchases (in
an open market transaction or otherwise) shares of Common Stock to deliver in satisfaction of a sale by the Holder of shares of Common Stock issuable upon such exercise that the Holder anticipated receiving from the Company (a
“Buy-In”), then the Company shall, within three (3) Trading Days after the Holder’s request and in the Holder’s discretion, either (i) pay cash to the Holder in an amount equal to the Holder’s total

  
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purchase price (including brokerage commissions and other reasonable out-of-pocket expenses, if any) for the shares of Common Stock so purchased (the “Buy-In Price”), at which
point the Company’s obligation to deliver such certificate (and to issue such shares of Common Stock) or credit such Holder’s balance account with DTC shall terminate, or (ii) promptly honor its obligation to deliver to the Holder a
certificate or certificates representing such shares of Common Stock or credit such Holder’s balance account with DTC and pay cash to the Holder in an amount equal to the excess (if any) of the Buy-In Price over the product of (A) such
number of shares of Common Stock, times (B) the Closing Bid Price on the date of exercise. 
 (d)
[SERIES A & C: Cashless Exercise. Notwithstanding anything contained herein to the contrary, [SERIES A: if a Registration Statement (as defined in the Registration Rights Agreement) covering the resale of the Warrant Shares
that are the subject of the Exercise Notice pursuant to the 1933 Act (the “Unavailable Warrant Shares”) is not available for the resale of such Unavailable Warrant Shares, the Holder may, in its sole discretion, exercise this
Warrant in whole or in part and, in lieu of making the cash payment otherwise contemplated to be made to the Company upon such exercise in payment of the Aggregate Exercise Price, elect instead to] [SERIES C: upon exercise of this Warrant, in
whole or in part, the Holder shall] receive upon such exercise the “Net Number” of shares of Common Stock determined according to the following formula (a “Cashless Exercise”): 

Net Number = (A x B) - (A x C) 
                         D 

For purposes of the foregoing formula: 
  

	 	A=	 the total number of shares with respect to which this Warrant is then being exercised. 

 

	 	B=	 the arithmetic average of the Weighted Average Prices of the Common Stock (as reported by Bloomberg) for the five (5) consecutive Trading Days
ending on the date immediately preceding the date of the Exercise Notice. 

  

	 	C=	 the Exercise Price then in effect for the applicable Warrant Shares at the time of such exercise. 

 

	 	D=	 the Weighted Average Price of the Common Stock on the Exercise Date. 

For purposes of Rule 144(d) promulgated under the 1933 Act, as in effect on the date hereof, it is intended and the
Company acknowledges that the Warrant Shares issued in a Cashless Exercise shall be deemed to have been acquired by the Holder, and the holding period for the Warrant Shares shall be deemed to have commenced, on the Issuance Date.] 

[SERIES B: [Intentionally Omitted]] 

  
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 (e) Disputes. In the case of a dispute as to the determination of
the Exercise Price or the arithmetic calculation of the Warrant Shares, the Company shall promptly issue to the Holder the number of Warrant Shares that are not disputed and resolve such dispute in accordance with Section 12. 

(f) Limitations on Exercises. The Company shall not effect the exercise of this Warrant and
the Holder shall not have the right to exercise this Warrant, to the extent that after giving effect to such exercise, such Person (together with such Person’s affiliates) would beneficially own in excess of 9.99% (the “Maximum
Percentage”) of the shares of Common Stock outstanding immediately after giving effect to such exercise. For purposes of the foregoing sentence, the aggregate number of shares of Common Stock beneficially owned by such Person and its
affiliates shall include the number of shares of Common Stock issuable upon exercise of this Warrant with respect to which the determination of such sentence is being made, but shall exclude shares of Common Stock which would be issuable upon
(i) exercise of the remaining, unexercised portion of this Warrant beneficially owned by such Person and its affiliates and (ii) exercise or conversion of the unexercised or unconverted portion of any other securities of the Company
beneficially owned by such Person and its affiliates (including, without limitation, any convertible notes or convertible preferred stock or warrants) subject to a limitation on conversion or exercise analogous to the limitation contained herein.
Except as set forth in the preceding sentence, for purposes of this paragraph, beneficial ownership shall be calculated in accordance with Section 13(d) of the Securities Exchange Act of 1934, as amended (the “1934 Act”). For
purposes of this Warrant, in determining the number of outstanding shares of Common Stock, the Holder may rely on the number of outstanding shares of Common Stock as reflected in (1) the Company’s most recent Form 10-K, Form 10-Q, Current
Report on Form 8-K or other public filing with the Securities and Exchange Commission, as the case may be, (2) a more recent public announcement by the Company or (3) any other notice by the Company or the Transfer Agent setting forth the
number of shares of Common Stock outstanding. For any reason at any time, upon the written or oral request of the Holder, the Company shall within one (1) Business Day confirm orally and in writing to the Holder the number of shares of Common
Stock then outstanding. In any case, the number of outstanding shares of Common Stock shall be determined after giving effect to the conversion or exercise of securities of the Company, including the SPA Warrants, by the Holder and its affiliates
since the date as of which such number of outstanding shares of Common Stock was reported. By written notice to the Company, the Holder may from time to time increase or decrease the Maximum Percentage to any other percentage not in excess of 9.99%
specified in such notice; provided that (i) any such increase will not be effective until the sixty-first
(61st) day after such notice is delivered to the
Company, and (ii) any such increase or decrease will apply only to the Holder and not to any other holder of SPA Warrants. The provisions of this paragraph shall be construed and implemented in a manner otherwise than in strict conformity with
the terms of this Section 1(f) to correct this paragraph (or any portion hereof) which may be defective or inconsistent with the intended beneficial ownership limitation herein contained or to make changes or supplements necessary or desirable
to properly give effect to such limitation. 
 (g) Insufficient Authorized Shares. If at any time while
this Warrant remains outstanding the Company does not have a sufficient number of authorized and unreserved shares of Common Stock to satisfy its obligation to reserve for issuance upon 

  
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exercise of this Warrant at least a number of shares of Common Stock equal to 100% (the “Required Reserve Amount”) of the number of shares of Common Stock as shall from time to
time be necessary to effect the exercise of all of this Warrant then outstanding (an “Authorized Share Failure”), then the Company shall immediately take all action necessary to increase the Company’s authorized shares of
Common Stock to an amount sufficient to allow the Company to reserve the Required Reserve Amount for this Warrant then outstanding. Without limiting the generality of the foregoing sentence, as soon as practicable after the date of the occurrence of
an Authorized Share Failure, but in no event later than sixty (60) days after the occurrence of such Authorized Share Failure, the Company shall hold a meeting of its stockholders for the approval of an increase in the number of authorized
shares of Common Stock. In connection with such meeting, the Company shall provide each stockholder with a proxy statement and shall use its best efforts to solicit its stockholders’ approval of such increase in authorized shares of Common
Stock and to cause its board of directors to recommend to the stockholders that they approve such proposal. 

(h) [SERIES C: Cash Settlement. If (a) on any Reset Date the Maximum Eligibility Number exceeds the
Number of Shares of Common Stock set forth on the first page of this Warrant, the Company shall promptly notify the Holder in writing of such event and no later than three (3) Trading Days following such event, the Company shall pay the Holder
in cash by wire transfer of immediately available funds a dollar amount determined by multiplying such excess number of shares of Common Stock by the Weighted Average Price of the Common Stock on the date of such event or (b) the Stockholder
Approval (as defined in the Securities Purchase Agreement) is not obtained on or prior to the First Reset Date, upon exercise of this Warrant, in lieu of delivering the shares of Common Stock otherwise required to be delivered hereunder, the Company
shall pay the Holder in cash by wire transfer of immediately available funds in a dollar amount determined by multiplying the number of shares of Common Stock otherwise deliverable upon such exercise by the Weighted Average Price of the Common Stock
on the date of such exercise.] 
 2. [SERIES A & B: ADJUSTMENT OF EXERCISE PRICE AND NUMBER OF
WARRANT SHARES. The Exercise Price and the number of Warrant Shares shall be adjusted from time to time as follows: 
 (a) Adjustment upon Issuance of shares of Common Stock. If and whenever on or after the Subscription Date, the Company issues or sells, or in accordance with this Section 2 is deemed to have
issued or sold, any shares of Common Stock (including the issuance or sale of shares of Common Stock owned or held by or for the account of the Company, but excluding shares of Common Stock deemed to have been issued by the Company in connection
with any Excluded Securities (as defined below) for a consideration per share (the “New Issuance Price”) less than a price (the “Applicable Price”) equal to the Exercise Price in effect immediately prior to such
issue or sale or deemed issuance or sale (the foregoing a “Dilutive Issuance”), then immediately after such Dilutive Issuance, the Exercise Price then in effect shall be reduced to an amount equal to the New Issuance Price. For
purposes of determining the adjusted Exercise Price under this Section 2(a), the following shall be applicable: 

  
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 (i) Issuance of Options. If the Company in any manner grants any
Options and the lowest price per share for which one share of Common Stock is issuable upon the exercise of any such Option or upon conversion, exercise or exchange of any Convertible Securities issuable upon exercise of any such Option is less than
the Applicable Price, then such share of Common Stock shall be deemed to be outstanding and to have been issued and sold by the Company at the time of the granting or sale of such Option for such price per share. For purposes of this
Section 2(a)(i), the “lowest price per share for which one share of Common Stock is issuable upon exercise of such Options or upon conversion, exercise or exchange of such Convertible Securities issuable upon exercise of any such
Option” shall be equal to the sum of the lowest amounts of consideration (if any) received or receivable by the Company with respect to any one share of Common Stock upon the granting or sale of the Option, upon exercise of the Option and upon
conversion, exercise or exchange of any Convertible Security issuable upon exercise of such Option less any consideration paid or payable by the Company with respect to such one share of Common Stock upon the granting or sale of such Option, upon
exercise of such Option and upon conversion exercise or exchange of any Convertible Security issubale upon exercise of such Option. No further adjustment of the Exercise Price or number of Warrant Shares shall be made upon the actual issuance of
such shares of Common Stock or of such Convertible Securities upon the exercise of such Options or upon the actual issuance of such shares of Common Stock upon conversion, exercise or exchange of such Convertible Securities. 

(ii) Issuance of Convertible Securities. If the Company in any manner issues or sells any Convertible Securities
and the lowest price per share for which one share of Common Stock is issuable upon the conversion, exercise or exchange thereof is less than the Applicable Price, then such share of Common Stock shall be deemed to be outstanding and to have been
issued and sold by the Company at the time of the issuance or sale of such Convertible Securities for such price per share. For the purposes of this Section 2(a)(ii), the “lowest price per share for which one share of Common Stock is
issuable upon the conversion, exercise or exchange thereof” shall be equal to the sum of the lowest amounts of consideration (if any) received or receivable by the Company with respect to one share of Common Stock upon the issuance or sale of
the Convertible Security and upon conversion, exercise or exchange of such Convertible Security less any consideration paid or payable by the Company with respect to such one share of Common Stock upon the issuance or sale of such Convertible
Security and upon conversion, exercise or exchange of such Convertible Security. No further adjustment of the Exercise Price or number of Warrant Shares shall be made upon the actual issuance of such shares of Common Stock upon conversion, exercise
or exchange of such Convertible Securities, and if any such issue or sale of such Convertible Securities is made upon exercise of any Options for which adjustment of 

  
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this Warrant has been or is to be made pursuant to other provisions of this Section 2(a), no further adjustment of the Exercise Price or number of Warrant Shares shall be made by reason of
such issue or sale. 
 (iii) Change in Option Price or Rate of Conversion. If the purchase price provided
for in any Options, the additional consideration, if any, payable upon the issue, conversion, exercise or exchange of any Convertible Securities, or the rate at which any Convertible Securities are convertible into or exercisable or exchangeable for
shares of Common Stock increases or decreases at any time, the Exercise Price and the number of Warrant Shares in effect at the time of such increase or decrease shall be adjusted to the Exercise Price and the number of Warrant Shares which would
have been in effect at such time had such Options or Convertible Securities provided for such increased or decreased purchase price, additional consideration or increased or decreased conversion rate, as the case may be, at the time initially
granted, issued or sold. For purposes of this Section 2(a)(iii), if the terms of any Option or Convertible Security that was outstanding as of the date of issuance of this Warrant are increased or decreased in the manner described in the
immediately preceding sentence, then such Option or Convertible Security and the shares of Common Stock deemed issuable upon exercise, conversion or exchange thereof shall be deemed to have been issued as of the date of such increase or decrease. No
adjustment pursuant to this Section 2(a) shall be made if such adjustment would result in an increase of the Exercise Price then in effect or a decrease in the number of Warrant Shares. 

(iv) Calculation of Consideration Received. In case any Option is issued in connection with the issue or sale of
other securities of the Company, together comprising one integrated transaction, (x) the Options will be deemed to have been issued for the Option Value of such Options and (y) the other securities issued or sold in such integrated
transaction shall be deemed to have been issued for the difference of (I) the aggregate consideration received by the Company less any consideration paid or payable by the Company pursuant to the terms of such other securities of the Company,
less (II) the Option Value. If any shares of Common Stock, Options or Convertible Securities are issued or sold or deemed to have been issued or sold for cash, the consideration received therefor will be deemed to be the net amount received by the
Company therefor. If any shares of Common Stock, Options or Convertible Securities are issued or sold for a consideration other than cash, the amount of such consideration received by the Company will be the fair value of such consideration, except
where such consideration consists of securities, in which case the amount of consideration received by the Company will be the Closing Sale Price of such security on the date of receipt. If any shares of Common Stock, Options or Convertible
Securities are issued to the owners of the non-surviving entity in connection with any merger in 

  
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which the Company is the surviving entity, the amount of consideration therefor will be deemed to be the fair value of such portion of the net assets and business of the non-surviving entity as
is attributable to such shares of Common Stock, Options or Convertible Securities, as the case may be. The fair value of any consideration other than cash or securities will be determined jointly by the Company and the Required Holders. If such
parties are unable to reach agreement within ten (10) days after the occurrence of an event requiring valuation (the “Valuation Event”), the fair value of such consideration will be determined within five (5) Trading Days
after the tenth (10th) day following the Valuation
Event by an independent, reputable appraiser jointly selected by the Company and the Required Holders. The determination of such appraiser shall be final and binding upon all parties absent manifest error and the fees and expenses of such appraiser
shall be borne by the Company. 
 (v) Record Date. If the Company takes a record of the holders of shares
of Common Stock for the purpose of entitling them (A) to receive a dividend or other distribution payable in shares of Common Stock, Options or in Convertible Securities or (B) to subscribe for or purchase shares of Common Stock, Options
or Convertible Securities, then such record date will be deemed to be the date of the issue or sale of the shares of Common Stock deemed to have been issued or sold upon the declaration of such dividend or the making of such other distribution or
the date of the granting of such right of subscription or purchase, as the case may be. 
 (b) Voluntary
Adjustment By Company. The Company may at any time during the term of this Warrant reduce the then current Exercise Price to any amount and for any period of time deemed appropriate by the Board of Directors of the Company.] [SERIES C:
[Intentionally Omitted] 
 (c) Adjustment upon Subdivision or Combination of shares of Common Stock. If
the Company at any time on or after the Subscription Date subdivides (by any stock split, stock dividend, recapitalization or otherwise) one or more classes of its outstanding shares of Common Stock into a greater number of shares, the Exercise
Price in effect immediately prior to such subdivision will be proportionately reduced and the number of Warrant Shares will be proportionately increased. If the Company at any time on or after the Subscription Date combines (by combination, reverse
stock split or otherwise) one or more classes of its outstanding shares of Common Stock into a smaller number of shares, the Exercise Price in effect immediately prior to such combination will be proportionately increased and the number of Warrant
Shares will be proportionately decreased. Any adjustment under this Section 2(c) shall become effective at the close of business on the date the subdivision or combination becomes effective. 

(d) Other Events. If any event occurs of the type contemplated by the provisions of this Section 2 but not
expressly provided for by such provisions (including, without limitation, the granting of stock appreciation rights, phantom stock rights or other rights with 

  
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equity features), then the Company’s Board of Directors will make an appropriate adjustment in the Exercise Price and the number of Warrant Shares so as to protect the rights of the Holder;
provided that no such adjustment pursuant to this Section 2(d) will increase the Exercise Price or decrease the number of Warrant Shares as otherwise determined pursuant to this Section 2. 

(e) [SERIES A: Stockholder Approval. Unless and until such time as the Company obtains the Stockholder
Approval (as defined in the Securities Purchase Agreement), no adjustment pursuant to this Section 2 shall cause the Exercise Price to be less than $1.57, as adjusted for any stock dividend, stock split, stock combination, reclassification or
similar transaction (the “Exercise Floor Price”). Upon the receipt of the Stockholder Approval any adjustment to the Exercise Price and number of Warrant Shares that would have made pursuant to this Section 2 but for this
Section 2(e) shall be made on the date of such receipt.] 
 3. RIGHTS UPON DISTRIBUTION OF ASSETS.
If the Company shall declare or make any dividend or other distribution of its assets (or rights to acquire its assets) to holders of shares of Common Stock, by way of return of capital or otherwise (including, without limitation, any distribution
of cash, stock or other securities, property or options by way of a dividend, spin off, reclassification, corporate rearrangement, scheme of arrangement or other similar transaction) (a “Distribution”), at any time after the
issuance of this Warrant, then, in each such case, the Holder shall be entitled to participate in such Distribution to the same extent that the Holder would have participated therein if the Holder had held the number of shares of Common Stock
acquirable upon complete exercise of this Warrant (without regard to any limitations on exercise hereof, including without limitation, the Maximum Percentage) immediately before the date of which a record is taken for such Distribution, or, if no
such record is taken, the date as of which the record holders of shares of Common Stock are to be determined for the participation in such Distribution (provided, however, to the extent that the Holder’s right to participate in any such
Distribution would result in the Holder exceeding the Maximum Percentage, then the Holder shall not be entitled to participate in such Distribution to such extent (or in the beneficial ownership of any shares of Common Stock as a result of such
Distribution to such extent) and the portion of such Distribution shall be held in abeyance for the benefit of the Holder until such time, if ever, as its right thereto would not result in the Holder exceeding the Maximum Percentage. 

4. PURCHASE RIGHTS; FUNDAMENTAL TRANSACTIONS. 

(a) Purchase Rights. In addition to any adjustments pursuant to Section 2 above, if at any time the Company
grants, issues or sells any Options, Convertible Securities or rights to purchase stock, warrants, securities or other property pro rata to the record holders of any class of Common Stock (the “Purchase Rights”), then the Holder
will be entitled to acquire, upon the terms applicable to such Purchase Rights, the aggregate Purchase Rights which the Holder could have acquired if the Holder had held the number of shares of Common Stock acquirable upon complete exercise of this
Warrant (without regard to any limitations on the exercise of this Warrant) immediately before the date on which a record is taken for the grant, issuance or sale of such Purchase Rights, or, if no such record is taken, the date as of which the
record holders of shares of Common Stock are to be determined for the grant, issue or sale of such Purchase Rights. 

  
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 (b) Fundamental Transactions. The Company shall not enter into or be
party to a Fundamental Transaction unless (i) the Successor Entity assumes in writing (unless the Company is the Successor Entity) all of the obligations of the Company under this Warrant and the other Transaction Documents in accordance with
the provisions of this Section (4)(b) pursuant to written agreements in form and substance reasonably satisfactory to the Required Holders and approved by the Required Holders prior to such Fundamental Transaction, including agreements to
deliver to each holder of the SPA Warrants in exchange for such SPA Warrants a security of the Successor Entity evidenced by a written instrument substantially similar in form and substance to this Warrant, including, without limitation, an adjusted
exercise price equal to the value for the shares of Common Stock reflected by the terms of such Fundamental Transaction, and exercisable for a corresponding number of shares of capital stock equivalent to the shares of Common Stock acquirable and
receivable upon exercise of this Warrant (without regard to any limitations on the exercise of this Warrant) prior to such Fundamental Transaction, and reasonably satisfactory to the Required Holders and (ii) the Successor Entity (including its
Parent Entity) is a publicly traded corporation whose common stock is quoted on or listed for trading on an Eligible Market. Upon the occurrence of any Fundamental Transaction, the Successor Entity shall succeed to, and be substituted for (so that
from and after the date of such Fundamental Transaction, the provisions of this Warrant referring to the “Company” shall refer instead to the Successor Entity), and may exercise every right and power of the Company and shall assume all of
the obligations of the Company under this Warrant with the same effect as if such Successor Entity had been named as the Company herein. Upon consummation of the Fundamental Transaction, the Successor Entity shall deliver to the Holder confirmation
that there shall be issued upon exercise of this Warrant at any time after the consummation of the Fundamental Transaction, in lieu of the shares of Common Stock (or other securities, cash, assets or other property) issuable upon the exercise of the
Warrant prior to such Fundamental Transaction, such shares of the publicly traded common stock or common shares (or its equivalent) of the Successor Entity (including its Parent Entity) which the Holder would have been entitled to receive upon the
happening of such Fundamental Transaction had this Warrant been converted immediately prior to such Fundamental Transaction, as adjusted in accordance with the provisions of this Warrant. In addition to and not in substitution for any other rights
hereunder, prior to the consummation of any Fundamental Transaction pursuant to which holders of shares of Common Stock are entitled to receive securities or other assets with respect to or in exchange for shares of Common Stock (a
“Corporate Event”), the Company shall make appropriate provision to insure that the Holder will thereafter have the right to receive upon an exercise of this Warrant at any time after the consummation of the Corporate Event but
prior to the Expiration Date, in lieu of shares of Common Stock (or other securities, cash, assets or other property) purchasable upon the exercise of this Warrant prior to such Corporate Event, such shares of stock, securities, cash, assets or any
other property whatsoever (including warrants or other purchase or subscription rights) which the Holder would have been entitled to receive upon the happening of such Corporate Event had this Warrant been exercised immediately prior to such
Corporate Event. Provision made pursuant to the preceding sentence shall be in a form and substance reasonably satisfactory to the Required Holders. The provisions of this Section 4(b) shall apply similarly and equally to successive Fundamental
Transactions and Corporate Events and shall be applied without regard to any limitations on the exercise of this Warrant. 
 (c) Notwithstanding the foregoing, in the event of a Fundamental Transaction, at the request of the Holder delivered before the ninetieth (90th) day after the 

  
 - 11 -

 
consummation of such Fundamental Transaction, the Company (or the Successor Entity) shall purchase this Warrant from the Holder by paying to the Holder, within five (5) Business Days after
such request (or, if later, on the effective date of the Fundamental Transaction), cash in an amount equal to the Black Scholes Value of the remaining unexercised portion of this Warrant on the date of such Fundamental Transaction. 

4A. [SERIES B: FORCED EXERCISE. From and after the twenty sixth (26th) Trading Day after the Initial
Exercisability Date, the Company may deliver a notice to the Holder (a “Forced Exercise Notice” and, for purposes of this Section 4A, such date, the “Forced Exercise Notice Date”), of its irrevocable
election to require the exercise of all, or any portion, of this Warrant, which notice must be delivered at least twenty six (26) Trading Days prior to date of such forced exercise. Subject to the provisions herein, the date of such forced
exercise shall be the twenty sixth (26th) Trading Day after the Forced Exercise Notice Date (the “Forced Exercise Date”). The Company may only deliver a Forced Exercise Notice if there is no Equity Conditions Failure (unless
the Holder has waived such Equity Conditions Failure) and the Company shall so certify in the Forced Exercise Notice and set forth the number of Warrant Shares to which the forced exercise relates (the “Forced Exercise Share
Number”). The forced exercise thereunder may only occur on the Forced Exercise Date, if each of the following shall be true: (i) there is no Equity Conditions Failure (unless the Holder has waived such Equity Conditions Failure),
(ii) the conditions in clauses (i) through (iii) of the definition of Series B Eligibility Date are satisfied and (iii) the daily dollar trading volume of shares traded on each Trading Day during the period from the Forced
Exercise Notice Date through the Forced Exercise Date (but excluding the three (3) Trading Days with the lowest daily dollar trading volume during such period) is greater than 4% of the product of (a) the Forced Exercise Share Number and
(b) the Exercise Price (clauses (i), (ii) and (iii), the “Forced Exercise Conditions”). The Company shall deliver to the Holder a notice no later than 10:00 a.m., New York time on the Forced Exercise Date (the
“Forced Exercise Bring-Down Notice”), which notice shall certify whether or not the Forced Exercise Conditions have been satisfied. If the Forced Exercise Conditions have not been satisfied at such time (and are not waived by the
Holder), the Forced Exercise Notice will be null and void, ab initio. The Company may deliver up to two (2) Forced Exercise Notices hereunder provided that the second such notice may not be delivered until after the Forced Exercise Date
relating to the previous Forced Exercise Notice. Notwithstanding the foregoing, nothing in this Warrant (including delivery of a Forced Exercise Notice) shall prevent the Holder from exercising this Warrant, in whole or part, on or prior to the
Expiration Date. The Company covenants and agrees that it will honor all Exercise Notices tendered from the time of delivery of the Forced Exercise Notice through the Expiration Date. Upon an Equity Conditions Failure, the Holder may revoke any
Exercise Notice delivered after the Forced Exercise Notice is received by the Holder and the Company, within one (1) Business Day of such revocation, shall return the Aggregate Exercise Price applicable to any such Exercise Notice(s) to the
Holder by wire transfer of immediately available funds and any Warrants so exercised shall be deemed reinstated and returned to the Holder, if applicable. Any actions by the Company pursuant to this Section 4A, including delivery of any
Forced Exercise Notice or determining a Forced Exercise Share Number shall be made pro rata with the Holder and all other Holders of Series B Warrants (as defined in the Securities Purchase Agreement) based on the number of Series B Warrants
initially issued on the Issuance Date.] 

  
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 5. NONCIRCUMVENTION. The Company hereby covenants and agrees that the
Company will not, by amendment of its Certificate of Incorporation or Bylaws, or through any reorganization, transfer of assets, consolidation, merger, scheme of arrangement, dissolution, issue or sale of securities, or any other voluntary action,
avoid or seek to avoid the observance or performance of any of the terms of this Warrant, and will at all times in good faith carry out all the provisions of this Warrant and take all action as may be required to protect the rights of the Holder.
Without limiting the generality of the foregoing, the Company (i) shall not increase the par value of any shares of Common Stock receivable upon the exercise of this Warrant above the Exercise Price then in effect, (ii) shall take all such
actions as may be necessary or appropriate in order that the Company may validly and legally issue fully paid and nonassessable shares of Common Stock upon the exercise of this Warrant, and (iii) shall, so long as any of the SPA Warrants are
outstanding, take all action necessary to reserve and keep available out of its authorized and unissued shares of Common Stock, solely for the purpose of effecting the exercise of the SPA Warrants, 100% of the number of shares of Common Stock as
shall from time to time be necessary to effect the exercise of the SPA Warrants then outstanding (without regard to any limitations on exercise). 
 6. WARRANT HOLDER NOT DEEMED A STOCKHOLDER. Except as otherwise specifically provided herein, the Holder, solely in such Person’s capacity as a holder of this Warrant, shall not be entitled to
vote or receive dividends or be deemed the holder of share capital of the Company for any purpose, nor shall anything contained in this Warrant be construed to confer upon the Holder, solely in such Person’s capacity as the Holder of this
Warrant, any of the rights of a stockholder of the Company or any right to vote, give or withhold consent to any corporate action (whether any reorganization, issue of stock, reclassification of stock, consolidation, merger, conveyance or
otherwise), receive notice of meetings, receive dividends or subscription rights, or otherwise, prior to the issuance to the Holder of the Warrant Shares which such Person is then entitled to receive upon the due exercise of this Warrant. In
addition, nothing contained in this Warrant shall be construed as imposing any liabilities on the Holder to purchase any securities (upon exercise of this Warrant or otherwise) or as a stockholder of the Company, whether such liabilities are
asserted by the Company or by creditors of the Company [Series B: , other than in connection with a forced exercise pursuant to Section 4A]. Notwithstanding this Section 6, the Company shall provide the Holder with copies of the
same notices and other information given to the stockholders of the Company generally, contemporaneously with the giving thereof to the stockholders. 

  
 - 13 -

 7. REISSUANCE OF WARRANTS. 

(a) Transfer of Warrant. If this Warrant is to be transferred as permitted herein, the Holder shall surrender
this Warrant to the Company, whereupon the Company will forthwith issue and deliver upon the order of the Holder a new Warrant (in accordance with Section 7(d)), registered as the Holder may request, representing the right to purchase the
number of Warrant Shares being transferred by the Holder and, if less than the total number of Warrant Shares then underlying this Warrant is being transferred, a new Warrant (in accordance with Section 7(d)) to the Holder representing the
right to purchase the number of Warrant Shares not being transferred. 
 (b) Lost, Stolen or Mutilated
Warrant. Upon receipt by the Company of evidence reasonably satisfactory to the Company of the loss, theft, destruction or mutilation of this Warrant, and, in the case of loss, theft or destruction, of any indemnification undertaking by the
Holder to the Company in customary form and, in the case of mutilation, upon surrender and cancellation of this Warrant, the Company shall execute and deliver to the Holder a new Warrant (in accordance with Section 7(d)) representing the right
to purchase the Warrant Shares then underlying this Warrant. 
 (c) Exchangeable for Multiple Warrants.
This Warrant is exchangeable, upon the surrender hereof by the Holder at the principal office of the Company, for a new Warrant or Warrants (in accordance with Section 7(d)) representing in the aggregate the right to purchase the number of
Warrant Shares then underlying this Warrant, and each such new Warrant will represent the right to purchase such portion of such Warrant Shares as is designated by the Holder at the time of such surrender; provided, however, that no Warrants for
fractional shares of Common Stock shall be given. 
 (d) Issuance of New Warrants. Whenever the Company
is required to issue a new Warrant pursuant to the terms of this Warrant, such new Warrant (i) shall be of like tenor with this Warrant, (ii) shall represent, as indicated on the face of such new Warrant, the right to purchase the Warrant
Shares then underlying this Warrant (or in the case of a new Warrant being issued pursuant to Section 7(a) or Section 7(c), the Warrant Shares designated by the Holder which, when added to the number of shares of Common Stock underlying
the other new Warrants issued in connection with such issuance, does not exceed the number of Warrant Shares then underlying this Warrant), (iii) shall have an issuance date, as indicated on the face of such new Warrant which is the same as the
Issuance Date, and (iv) shall have the same rights and conditions as this Warrant. 
 8. NOTICES.
Whenever notice is required to be given under this Warrant, unless otherwise provided herein, such notice shall be given in accordance with Section 9(f) of the Securities Purchase Agreement. The Company shall provide the Holder with prompt
written notice of all actions taken pursuant to this Warrant, including in reasonable detail a description of such action and the reason therefor. Without limiting the generality of the foregoing, the Company will give written notice to the Holder
(i) immediately upon any adjustment of the Exercise Price, setting forth in reasonable detail, and certifying, the calculation of such adjustment and (ii) at least fifteen (15) days prior to the date on which the Company closes its
books or takes a record (A) with respect to any dividend or distribution upon the shares of 

  
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Common Stock, (B) with respect to any grants, issuances or sales of any Options, Convertible Securities or rights to purchase stock, warrants, securities or other property to holders of
shares of Common Stock other than pursuant to an Approved Stock Plan or (C) for determining rights to vote with respect to any Fundamental Transaction, dissolution or liquidation, provided in each case that such information shall be made known
to the public prior to or in conjunction with such notice being provided to the Holder. 
 9. AMENDMENT AND
WAIVER. Except as otherwise provided herein, the provisions of this Warrant may be amended and the Company may take any action herein prohibited, or omit to perform any act herein required to be performed by it, only if the Company has obtained
the written consent of the Holder. 
 10. GOVERNING LAW. This Warrant shall be governed by and construed
and enforced in accordance with, and all questions concerning the construction, validity, interpretation and performance of this Warrant shall be governed by, the internal laws of the State of New York, without giving effect to any choice of law or
conflict of law provision or rule (whether of the State of New York or any other jurisdictions) that would cause the application of the laws of any jurisdictions other than the State of New York. 

11. CONSTRUCTION; HEADINGS. This Warrant shall be deemed to be jointly drafted by the Company and all the Buyers
and shall not be construed against any person as the drafter hereof. The headings of this Warrant are for convenience of reference and shall not form part of, or affect the interpretation of, this Warrant. 

12. DISPUTE RESOLUTION. In the case of a dispute as to the determination of the Exercise Price or the arithmetic
calculation of the Warrant Shares, the Company shall submit the disputed determinations or arithmetic calculations via facsimile within two (2) Business Days of receipt of the Exercise Notice giving rise to such dispute, as the case may be, to
the Holder. If the Holder and the Company are unable to agree upon such determination or calculation of the Exercise Price or the Warrant Shares within three (3) Business Days of such disputed determination or arithmetic calculation being
submitted to the Holder, then the Company shall, within two (2) Business Days submit via facsimile (a) the disputed determination of the Exercise Price to an independent, reputable investment bank selected by the Company and approved by
the Holder or (b) the disputed arithmetic calculation of the Warrant Shares to the Company’s independent, outside accountant. The Company shall cause at its expense the investment bank or the accountant, as the case may be, to perform the
determinations or calculations and notify the Company and the Holder of the results no later than ten Business Days from the time it receives the disputed determinations or calculations. Such investment bank’s or accountant’s determination
or calculation, as the case may be, shall be binding upon all parties absent demonstrable error. 
 13.
REMEDIES, OTHER OBLIGATIONS, BREACHES AND INJUNCTIVE RELIEF. The remedies provided in this Warrant shall be cumulative and in addition to all other remedies available under this Warrant and the other Transaction Documents, at law or in equity
(including a decree of specific performance and/or other injunctive relief), and nothing herein shall limit the right of the Holder to pursue actual damages for any failure by the Company to comply with the terms of this Warrant. The Company
acknowledges that a breach by it of its 

  
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obligations hereunder will cause irreparable harm to the Holder and that the remedy at law for any such breach may be inadequate. The Company therefore agrees that, in the event of any such
breach or threatened breach, the holder of this Warrant shall be entitled, in addition to all other available remedies, to an injunction restraining any breach, without the necessity of showing economic loss and without any bond or other security
being required. 
 14. TRANSFER. This Warrant may be offered for sale, sold, transferred or assigned
without the consent of the Company, except as may otherwise be required by Section 2(f) of the Securities Purchase Agreement. 
 15. SEVERABILITY. If any provision of this Warrant is prohibited by law or otherwise determined to be invalid or unenforceable by a court of competent jurisdiction, the provision that would
otherwise be prohibited, invalid or unenforceable shall be deemed amended to apply to the broadest extent that it would be valid and enforceable, and the invalidity or unenforceability of such provision shall not affect the validity of the remaining
provisions of this Warrant so long as this Warrant as so modified continues to express, without material change, the original intentions of the parties as to the subject matter hereof and the prohibited nature, invalidity or unenforceability of the
provision(s) in question does not substantially impair the respective expectations or reciprocal obligations of the parties or the practical realization of the benefits that would otherwise be conferred upon the parties. The parties will endeavor in
good faith negotiations to replace the prohibited, invalid or unenforceable provision(s) with a valid provision(s), the effect of which comes as close as possible to that of the prohibited, invalid or unenforceable provision(s). 

16. CERTAIN DEFINITIONS. For purposes of this Warrant, the following terms shall have the following meanings:

 (a) “Approved Stock Plan” means any employee benefit plan or other issuance, employment
agreement or option grant or similar agreement which has been approved by the Board of Directors of the Company, pursuant to which the Company’s securities may be issued to any employee, officer or director for services provided to the Company.

 (b) “Black Scholes Value” means the value of this Warrant based on the Black and Scholes
Option Pricing Model obtained from the “OV” function on Bloomberg determined as of the Trading Day immediately following the public announcement of the applicable Fundamental Transaction for pricing purposes and reflecting (i) a
risk-free interest rate corresponding to the U.S. Treasury rate for a period equal to the remaining term of this Warrant as of such date of request, (ii) an expected volatility equal to the greater of 100% and the 100 day volatility obtained
from the HVT function on Bloomberg as of the day immediately following the public announcement of the applicable Fundamental Transaction, (iii) the underlying price per share used in such calculation shall be the sum of the price per share
being offered in cash, if any, plus the value of any non cash consideration, if any, being offered in the Fundamental Transaction and (iv) a 360 day annualization factor. 

(c) “Bloomberg” means Bloomberg Financial Markets. 

  
 - 16 -

 (d) “Business Day” means any day other than Saturday,
Sunday or other day on which commercial banks in The City of New York are authorized or required by law to remain closed. 
 (e) “Closing Bid Price” and “Closing Sale Price” means, for any security as of any date, the last closing bid price and last closing trade price, respectively, for such
security on the Principal Market, as reported by Bloomberg, or, if the Principal Market begins to operate on an extended hours basis and does not designate the closing bid price or the closing trade price, as the case may be, then the last bid price
or the last trade price, respectively, of such security prior to 4:00:00 p.m., New York time, as reported by Bloomberg, or, if the Principal Market is not the principal securities exchange or trading market for such security, the last closing bid
price or last trade price, respectively, of such security on the principal securities exchange or trading market where such security is listed or traded as reported by Bloomberg, or if the foregoing do not apply, the last closing bid price or last
trade price, respectively, of such security in the over-the-counter market on the electronic bulletin board for such security as reported by Bloomberg, or, if no closing bid price or last trade price, respectively, is reported for such security by
Bloomberg, the average of the bid prices, or the ask prices, respectively, of any market makers for such security as reported in the “pink sheets” by Pink Sheets LLC (formerly the National Quotation Bureau, Inc.). If the Closing Bid Price
or the Closing Sale Price cannot be calculated for a security on a particular date on any of the foregoing bases, the Closing Bid Price or the Closing Sale Price, as the case may be, of such security on such date shall be the fair market value as
mutually determined by the Company and the Holder. If the Company and the Holder are unable to agree upon the fair market value of such security, then such dispute shall be resolved pursuant to Section 12. All such determinations to be
appropriately adjusted for any stock dividend, stock split, stock combination or other similar transaction during the applicable calculation period. 
 (f) “Common Stock” means (i) the Company’s shares of Common Stock, par value $0.00000002 per share, and (ii) any share capital into which such Common Stock shall have been
changed or any share capital resulting from a reclassification of such Common Stock. 
 (g)
“Convertible Securities” means any stock or securities (other than Options) directly or indirectly convertible into or exercisable or exchangeable for shares of Common Stock. 

(h) “Eligible Market” means the Principal Market, The NASDAQ Global Market, The NASDAQ Global Select
Market, The New York Stock Exchange, Inc., or The NYSE Amex. 
 (i) [SERIES B: “Equity
Conditions” means (i) on each day during the period beginning thirty (30) Trading Days prior to the applicable date of determination and ending on and including the applicable date of determination (the “Equity Conditions
Measuring Period”), the Common Stock is designated for quotation on the Principal Market or any other Eligible Market and shall not have been suspended from trading on such exchange or market nor shall delisting or suspension by such
exchange or market been threatened or pending either (A) in writing by such exchange or market or (B) by falling below the then effective minimum listing maintenance requirements of such exchange or market; (ii) no Allowed

  
 - 17 -

 
Subsequent Placement shall have occurred; (iii) during the Equity Conditions Measuring Period, the Company shall have delivered shares of Common Stock upon all exercises of the SPA Warrants
in accordance with their terms to the holders on a timely basis as set forth in Section 1(a) of the SPA Warrants; (iv) any applicable shares of Common Stock to be issued in connection with the event requiring determination may be issued in
full without violating the rules or regulations of the Principal Market or any applicable Eligible Market or Section 1(f) hereof; (v) during the Equity Conditions Measuring Period, the Company shall not have failed to timely make any
payments within five (5) Business Days of when such payment is due pursuant to any Transaction Document (as defined in the Securities Purchase Agreement); (vi) during the Equity Conditions Measuring Period, there shall not have occurred
the public announcement of a pending, proposed or intended Fundamental Transaction which has not been abandoned, terminated or consummated, (vii) the Company shall have no knowledge of any fact that would cause (x) the Registration
Statement not to be effective and available for the resale of all the Warrant Shares or (y) both the Registration Statement not to be effective and available and Rule 144 (as defined in the Securities Purchase Agreement) not to be available for
the resale of all the Registrable Securities (as defined in the Registration Rights Agreement) and shares of Common Stock underlying the Series C Warrants; and (viii) the Company otherwise shall have been in compliance with and shall not have
breached any provision, covenant, representation or warranty of any Transaction Document. 
 (j)
“Equity Conditions Failure” means that on each Trading Day during the period commencing on the date of the Forced Exercise Notice through the Forced Exercise Date, the Equity Conditions have not been satisfied (or waived in writing
by the Holder).] 
 (k) “Expiration Date” means the date [SERIES A: five years
after the Initial Exercisability Date] [SERIES B: one year after the Issuance Date] [SERIES C: one year after the Initial Exercisability Date] or, if such date falls on a day other than a Business Day or on which trading does
not take place on the Principal Market (a “Holiday”), the next day that is not a Holiday. 

(l) “Excluded Securities” means: (i) any equity or equity equivalent security of the Company
issued or issuable, including any shares of Common Stock issued or issuable upon conversion or exercise thereof, in connection with any Approved Stock Plan, (ii) any shares of Common Stock issued or issuable upon exercise of any Warrants;
provided that the terms of such Warrants are not amended, modified or changed on or after the Subscription Date, (iii) any shares of Common Stock issued or issuable upon conversion of any Options or Convertible Securities which are outstanding
on the day immediately preceding the Subscription Date, provided that the terms of such Options or Convertible Securities are not amended, modified or changed on or after the Subscription Date and (iv) the Series A Preferred Stock, par value
$0.01 per share, of the Company issuable to Novogen Limited (“Novogen”) pursuant to the Asset Purchase Agreement, dated as of December 21, 2010, by and among the Company, Novogen and Novogen Research Pty Limited in the form
attached to the Current Report on Form 8-K filed by the Company on December 22, 2010 (the “Asset Purchase Agreement”) (the “Series A Preferred Stock”) and the shares of Common Stock issuable upon conversion by
Novogen of the Series A Preferred Stock on the terms set forth in the certificate of designations attached as Exhibit A to the Asset Purchase Agreement. 

  
 - 18 -

 (m) “Fundamental Transaction” means that (A) the
Company shall, directly or indirectly, in one or more related transactions, (i) consolidate or merge with or into (whether or not the Company is the surviving corporation) another Person, or (ii) sell, assign, transfer, convey or otherwise
dispose of all or substantially all of the properties or assets of the Company to another Person, or (iii) consummate a stock purchase agreement or other business combination (including, without limitation, a reorganization, recapitalization,
spin-off or scheme of arrangement) with another Person whereby such other Person acquires more than the 50% of the outstanding shares of Common Stock (not including any shares of Common Stock held by the other Person or other Persons making or party
to, or associated or affiliated with the other Persons making or party to, such stock purchase agreement or other business combination), or (iv) reorganize, recapitalize or reclassify its Common Stock, (B) a Person makes a purchase, tender
or exchange offer that is accepted by the holders of more than the 50% of the outstanding shares of Common Stock (not including any shares of Common Stock held by the Person or Persons making or party to, or associated or affiliated with the Persons
making or party to, such purchase, tender or exchange offer) or (C) any “person” or “group” (as these terms are used for purposes of Sections 13(d) and 14(d) of the 1934 Act) is or shall become the “beneficial
owner” (as defined in Rule 13d-3 under the 1934 Act), directly or indirectly, of (x) 50% of the aggregate ordinary voting power represented by issued and outstanding shares of Common Stock, (y) 50% of the aggregate ordinary voting
power represented by issued and outstanding shares of Common Stock not beneficially owned by such Person on the Subscription Date or (z) a percentage of the aggregate ordinary voting power represented by issued and outstanding shares of Common
Stock or other equity securities of the Company sufficient to allow such Person to effect a statutory short form merger or other transaction requiring other stockholders of the Company to surrender their shares of Common Stock without approval of
the stockholders of the Company. 
 (n) [SERIES A: “Maximum Eligibility
Number” means initially a number of shares equal to 75% of the number of Common Shares (as defined in the Securities Purchase Agreement) issued to the Holder on the Issuance Date and shall be successively increased (but not decreased) upon
each exercise of the Holder’s Series B Warrants (as defined in the Securities Purchase Agreement) by an amount equal to 75% of the number of shares of Common Stock issued upon each such exercise of the Series B Warrants.] [SERIES C:
“Maximum Eligibility Number” means initially zero and such number shall be increased (but not decreased) on each of the First Reset Date (as defined below) and, if applicable, the Second Reset Date (as defined below), the Third
Reset Date (as defined below) and the Allowed Subsequent Placement Reset Date (as defined below). The Maximum Eligibility Number shall be increased (but not decreased) on the First Reset Date to equal the number obtained by subtracting (I) the
sum of [            ]2 and the number of Series B Warrants
exercised by the Holder (each as adjusted for stock splits, stock dividends, recapitalizations, reorganizations, reclassification, combinations, reverse stock splits or other similar events ) (the “Initial Shares”) from (II) the
quotient determined by dividing (x) the sum of $[            ]3 and the aggregate exercise price paid upon exercise of the Series B Warrants exercised by the Holder by (y) the First Reset Price (such increased number, the “First Maximum Eligibility
Number”). If (A) the First 
  

	2 	 Insert the number of Common Shares (as defined in the Securities Purchase Agreement) issued to the Holder on the Issuance Date.

	3 	 Insert the Purchase Price (as defined in the Securities Purchase Agreement) paid by the Holder.

  
 - 19 -

 
Reset Date was triggered by clause (1) of such definition and the Registration Statement is not available for the resale of all Registrable Securities thereunder at all times from the First
Reset Date until the sixtieth (60th) day following the First Reset Date or (B) the First Reset Date was triggered by either clause (2) or clause (3) of such definition and there shall occur a Public Information Failure (as
defined in the Securities Purchase Agreement) at any time on or prior to the sixtieth (60th) day following the First Reset Date, the Maximum Eligibility Number shall be further increased (but not decreased) on the Second Reset Date, to equal
the number obtained by subtracting the sum of the First Maximum Eligibility Number and the Initial Shares from the quotient determined by dividing the sum of $[            ]4 and the aggregate exercise price paid upon exercise of the Series B Warrants exercised by the Holder by the Second Reset
Price. If (A) the Second Reset Date was triggered by clause (1) of such definition and the Registration Statement is not available for the resale of all Registrable Securities thereunder at all times from the Second Reset Date until the
sixtieth (60th) day following the Second Reset Date or (B) the Second Reset Date was triggered by clause (2) of such definition and there shall occur a Public Information Failure at any time on or prior to the sixtieth (60th) day
following the Second Reset Date, the Maximum Eligibility Number shall be further increased (but not decreased) on the Third Reset Date, to equal the number obtained by subtracting the sum of the Second Maximum Eligibility Number, the First Maximum
Eligibility Number and the Initial Shares from the quotient determined by dividing the sum of $[            ]5 and the aggregate exercise price paid upon exercise of the Series B Warrants exercised by the Holder by the Third Reset Price. The Maximum Eligibility Number shall be increased (but not decreased) upon
the occurrence of any Allowed Subsequent Placement (the “Allowed Subsequent Placement Reset Date”) by the number of shares obtained by subtracting (I) the number of Common Shares issued to the Holder on the Issuance Date from
(II) the quotient obtained by dividing (i) the aggregate Purchase Price (as defined in the Securities Purchase Agreement) paid by the Holder by (ii) the lowest deemed consideration per share of Common Stock (as determined in accordance
with the provisions of Section 2(a) of the Series A Warrants (as defined in the Securities Purchase Agreement)) issued in such Allowed Subsequent Placement. As used herein, (u) the “First Reset Date” means the date that is
the twenty sixth (26th) Trading Day after the earliest of (1) the date that all Registrable Securities (as defined in the Registration Rights Agreement) and the Warrant Shares issuable hereunder have become registered pursuant to an
effective Registration Statement that is available for the resale of all such Registrable Securities and Warrant Shares, (2) the date that the Holder can sell all of the Warrant Shares issuable hereunder pursuant to Rule 144 and (3) the
six month anniversary of the Issuance Date (the earliest of (1), (2) and (3), the “First Trigger Date”); (v) the “First Reset Price” means eighty five percent (85%) of the eight (8) lowest
Weighted Average Prices of the Common Stock during the twenty (20) Trading Days immediately following the fifth (5th) Trading Day after the First Trigger Date (as adjusted for stock splits, stock dividends, recapitalizations,
reorganizations, reclassification, combinations, reverse stock splits or other similar events during such period); (w) the “Second Reset Date” means the earlier of (1) the date that all Registrable Securities and the
Warrant Shares issuable hereunder are registered pursuant to an effective Registration Statement that is available for the resale of all such Registrable Securities and Warrant Shares (2) the date that the Holder can sell all of the Warrant
Shares issuable hereunder pursuant to Rule 144 and (3) the one (1) year 
  

	4 	 Insert the Holder’s Purchase Price paid by the Holder. 

	5 	 Insert the Holder’s Purchase Price paid by the Holder. 

  
 - 20 -

 
anniversary of the Issuance Date (the earliest of (1), (2) and (3), the “Second Trigger Date”); (x) “Second Reset Price” means eighty five percent
(85%) of the eight (8) lowest Weighted Average Prices of the Common Stock during the twenty (20) Trading days immediately following the fifth (5th) Trading Day after the Second Trigger Date (as adjusted for stock splits, stock
dividends, recapitalizations, reorganizations, reclassification, combinations, reverse stock splits or other similar events during such period), (y) the “Third Reset Date” means the one (1) year anniversary of the Issuance
Date; and (z) “Third Reset Price” means eighty five percent (85%) of the eight (8) lowest Weighted Average Prices of the Common Stock during the twenty (20) Trading days immediately following the fifth
(5th) Trading Day after the one (1) year anniversary of the Issuance Date (as adjusted for stock splits, stock dividends, recapitalizations, reorganizations, reclassification, combinations, reverse stock splits or other similar events
during such period).] 
 (o) “Options” means any rights, warrants or options to subscribe for
or purchase shares of Common Stock or Convertible Securities. 
 (p) “Option Value” means the
value of an Option based on the Black and Scholes Option Pricing model obtained from the “OV” function on Bloomberg determined as of the day prior to the public announcement of the applicable Option for pricing purposes and reflecting
(i) a risk-free interest rate corresponding to the U.S. Treasury rate for a period equal to the remaining term of the applicable Option as of the applicable date of determination, (ii) an expected volatility equal to the greater of
(a) 100% and (b) the 100 day volatility obtained from the HVT function on Bloomberg as of the day immediately following the public announcement of the issuance of the applicable Option, (iii) the underlying price per share used in
such calculation shall be the highest Weighted Average Price of the Common Stock during the period beginning on the day prior to the execution of definitive documentation relating to the issuance of the applicable Option and the public announcement
of such issuance and (iv) a 360 day annualization factor. 
 (q) “Parent Entity” of a
Person means an entity that, directly or indirectly, controls the applicable Person and whose common shares or common stock or equivalent equity security is quoted or listed on an Eligible Market, or, if there is more than one such Person or Parent
Entity, the Person or Parent Entity with the largest public market capitalization as of the date of consummation of the Fundamental Transaction. 
 (r) “Person” means an individual, a limited liability company, a partnership, a joint venture, a corporation, a trust, an unincorporated organization, any other entity and a government or
any department or agency thereof. 
 (s) “Principal Market” means The NASDAQ Capital Market.

 (t) “Registration Rights Agreement” means that certain registration rights agreement by and
among the Company and the Buyers. 
 (u) “Required Holders” means the holders of the SPA
Warrants representing at least seventy-five percent (75%) of the shares of Common Stock underlying the SPA Warrants then outstanding. 

  
 - 21 -

 (v) [SERIES B: “Series B Eligibility Date” means
the first date on which all of the following conditions are satisfied (or waived by the Holder): (i) the Stockholder Approval shall have been obtained, (ii) all of the Warrant Shares shall be able to be resold without restriction or
limitation pursuant to the Registration Statement and (iii) all of the Registrable Securities and shares of Common Stock underlying the Series C Warrants shall be able to be resold without restriction or limitation pursuant to the Registration
Statement or Rule 144.] 
 (w) “Successor Entity” means the Person (or, if so elected by the
Required Holders, the Parent Entity) formed by, resulting from or surviving any Fundamental Transaction or the Person (or, if so elected by the Required Holders, the Parent Entity) with which such Fundamental Transaction shall have been entered
into. 
 (x) “Trading Day” means any day on which the Common Stock is traded on the Principal
Market, or, if the Principal Market is not the principal trading market for the Common Stock, then on the principal securities exchange or securities market on which the Common Stock is then traded; provided that “Trading Day” shall not
include any day on which the Common Stock is scheduled to trade on such exchange or market for less than 4.5 hours or any day that the Common Stock is suspended from trading during the final hour of trading on such exchange or market (or if such
exchange or market does not designate in advance the closing time of trading on such exchange or market, then during the hour ending at 4:00:00 p.m., New York time). 

(y) “Weighted Average Price” means, for any security as of any date, the dollar volume-weighted average
price for such security on the Principal Market during the period beginning at 9:30:01 a.m., New York time (or such other time as the Principal Market publicly announces is the official open of trading), and ending at 4:00:00 p.m., New York time (or
such other time as the Principal Market publicly announces is the official close of trading), as reported by Bloomberg through its “Volume at Price” function or, if the foregoing does not apply, the dollar volume-weighted average price of
such security in the over-the-counter market on the electronic bulletin board for such security during the period beginning at 9:30:01 a.m., New York time (or such other time as the Principal Market publicly announces is the official open of
trading), and ending at 4:00:00 p.m., New York time (or such other time as the Principal Market publicly announces is the official close of trading), as reported by Bloomberg, or, if no dollar volume-weighted average price is reported for such
security by Bloomberg for such hours, the average of the highest closing bid price and the lowest closing ask price of any of the market makers for such security as reported in the “pink sheets” by Pink Sheets LLC (formerly the National
Quotation Bureau, Inc.). If the Weighted Average Price cannot be calculated for a security on a particular date on any of the foregoing bases, the Weighted Average Price of such security on such date shall be the fair market value as mutually
determined by the Company and the Holder. If the Company and the Holder are unable to agree upon the fair market value of such security, then such dispute shall be resolved pursuant to Section 12 with the term “Weighted Average Price”
being substituted for the term “Exercise Price.” All such determinations shall be appropriately adjusted for any stock dividend, stock split, stock combination or other similar transaction during the applicable calculation period.

 [Signature Page Follows] 

  
 - 22 -

 IN WITNESS WHEREOF, the Company has caused this Warrant to Purchase
Common Stock to be duly executed as of the Issuance Date set out above. 
  

			
	 MARSHALL EDWARDS, INC.

		
	 By:
	 	  

	 Name:
	 	
	 Title:
	 	

 EXHIBIT A 
 EXERCISE NOTICE 
 TO BE EXECUTED BY THE REGISTERED HOLDER TO EXERCISE
THIS 
 WARRANT TO PURCHASE COMMON STOCK 
 MARSHALL EDWARDS, INC. 
 The undersigned holder hereby
exercises the right to purchase                      of the Common Stock (“Warrant Shares”) of Marshall Edwards, Inc., a
company incorporated under the laws of Delaware (the “Company”), evidenced by the attached Warrant to Purchase Common Stock (the “Warrant”). Capitalized terms used herein and not otherwise defined shall have the
respective meanings set forth in the Warrant. 
 [SERIES A&B: 1. Form of Exercise Price. The Holder
intends that payment of the Exercise Price shall be made as: 
  

			
	
                    
 
	 	a “Cash Exercise” with respect to
                                 Warrant Shares; [SERIES A:
and/or
	
                    
 
	 	a “Cashless Exercise” with respect to
                                 Warrant Shares.]

2. Payment of Exercise Price. In the event that the holder has elected a Cash Exercise with respect to some or all of the
Warrant Shares to be issued pursuant hereto, the holder shall pay the Aggregate Exercise Price in the sum of
$                                 to the Company in accordance with the terms of
the Warrant. 
 3.] Delivery of Warrant Shares. The Company shall deliver to the holder
                     Warrant Shares in accordance with the terms of the Warrant. 

Account Number (if electronic book entry transfer):
                                        

 DTC Participant Number (if electronic book entry transfer):
                                        

 Date:                  ,
         
  

			
	  

	 Name of Registered Holder

		
	 By:
	 	  

		 	 Name:

		 	 Title:

 ACKNOWLEDGMENT 

The Company hereby acknowledges this Exercise Notice and hereby directs Computershare, Inc. to issue the above indicated
number of shares of Common Stock in accordance with the Transfer Agent Instructions dated May [__], 2011 from the Company and acknowledged and agreed to Computershare, Inc. 

 

			
	 MARSHALL EDWARDS, INC.

		
	 By:
	 	  

	 Name:
	 	
	 Title:Exhibit 10.2

 Exhibit 10.2 
 NONSTANDARDIZED ADOPTION AGREEMENT 
 PROTOTYPE
CASH OR DEFERRED PROFIT-SHARING PLAN 
 Sponsored by 

Clark, Schaefer, Hackett & Co. 
 The Employer named below hereby establishes a Cash or Deferred Profit-Sharing Plan for eligible Employees as provided in this Adoption Agreement and the accompanying Basic Plan Document #01. 

 

	I.	EMPLOYER INFORMATION 

 If more than one Employer is adopting the Plan, complete this section based on the lead Employer. Additional Employers who are members of the same controlled group or affiliated service group may adopt
this Plan by completing and executing a Participation Agreement that, once executed, will become part of this Adoption Agreement. 
  

	 	A.	Name And Address: 

 UNITED
COMMUNITY BANK 
 P.O. BOX 4070 
 LAWRENCEBURG, IN 47025 
  

	 	B.	Telephone Number: 812-537-4822 

  

	 	C.	Employer’s Tax ID Number: 35-0593216 

  

	 	D.	Form Of Business: 

  

											
	 ̈	  	1.	  	 Sole Proprietor
	  	 ̈	  	5.	 	Limited Liability Company
	 ̈	  	2.	  	 Partnership
	  	 ̈	  	6.	 	Limited Liability Partnership
	x	  	3.	  	 Corporation
	  	 ̈	  	7.	 	 
	 ̈	  	4.	  	 S Corporation
	  		  		 	

  

											
	
E.     Is The Employer Part Of A Controlled Group?
	  	 ̈	 YES	  	  	x	 NO	  	  	
	          Part Of An Affiliated Service Group?
	  	 ̈	YES	  	  	x	NO	  	  	

  

	 	F.	Name Of Plan: UNITED COMMUNITY BANK 401(k) PROFIT SHARING PLAN 

  

	 	G.	Three Digit Plan Number: 002 

  

	 	H.	Employer’s Tax Year End: December 31 

  

	 	I.	Employer’s Business Code: 522120 

  

	II.	EFFECTIVE DATE 

  

	 	A.	New Plan: 

 This is a new
Plan having an Effective Date of
                                         
       . The Effective Date may be no earlier than the Plan Year beginning after December 31, 2001 or if later, the first day of the Plan Year in which it is adopted. 

  

					
		 	1	 	401(k) NS AA #010

	 	B.	Amended and Restated Plans: 

 This is an amendment and/or restatement of an existing Plan. The initial Effective Date of the Plan was April 1, 1997. The Effective Date of this amendment and/or restatement is
June 5, 2010. The Effective Date of the restated Plan may be no earlier than for Plan Years beginning after December 31, 2001. 
  

	 	C.	Amended or Restated Plans for EGTRRA: 

 This is an amendment and/or restatement of an existing Plan to comply with the Economic Growth and Tax Relief Reconciliation Act of 2001, Pub. L. 107-17 (EGTRRA)]. The initial Effective Date of the Plan
was
                                         
               . Except as provided for in the Plan, the Effective Date of this amendment and/or restatement is
                                        .
(The restatement date should be no earlier than the first day of the current Plan Year. The Plan contains appropriate retroactive Effective Dates with respect to provisions of EGTRRA.) 

Except to the extent permitted under Code Section 411(d)(6) and the Regulations issued thereunder, an Employer cannot reduce,
eliminate or make subject to Employer discretion any Code Section 411(d)(6) protected benefit. Where this Plan document is being adopted to amend another plan that contains a protected benefit not provided for in the Basic Plan Document #01,
the Employer may complete Schedule A as an addendum to this Adoption Agreement. Schedule A describes such protected benefits and shall become part of this Plan. If a prior plan document contains a plan feature not provided for in the Basic Plan
Document #01, the Employer may attach Schedule B describing such feature. Provisions listed on Schedule B may not be covered by the IRS Opinion Letter issued with respect to the Basic Plan Document #01. 

 

	 	D.	Effective Date for Elective Deferrals: 

 If different from above, the Elective Deferral provisions shall be effective
                                        .

  

	 	E.	Effective Date for Safe Harbor 401(k) Contributions: 

 If different from above, this provision shall be effective
                                        .
This provision must be adopted prior to the first day of the Plan Year and remain in effect for an entire twelve (12) month period. 
  

	 	F.	Effective Date for Roth Elective Deferrals: 

 If different from above, Roth Elective Deferral provisions shall be effective
                                        .
The Effective Date of this provision cannot be earlier than January 1, 2006. 
  

	 	G.	Frozen Plan: 

 This Plan
was frozen effective
                                        .
For any period following this Effective Date, neither the Employer nor any Participant may contribute to this Plan, and no otherwise eligible Employee shall become a Participant in this Plan. All existing account balances will become fully vested as
of the date specified above. 
  

	III.	DEFINITIONS 

  

	 	A.	“Compensation” 

Select the definition of Compensation, the Compensation Computation Period, any Compensation Dollar Limitation and Exclusions from
Compensation for each contribution type from the options listed below. Enter the letter of the option selected on the lines provided below. Leave the line blank if no election needs to be made. The Compensation Computation Period must be the same
as the Limitation Year defined at Section III(F).  

  

					
		 	2	 	401(k) NS AA #010

													
	 Employer
 Contribution Type
	  	Compensation
Definition	  	Compensation
Computation
Period	  	Compensation
Dollar
Limitation
	 	  	Exclusions
From
Compensation
	 
	 All Contributions
	  	d	  	a	  	$	 	  	  	 	a	  
	 Elective Deferrals (including Roth Elective Deferrals, if applicable)
	  		  		  	$	 	  	  			
	 Voluntary After-tax
	  		  		  	$	 	  	  			
	 Required After-tax
	  		  		  	$	 	  	  			
	 Matching Contribution (Formula 1)
	  		  		  	$	 	  	  			
	 Matching Contribution (Formula 2)
	  		  		  	$	 	  	  			
	 Non-Elective Contribution (Formula 1)
	  		  		  	$	 	  	  			
	 Non-Elective Contribution (Formula 2)
	  		  		  	$	 	  	  			
	 Safe Harbor Contribution
	  		  		  	 	N/A	  	  	 	N/A	  
	 QNEC
	  		  		  	$	 	  	  			
	 QMAC
	  		  		  	$	 	  	  			
	 ADP/ACP Tests
	  		  		  	 	N/A	  	  	 	N/A	  

  

	 	1.	Compensation Definition: 

  

	 	a.	Code Section 3401(a) - W-2 Compensation subject to income tax withholding at the source, with all pre-tax contributions excluded. 

 

	 	b.	Code Section 3401(a) - W-2 Compensation subject to income tax withholding at the source, with all pre-tax contributions included [Plan defaults to this election].

  

	 	c.	Code Section 6041/6051 - Income reportable on Form W-2, with all pre-tax contributions excluded. 

 

	 	d.	Code Section 6041/6051 - Income reportable on Form W-2, with all pre-tax contributions included. 

 

	 	e.	Code Section 415 - All income received for services performed for the Employer, with all pre-tax contributions excluded. 

 

	 	f.	Code Section 415 - All income received for services performed for the Employer, with all pre-tax contributions included. 

The selection of any of the above definitions of Compensation meets the Code Section 414(s) definition of Compensation. The Code
Section 415 definition shall always apply with respect to sole proprietors and partners. 
  

	 	 ̈     2.	Deemed Compensation from permitted waiver of group health coverage under a Cafeteria Plan Arrangement: The Employer elects to include deemed Code
Section 125 Compensation not available to a Participant in cash in lieu of group health coverage in the Plan’s definition of Compensation. 

  

	 	3.	Compensation Computation Period: 

  

	 	a.	Compensation paid during a Plan Year while a Participant [Plan defaults to this election]. 

 

	 	b.	Compensation paid during the entire Plan Year. 

  

	 	c.	Compensation paid during the Employer’s fiscal year. 

  

					
		 	3	 	401(k) NS AA #010

	 	d.	Compensation paid during the calendar year. 

  

	 	4.	Compensation Dollar Limitation: The dollar limitation section does not need to be completed unless Compensation of less than the Code Section 401(a)(17)
limit of $200,000 is to be used. When an integrated allocation formula in Section VI is selected, Compensation cannot be limited to an amount less than the maximum amount under Code Section 401(a)(17).  

 

	 	5.	Exclusions from Compensation (non-integrated plans only): 

  

	 	a.	There will be no exclusions from Compensation under the Plan [Plan defaults to this safe harbor election]. 

 

	 	b.	Overtime 

  

	 	c.	Bonuses 

  

	 	d.	Commissions 

  

	 	e.	Exclusion applies only to Participants who are Highly Compensated Employees [safe harbor]. 

 

	 	f.	Holiday and vacation pay 

  

	 	g.	Reimbursements or other expense allowances, fringe benefits (cash and non-cash), moving expenses, deferred compensation, and welfare benefits [safe harbor].

  

	 	h.	Post-severance payments, as described in paragraph 1.17(c)(6) of Basic Plan Document #01. (This exclusion may apply no earlier than the 2005 Limitation Year.)

  

	 	i.	Compensation in excess of
$                                        
for Highly Compensated Employees [safe harbor]. 

  

	 	j.	Other:
                                        

 Any exclusion of Compensation except (a), (e), (g), (h) and (i) must satisfy the requirements of
Section 1.401(a)(4) of the Income Tax Regulations and Code Section 414(s) and the Regulations thereunder. These exclusions do not fall under the “safe harbor” modifications to Compensation and therefore must be tested to
determine if the modified definition of Compensation satisfies Code Section 414(s). 
  

	 	B.	“Disability” 

  

	 	x     1.	As defined in the Basic Plan Document #01 [Plan defaults to this election]. 

 

	 	 ̈     2.	As defined in the Employer’s Disability Insurance Plan. 

  

	 	 ̈     3.	An individual will be considered to be disabled if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or to be of long, continued and indefinite duration. An individual shall not be considered to be disabled unless he or she furnishes proof of the existence thereof in such form and manner as
the Secretary of the Treasury may prescribe. 

  

					
		 	4	 	401(k) NS AA #010

	 	C.	“Highly Compensated Employees – Top-Paid Group Election” 

 

	 	1.	Top-Paid Group Election: In determining who is a Highly Compensated Employee, the Employer may make the Top-Paid Group election. The effect of this election is
that an Employee (who is not a 5% owner at any time during the determination year or the look-back year) who earned more than $95,000, as indexed for the look-back year, is a Highly Compensated Employee if the Employee was in the Top-Paid Group for
the look-back year. This election is applicable for the Plan Year in which this Plan is effective. 

  

	 	 ̈       a.	The Employer does not make the Top-Paid Group election. 

  

	 	x       b.	The Employer makes the Top-Paid Group election [Plan defaults to this election]. 

 

	 	 ̈     2.	Calendar Year Data Election: If the Plan Year is not the calendar year, the prior year computation period for purposes of determining if an Employee earned more
than $95,000, as indexed, is the calendar year beginning in the prior Plan Year. This election is applicable for the Plan Year in which this Plan is effective. 

 

	 	D.	“Hours Of Service”  

 Hours shall be determined by the method selected below. The method selected shall be applied to all Employees: 
  

	 	 ̈     1.	Not applicable. A Year of Service (Period of Service) is defined using the Elapsed Time method. 

 

	 	x     2.	On the basis of actual hours for which an Employee is paid or entitled to payment [Plan defaults to this election]. 

 

	 	 ̈     3.	On the basis of days worked. An Employee shall be credited with ten (10) Hours of Service if the Employee would be credited with at least one (1) Hour of
Service during the day. 

  

	 	 ̈     4.	On the basis of weeks worked. An Employee shall be credited with forty-five (45) Hours of Service if the Employee would be credited with at least one (1) Hour
of Service during the week. 

  

	 	 ̈     5.	On the basis of semi-monthly payroll periods. An Employee shall be credited with ninety-five (95) Hours of Service if the Employee would be credited with at least
one (1) Hour of Service during the semi-monthly payroll period. 

  

	 	 ̈     6.	On the basis of months worked. An Employee shall be credited with one-hundred-ninety (190) Hours of Service if the Employee would be credited with at least one
(1) Hour of Service during the month. 

  

	 	E.	“Integration Level” 

  

	 	x     1.	Not applicable. Either the Plan’s allocation formula is not integrated with Social Security or there are no Non-Elective Employer Contributions being made to the
Plan [Plan defaults to this election]. 

  

	 	 ̈     2.	The Taxable Wage Base. 

  

	 	 ̈     3.	________% (not more than 100%) of the Taxable Wage Base. 

  

	 	 ̈     4.	$            , provided that such amount is not in excess of the amount determined under
paragraph (E)(2) above. 

  

	 	 ̈     5.	One dollar over 80% of the Taxable Wage Base. 

  

	 	 ̈     6.	20% of the Taxable Wage Base. 

  

					
		 	5	 	401(k) NS AA #010

	 	F.	“Limitation Year” 

 Unless elected otherwise below, the Limitation Year shall be the Plan Year. 
 The
twelve (12) consecutive month period commencing on January 1 and ending on December 31. 
 If
applicable, there will be a short Limitation Year commencing on
                                        
and ending on
                                        .
Thereafter, the Limitation Year shall end on the date specified above. 
  

	 	G.	“Net Profit” 

  

	 	x     1.	Not applicable. Employer contributions to the Plan are not conditioned on profits [Plan defaults to this election]. 

 

	 	 ̈     2.	Net Profits are required for making Employer contributions and are defined as follows: 

 

	 	 ̈       a.	As defined in the Basic Plan Document #01. 

  

	 	 ̈       b.	Net Profits will be defined in a uniform and nondiscriminatory manner which will not result in a deprivation of an eligible Participant of any Employer Contribution.

  

	 	c.	Net Profits are required for the following types of contributions: 

  

	 	 ̈     i.	Employer Matching Contributions (Formula 1). 

  

	 	 ̈     ii.	Employer Matching Contributions (Formula 2). 

  

	 	 ̈     iii.	Employer QNEC and QMAC Contributions. 

  

	 	 ̈     iv.	Non-Elective Employer Contributions (Formula 1). 

  

	 	 ̈     v.	Non-Elective Employer Contributions (Formula 2). 

 Elective Deferrals, Top-Heavy minimums (if required), and Safe Harbor Contributions (if applicable) must be contributed regardless of profits. 

 

	 	H.	“Plan Year” 

The 12-consecutive month period commencing on January 1 and ending on December 31. 

If applicable, there will be a short Plan Year commencing on
                                        
and ending on
                                        .
Thereafter, the Plan Year shall end on the date specified above. 
  

	 	I.	“QDRO Payment Date” 

  

	 	x     1.	The date the QDRO is determined to be qualified [Plan defaults to this election]. 

 

	 	 ̈     2.	The statutory age fifty (50) requirement applies for purposes of making distribution to an alternate payee under the provisions of a QDRO.

  

	 	J.	“Qualified Joint and Survivor Annuity” 

  

	 	x     1.	Not applicable. The Plan is not subject to Qualified Joint and Survivor Annuity rules. The safe harbor provisions of paragraph 8.7 of the Basic Plan Document #01 apply.
The normal form of payment is a lump sum. No annuities are offered under the Plan [Plan defaults to this election]. 

  

	 	 ̈     2.	The normal form of payment is a lump sum. The Plan does provide for annuities as an optional form of payment at Section XVI(D) of the Adoption Agreement. The
Plan’s Joint and Survivor Annuity rules are avoided and the safe harbor provisions of paragraph 8.7 of the Basic Plan Document #01 will apply, unless the Participant elects to receive his or her distribution in the form of an annuity. If this
option is selected, Section III(K) below must also be completed. 

  

					
		 	6	 	401(k) NS AA #010

	 	 ̈     3.	The Joint and Survivor Annuity rules are applicable and the survivor annuity will be ________% (50%, 66-2/3%, 75% or 100%) of the annuity payable during the
lives of the Participant and his or her Spouse. If no selection is specified, 50% shall be deemed elected. 

  

	 	K.	“Qualified Pre-Retirement Survivor Annuity” 

 Do not complete this section if paragraph (J)(1) was elected. 
  

	 	 ̈     1.	The Qualified Pre-Retirement Survivor Annuity shall be 100% of the Participant’s Vested Account Balance in the Plan as of the date of the Participant’s death.

  

	 	 ̈     2.	The Qualified Pre-Retirement Survivor Annuity shall be 50% of the Participant’s Vested Account Balance in the Plan as of the date of the Participant’s death.

 If this provision applies but no selection is made, the Qualified Pre-Retirement Survivor Annuity shall be
50%. 
  

	 	L.	“Valuation of Plan Assets” 

 The assets of the Plan shall be valued on the last day of the Plan Year and on the following Valuation Date(s): 
  

	 	 ̈     1.	There are no other mandatory Valuation Dates. 

  

	 	x     2.	The Valuation Dates are applicable for the contribution type specified below: 

 

			
	 Contribution Type
	  	 Valuation Date

	 All Contributions
	  	a
	 Elective Deferrals (including Roth Elective Deferrals, if applicable)
	  	
	 Voluntary After-tax Contributions
	  	
	 Required After-tax Contributions
	  	
	 Deemed IRA Contribution
	  	
	 Matching Contributions (Formula 1)
	  	
	 Matching Contributions (Formula 2)
	  	
	 Non-Elective Contributions (Formula 1)
	  	
	 Non-Elective Contributions (Formula 2)
	  	
	 Safe Harbor Contributions
	  	
	 QNEC
	  	
	 QMAC
	  	

  

	 	a.	Daily valued. 

  

	 	b.	The last day of each month. 

  

	 	c.	The last day of each quarter in the Plan Year. 

  

	 	d.	The last day of each semi-annual period in the Plan Year. 

  

	 	e.	Other:
                                         
                                         
                                         
                                     .

 (Note: Date must be at least once during the Plan Year.) 

  

					
		 	7	 	401(k) NS AA #010

	IV.	ELIGIBILITY REQUIREMENTS 

 Complete the following using the eligibility requirements as specified for each contribution type. To become a Participant in the Plan, the Employee must satisfy the following eligibility requirements.

  

																					
	 Contribution Type
	  	Minimum
Age	 	  	Service
Requirement	 	  	Class
Exclusions	 	  	Eligibility
Computation
Period	 	  	Entry
Date	 
	 All Contributions
	  	 	18	  	  	 	3	  	  	 	1, 2, 10	  	  	 	1	  	  	 	2	  
	 Elective Deferrals (including Roth Elective Deferrals, if applicable)
	  				  				  				  				  			
	 Voluntary After-tax Contributions
	  				  				  				  				  			
	 Required After-tax Contributions
	  				  				  				  				  			
	 Matching Contributions (Formula 1)
	  				  				  				  				  			
	 Matching Contributions (Formula 2)
	  				  				  				  				  			
	 Non-Elective Contributions (Formula 1)
	  				  				  				  				  			
	 Non-Elective Contributions (Formula 2)
	  				  				  				  				  			
	 Safe Harbor Contributions*
	  				  				  				  				  			
	 QNECs
	  				  				  				  				  			
	 QMACs
	  				  				  				  				  			

  

	 	*	If any age or Service requirement selected is more restrictive than that which is imposed on any Employee contribution, that group of Employees will be subject to
the ADP and/or ACP testing as prescribed under applicable IRS Regulations 

  

	 	A.	Age: 

  

	 	1.	No age requirement. 

  

	 	2.	Insert the applicable age in the chart above. The age may not be more than twenty-one (21). 

 

	 	B.	Service: 

 The maximum
Service requirement for Elective Deferrals is one (1) year. For all other contributions, the maximum is two (2) years. If a Service requirement greater than one (1) year is selected, Participants must be 100% vested in that
contribution. 
  

	 	1.	No Service requirement. 

  

	 	2.	Completion of _______ Days of Service. [No more than 730 Days of Service may be required; if more than 365 days are entered here, Participants must be 100%
vested upon entering the Plan.] 

  

	 	3.	Completion of 1 months of Service [No more than twenty-four (24) months of Service may be required; if more than twelve (12) months are entered here,
Participants must be 100% vested upon entering the Plan.] 

  

					
		 	8	 	401(k) NS AA #010

	 	4.	Completion of _______ months of Service [No more than twenty-four (24) months of Service may be required; if more than twelve (12) months are entered
here, Participants must be 100% vested upon entering the Plan.] 

  

	 	5.	One (1) Year of Service or Period of Service. 

  

	 	6.	Two (2) Years of Service or Periods of Service. 

  

	 	7.	One (1) Expected Year of Service. An Employee whose position is required as a condition of employment to work a Year of Service may enter after six (6) months
of actual Service. 

  

	 	8.	One (1) Expected Year of Service. An Employee whose position is required as a condition of employment to work a Year of Service may enter after __________
months of actual Service [must be twelve (12) months or less]. 

  

	 	9.	One (1) Expected Year of Service. An Employee whose position is required as a condition of employment to work a Year of Service may enter after __________
months of actual Service [must be twelve (12) months or less]. 

  

	 	10.	Completion of ___________ Hours of Service (1,000 hours or less) within the ___________ month(s) time period [the monthly period must be a pro-ration of
twelve (12) months or less] following an Employee’s commencement of employment. An Employee who is otherwise eligible who meets the statutory one (1) Year of Service requirement and any age requirement if applicable, shall participate
in the Plan not later than the earlier of the first day of the first Plan Year after the Employee has met the statutory requirements or six (6) months after the day such requirements are met. 

 

	 	11.	Completion of ___________ Hours of Service (may not be more than 1,000 Hours). 

 

	 	C.	Method for Measuring Service Eligibility Period (do not enter this method in the table above): 

A Year of Service for eligibility purposes is defined as follows (choose one): 

 

	 	 ̈     1.	Not applicable. 

  

	 	 ̈     2.	Hours of Service method. A Year of Service will be credited upon completion of ____________ Hours of Service. A Year of Service for eligibility purposes may not
be less than one (1) Hour of Service nor greater than 1,000 hours by operation of law. If left blank, the Plan will use 1,000 hours. 

  

	 	x     3.	Elapsed Time method 

  

	 	D.	Employee Class Exclusions: 

The exclusion of any classification may cause the Plan to fail the ratio percentage test under Code Section 410(b)(1)(A) or
(B) which may require the Plan to be tested under the average benefits test of Code Section 410(b)(1)(C). 
  

	 	1.	Employees included in a unit of Employees covered by a collective bargaining agreement between the Employer and Employee Representatives, if benefits were the subject
of good faith bargaining and if two percent or less of the Employees are covered pursuant to the agreement are professionals as defined in Regulations Section 1.410(b)-9, unless participation in this Plan is specifically provided for in the
collective bargaining agreement. For this purpose, the term “employee representative” does not include any organization more than half of whose members are owners, officers, or executives of the Employer. 

 

	 	2.	Employees who are non-resident aliens [within the meaning of Code Section 7701(b)(1)(B)] who receive no Earned Income [within the meaning of Code
Section 911(d)(2)] from the Employer which constitutes income from sources within the United States [within the meaning of Code Section 861(a)(3)]. 

 

	 	3.	Employees compensated on an hourly basis. 

  

					
		 	9	 	401(k) NS AA #010

	 	4.	Employees compensated on a salaried basis. 

  

	 	5.	Employees compensated on a commission basis. 

  

	 	6.	Leased Employees. 

  

	 	7.	Highly Compensated Employees. 

  

	 	8.	Key Employees. 

  

	 	9.	Employees of any member of the controlled and/or affiliated service group Employer whose Employer does not affirmatively adopt this Plan. 

 

	 	10.	The Plan shall exclude from participation any nondiscriminatory classification of Employees determined as follows (any exclusion must pass coverage and
nondiscrimination testing): 

 Hourly/Full-Time/Temporary Employees, Hourly/Part-Time/Temporary Employees and
Salaried/Part-Time/Temporary Employees. 
  

	 	E.	Eligibility Computation Period:  

 The initial eligibility computation period shall commence on the date on which an Employee first performs an Hour of Service and end with the first anniversary thereof. Each subsequent computation period
shall commence on: 
  

	 	1.	Not applicable. The Plan has a Service requirement of less than one (1) year or uses the Elapsed Time method to determine eligibility. 

 

	 	2.	The anniversary of the Employee’s employment commencement date and each subsequent twelve (12) consecutive month period thereafter. 

 

	 	3.	The first day of the Plan Year which commences prior to the first anniversary date of the Employee’s employment commencement date and each subsequent Plan Year
thereafter. 

  

	 	F.	Entry Date: 

  

	 	1.	The Employee’s date of hire. 

  

	 	2.	The first day of the month coinciding with or next following the date on which an Employee meets the eligibility requirements. 

 

	 	3.	The first day of the payroll period coinciding with or next following the date on which an Employee meets the eligibility requirements, or as soon as administratively
feasible thereafter. 

  

	 	4.	When the Days of Service method is selected at Section IV(B)(2), the Entry Date shall be the day the Employee meets the eligibility requirements, or as soon as
administratively feasible thereafter. 

  

	 	5.	The earlier of the first day of the Plan Year, or the first day of the fourth, seventh or tenth month of the Plan Year coinciding with or next following the date on
which an Employee meets the eligibility requirements. 

  

	 	6.	The earlier of the first day of the Plan Year or the first day of the seventh month of the Plan Year coinciding with or next following the date on which an Employee
meets the eligibility requirements. 

  

	 	7.	 The first day of the Plan Year following the date on which the Employee meets the eligibility requirements. If this election is made, the Service
waiting period cannot be greater than one-half year and the minimum age requirement may not be greater than age twenty and one-half (20 1/2). 

  

					
		 	10	 	401(k) NS AA #010

	 	8.	The first day of the Plan Year nearest the date on which an Employee meets the eligibility requirements. This option can only be selected for Employer related
contributions. 

  

	 	9.	The first day of the Plan Year during which the Employee meets the eligibility requirements. This option can only be selected for Employer related contributions.

  

	 	10.	Other: ________________________. 

 This option may not require an entry date more than two (2) months following the date on which an Employee meets the eligibility requirements. 

 

	 	G.	Employees on Effective Date: 

 If option (1) is selected, options (2) and (3) should not be selected. Options (2) and (3) can be selected or just option (2) or (3). 

 

	 	 ̈     1.	All Employees will be required to satisfy both the age and Service requirements specified above. 

 

	 	 ̈     2.	Employees employed on the Plan’s Effective Date do not have to satisfy the age requirement specified above. 

 

	 	x     3.	Employees employed on the Plan’s Effective Date do not have to satisfy the Service requirement specified above. 

 

	 	H.	Special Waiver of Eligibility Requirements: 

 The age and/or Service eligibility requirements specified above shall be waived for the eligible Employees specified below who are employed on the specified date for the contribution type(s) specified.
This waiver applies to either the age or Service requirement or both as elected below. 
  

											
	 Waiver Date
	  	Waiver
of
Age
Requirement	 	  	Waiver
of
Service
Requirement	 	  	 Contribution Type

		  				  				  	 All Contributions

		  				  				  	 Elective Deferrals (including Roth Elective Deferrals, if applicable)

		  				  				  	 Matching Contribution (Formula 1)

		  				  				  	 Matching Contribution (Formula 2)

		  				  				  	 Non-Elective Contribution (Formula 1)

		  				  				  	 Non-Elective Contribution (Formula 2)

		  				  				  	 Safe Harbor Contribution

		  				  				  	 QNEC

		  				  				  	 QMAC

 The waiver above applies to: 
  

	 	 ̈     1.	All eligible Employees employed on the specified date. 

  

	 	 ̈     2.	The indicated class of Employees employed on the specified date. 

 _____________________________________________________________________________________ 
 _____________________________________________________________________________________ 
 Note: Any selection here may cause the Plan to be discriminatory in operation and therefore would have to be tested for nondiscrimination. 

  

					
		 	11	 	401(k) NS AA #010

	V.	RETIREMENT AGES 

  

	 	A.	Normal Retirement: 

Select option (1) or (2) and either (3)(a) or (3)(b). 

 

	 	 ̈     1.	Normal Retirement Age shall be age ________ [not to exceed sixty-five (65)]. 

 

	 	x     2.	Normal Retirement Age shall be the later of attaining age 65 [not to exceed age sixty-five (65)] or the 5th (not to exceed the fifth) anniversary of the
first day of the first Plan Year in which the Participant commenced participation in the Plan. 

  

	 	3.	The Normal Retirement Date shall be: 

  

	 	 ̈       a.	as of the date the Participant attains Normal Retirement Age [Plan defaults to this election]. 

 

	 	x       b.	the first day of the month next following the Participant’s attainment of Normal Retirement Age. 

 

	 	B.	Early Retirement: 

  

	 	x     1.	Not applicable. 

  

	 	 ̈     2.	The Plan shall have an Early Retirement Age of ________ [not less than age fifty-five (55)] and completion of ________ Years of Service.

  

	 	3.	The Early Retirement Date shall be: 

  

	 	 ̈       a.	as of the date the Participant attains Early Retirement Age [Plan defaults to this election]. 

 

	 	 ̈       b.	the first day of the month next following the Participant’s attainment of Early Retirement Age. 

 

	VI.	CONTRIBUTIONS TO THE PLAN 

 The Employer shall make contributions to the Plan in accordance with the formula or formulas selected below. The Employer’s contribution shall be subject to the limitations contained in Articles III
and X of the Basic Plan Document #01. For this purpose, a contribution for a Plan Year shall be limited by Compensation earned in the Limitation Year that ends with or within such Plan Year. For Limitation Years beginning on or after January 1,
2002, except to the extent permitted under paragraph 4.6(h) of the Basic Plan Document #01 and under Code Section 414(v), the Annual Addition that may be contributed or allocated to a Participant’s account under the Plan for any Limitation
Year beginning after December 31, 2001 shall not exceed the lesser of (a) $40,000, as adjusted for increases in the cost-of-living under Code Section 415(d), or (b) 100% of the Participant’s Compensation within the meaning
of Code Section 415(c)(3), for the Limitation Year. 
  

	 	A.	Elective Deferrals: 

  

	 	1.	Participants shall be permitted to make Elective Deferrals: 

  

	 	 ̈       a.	in any amount up to ____________% (may be no more than 100%) of Compensation. 

 

	 	 ̈       b.	in any amount from a minimum of _______% (may be no less than 1%) to a maximum of _______% (may be no more than 100%) of their Compensation not to exceed
$__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

					
		 	12	 	401(k) NS AA #010

	 	 ̈       c.	in a flat dollar amount from a minimum of $______________ (may be no less than $500) to a maximum of
$                    , [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable] not
to exceed ______% (no more than 100%) of their Compensation. 

  

	 	x       d.	in any amount up to the maximum percentage of Compensation and dollar amount permissible under Code Section 402(g) and 414(v) not to exceed the limits of Code
Section 401(k), 404 and 415. 

  

	 	 ̈       e.	Highly Compensated Employees may defer any amount up to ____% (may be no more than 100%) of Compensation or $__________ [may be no more than the Code
Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

	 	x       f.	Catch-up Contributions may be made by eligible Participants. 

  

	 	2.	Participants shall be permitted to terminate their Elective Deferrals (including Roth Elective Deferrals, if any) at any time upon proper and timely notice to the
Employer. Modifications and reinstatement of Participants’ Elective Deferrals will become effective as soon as administratively feasible on a prospective basis as provided for below: 

 

					
	 Modifications
	  	 Reinstatement
	  	 Method

	 ̈	  	 ̈	  	On a daily basis.
	 ̈	  	 ̈	  	On the first day of each quarter.
	 ̈	  	 ̈	  	On the first day of the next month.
	x	  	x	  	The beginning of the next payroll period.
	 ̈	  	 ̈	  	On the first day of the next semi-annual period.
	 ̈	  	n/a	  	Upon _____ days notice to the Plan Administrator.
	n/a	  	 ̈	  	Upon _____ days notice to the Plan Administrator.

  

	 ̈     B.	Roth Elective Deferrals: 

If Participants are permitted to make Elective Deferrals, they shall also be permitted to make Roth Elective Deferrals. Roth Elective
Deferrals may be treated as Catch-Up Contributions. 
  

	 	C.	Bonus Option: 

  

	 	 ̈     1.	Not applicable. The Plan’s definition of Compensation excludes bonuses from deferrable Compensation for both Elective Deferrals and Roth Elective Deferrals.

  

	 	 ̈     2.	Not applicable. Participants are not permitted to make a separate deferral election and the Participant’s deferral amount elected on their Salary Deferral
Agreement will also apply to any bonus received by the Participant for any Plan Year. 

  

	 	x     3.	The Employer permits a Participant to amend his or her deferral election to defer to the Plan an amount not to exceed 100% (may be no more than 100%) or $_________ [may
be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable] of any bonus received by the Participant for any Plan Year. 

 

	 ̈     D.	Automatic Enrollment: 

The Employer elects the automatic enrollment provisions for Elective Deferrals as follows. Automatic enrollment in Roth Elective Deferrals
is not permitted under the Plan. The automatic enrollment provisions apply to all eligible Employees. Employees and Participants shall have the right to amend the stated automatic Elective Deferral percentage or receive cash in lieu of deferral into
the Plan. 
  

	 	1.	RESERVED 

  

					
		 	13	 	401(k) NS AA #010

	 	 ̈       2.	Automatic Deferrals: 

  

	 	a.	New Employees: Employees who have not met the eligibility requirements shall have Elective Deferrals withheld in the amount of ________% (not more than
10%) of Compensation or $________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable] upon entering the Plan. 

 

	 	 ̈     i.	On an annual basis the Elective Deferral rate under the Plan shall be increased up to a maximum amount determined by the Employer. 

 

	 	 ̈     ii.	After _____ Years of Service, the amount specified above shall increase to ____% (no more than 10%) or $______ [may be no more than the Code
Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

	 	 ̈     This	requirement is effective for Employees hired on or after ______________________. 

 

	 	 ̈       b.	Current Employees: Employees who are eligible to participate but not deferring shall have Elective Deferrals withheld in the amount of ______ % (not more
than 10%) of Compensation or $_________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

	 	 ̈     i.	On an annual basis the Elective Deferral rate under the Plan shall be increased up to a maximum amount determined by the Employer. 

 

	 	 ̈     ii.	After _____ Years of Service, the amount specified above shall increase to _____% (no more than 10%) or $_______ [may be no more than the Code Section 402(g) limit
and Code Section 414(v) limit, if applicable]. 

  

	 	 ̈       c.	Current Participants: Current Participants who are deferring at a percentage less than the amount selected herein shall have Elective Deferrals withheld in the
amount of ________% (not more than 10%) of Compensation or $________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

 

	 	 ̈     i.	On an annual basis the Elective Deferral rate under the Plan shall be increased up to a maximum amount determined by the Employer. 

 

	 	 ̈     ii.	After _____ Years of Service, the amount specified above shall increase to _____% (no more than 10%) or $_______ [may be no more than the Code Section 402(g) limit
and Code Section 414(v) limit, if applicable]. 

 Employees and Participants shall have the right to amend
the stated automatic Elective Deferral provisions or receive cash in lieu of deferral into the Plan. For purposes of this provision, Employees returning an election form indicating a “zero” deferral amount shall be deemed “Current
Participants”. 
  

	 	E.	Voluntary After-tax Contributions: 

 If the Employer wishes to reserve the right to recharacterize Elective Deferrals as Voluntary After-tax Contributions in order to pass the ADP/ACP Test, this section must be completed. 

 

	 	x     1.	The Plan does not permit Voluntary After-tax Contributions. 

  

	 	 ̈     2.	Participants may make Voluntary After-tax Contributions in any amount from a minimum of ________% (may not be less than 1%) to a maximum of ______% (may
be no more than 100%) of their Compensation or a flat dollar amount from a minimum of $____________ (may not be less than $1,000) to a maximum of $______________ [may be no more than the Code Section 402(g) limit and Code
Section 414(v) limit, if applicable]. 

  

	 	 ̈     3.	Participants may make Voluntary After-tax Contributions in any amount up to the maximum permitted by law. 

  

					
		 	14	 	401(k) NS AA #010

	 	 ̈     4.	The maximum combined limit of Elective Deferrals, Roth Elective Deferrals, and Voluntary After-tax Contributions will not exceed ______% (may be no more than 100%) of
Compensation or $_______ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

	 	F.	Required After-tax Contributions (for Thrift Savings Plans only): 

 

	 	x     1.	The Plan does not permit Required After-tax Contributions. 

  

	 	 ̈     2.	Participants shall be required to make Required After-tax Contributions as follows: 

 

	 	 ̈       a.	________% (may be no more than 100%) of Compensation. 

  

	 	 ̈       b.	A percentage determined by the Employee. 

  

	 	 ̈       c.	A flat dollar amount of $________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

 

	 	 ̈       d.	The maximum combined limit of Elective Deferrals, Roth Elective Deferrals and Required After-tax Contributions will not exceed ______% (may be no more than 100%) of
Compensation or $_______ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. 

  

	 	G.	Rollover Contributions: 

  

	 	 ̈     1.	The Plan does not accept Rollover Contributions. 

  

	 	x     2.	Rollover Contributions may be made: 

  

	 	x       a.	after meeting the eligibility requirements for participation in the Plan. 

  

	 	 ̈       b.	prior to meeting the eligibility requirements for participation in the Plan. 

 

	 	3.	The Plan will accept a Participant Rollover Contribution of an Eligible Rollover Distribution from (check only those that apply): 

 

	 	x       a.	A Qualified Plan described in Code Section 401(a) or 403(a). 

  

	 	x       b.	An annuity contract described in Code Section 403(b). 

  

	 	x       c.	An eligible plan under Code Section 457(b) which is maintained by a state, political subdivision of a state, or any agency or instrumentality of a state or
political subdivision of a state. 

  

	 	 ̈       d.	An Individual Retirement Account (which was not used as a conduit from a Qualified Plan) or Annuity described in Code Section 408(a) or 408(b) that is eligible to
be rolled over and would otherwise be includable in gross income. 

  

	 	4.	The Plan will accept a Direct Rollover of an Eligible Rollover Distribution from (check only those that apply): 

 

	 	x       a.	A Qualified Plan described in Code Section 401(a) or 403(a), excluding Voluntary After-tax Contributions. 

 

	 	 ̈       b.	A Qualified Plan described in Code Section 401(a) or 403(a), including Voluntary After-tax Contributions. 

 

	 	x       c.	An annuity contract described in Code Section 403(b), excluding Voluntary After-tax Contributions. 

 

	 	 ̈       d.	An annuity contract described in Code Section 403(b), including Voluntary After-tax Contributions. 

  

					
		 	15	 	401(k) NS AA #010

	 	x       e.	An eligible plan under Code Section 457(b) which is maintained by a state, political subdivision of a state, or an agency or instrumentality of a state or
political subdivision of a state. 

  

	 	 ̈       f.	A Roth Elective Deferral Account if it is a Direct Rollover from another Roth Elective Deferral Account under a Qualified Plan described in Code Section 402A(e)(1)
and only to the extent the rollover is permitted under Code Section 402(c). 

  

	 	H.	Deemed IRA Contributions/Reserved: 

  

	 	x     1.	The Plan does not accept any Deemed IRA contributions. 

  

	 	 ̈       2.	Deemed IRA contributions may be made to this Plan for Plan Years beginning ___________ (may be no earlier than January 1, 2003): 

 

	 	 ̈       a.	In accordance with the Traditional IRA rules as described in the Basic Plan Document #01. An Individual must meet the eligibility requirements for participation in the
Plan in order to make a “Deemed IRA” contribution. 

  

	 	 ̈       b.	In accordance with the Roth IRA rules as described in the Basic Plan Document #01. An Individual must meet the eligibility requirements for participation in the Plan in
order to make a “Deemed IRA” contribution. 

  

	 ̈     I.	Safe Harbor Plan Provisions: 

 If the Safe Harbor Plan provisions are elected, the nondiscrimination tests at Article XI of the Basic Plan Document #01 are not applicable. Safe Harbor Contributions made are subject to the withdrawal
restrictions of Code Section 401(k)(2)(B) and Treasury Regulation Section 1.401(k)-1(d); such contributions (and earnings thereon) must not be distributable earlier than severance from employment, death, Disability, an event described in
Code Section 401(k)(10), or in the case of a profit-sharing or stock bonus plan, the attainment of age
59 1/2. Safe Harbor Contributions are NOT available
for Hardship withdrawals. 
 The ACP Test Safe Harbor is automatically satisfied if the only Matching Contribution to the
Plan is either a Basic Matching Contribution or an Enhanced Matching Contribution that does not provide a match on Elective Deferrals in excess of 6% of Compensation. For Plans that allow Voluntary or Required After-tax Contributions, the ACP Test
is applicable with regard to such contributions. 
 Employees eligible to make Elective Deferrals to this Plan must be eligible
to receive the Safe Harbor Contribution in the Plan listed below, to the extent required by applicable IRS Regulations. 
 The
Employer elects to comply with the Safe Harbor Cash or Deferred Arrangement provisions of Article XI of the Basic Plan Document #01 and elects one of the following contribution formulas: 

 

	 	1.	Safe Harbor Tests: 

  

	 	 ̈       a.	Only the ADP Test Safe Harbor provisions are applicable. A formula in paragraphs (3), (4) or (5) below has been selected and the ADP Safe Harbor has been
satisfied. 

  

	 	 ̈       b.	Only the ACP Test Safe Harbor provisions are applicable. No additional Matching Contributions would be needed in order to satisfy the ACP Safe Harbor if the Plans
satisfies the Basic or Enhanced Match. 

  

	 	 ̈       c.	Both the ADP and ACP Test Safe Harbor provisions are applicable. If both ADP and ACP provisions are applicable: 

 

	 	 ̈     i.	No additional Matching Contributions will be made in any Plan Year in which the Safe Harbor provisions are used. 

  

					
		 	16	 	401(k) NS AA #010

	 	 ̈     ii.	The Employer may make Matching Contributions in addition to any Safe Harbor Matching Contributions elected below. [Complete provisions in Section VI(J) regarding
Matching Contributions that will be made in addition to those Safe Harbor Matching Contributions made below.] 

Safe Harbor Contributions cannot be subject to an Hours of Service or employment on the last day of the Plan Year requirement.

  

	 	 ̈     2.	Designation of Alternate Plan to Receive Safe Harbor Contribution: If the Safe Harbor Contribution as elected below is not being made to this Plan, the name of
the other plan that will receive the Safe Harbor Contribution is:
                                . 

 

	 	 ̈     3.	Basic Matching Contribution Formula: Matching Contributions will be made on behalf of Participants in an amount equal to 100% of the amount of the Eligible
Participant’s Elective Deferrals that do not exceed 3% of the Participant’s Compensation and 50% of the amount of the Participant’s Elective Deferrals that exceed 3% of the Participant’s Compensation but that do not exceed 5% of
the Participant’s Compensation. 

  

	 	 ̈     4.	Enhanced Matching Contribution Formula: Matching Contributions will be made in an amount equal to the sum of: 

 

	 	a.	_________% of the Participant’s Elective Deferrals that do not exceed _________% of the Participant’s Compensation [insert a number that is
three (3) or greater but not greater than six (6); if a number greater than six (6) is inserted or if left blank, this will not qualify as an Enhanced Matching Contribution Formula and the ADP test will apply], plus

  

	 	 ̈       b.	_________% of the Participant’s Elective Deferrals that exceed _________% of the Participant’s Compensation but do not exceed _________%
of the Participant’s Compensation [insert a number that is three (3) or greater but not greater than six (6) in the second blank. Both blanks should be completed so that at any rate of Elective Deferrals, the Matching Contribution is
at least equal to the Matching Contribution receivable if the Employer were making a Basic Matching Contribution. The rate of match cannot increase as Elective Deferrals increase. If a number greater than six (6) is inserted or if left blank,
this will not qualify as an Enhanced Matching Contribution Formula and the ACP Test will apply.] 

 If an
additional discretionary Matching Contribution is made, the dollar amount of that contribution may not exceed 4% of eligible Plan Compensation. 
  

	 	 ̈     5.	Guaranteed Non-Elective Contribution Formula: The Employer shall make a Non-Elective Contribution equal to _________% (not less than 3%) of the
Compensation of each Eligible Participant. 

  

	 	 ̈     6.	Flexible Non-Elective Contribution Formula: This provision provides the Employer with the ability to amend the Plan to comply with the Safe Harbor provisions
during the Plan Year. To provide such option, the Employer must amend the Plan and indicate on Schedule C that the Safe Harbor Non-Elective Contribution (not less than 3%) will be made for the specified Plan Year. Such election must comply with all
the applicable notice requirements. 

 Additional non-Safe Harbor Contributions may be made to the Plan pursuant
to Section VI(J) hereof. Any additional contributions may be subject to nondiscrimination testing. 
  

	 	7.	Limitations on Safe Harbor Matching Contributions: If a Safe Harbor Matching Contribution is made to the Plan: 

 

	 	 ̈     a.	The Employer elects to match Safe Harbor Matching Contributions on an annual basis. 

 

	 	 ̈     b.	The Employer elects to match actual Elective Deferrals made: 

  

					
		 	17	 	401(k) NS AA #010

	 	 ̈     i.	on a payroll basis [Plan defaults to this election]. 

  

	 	 ̈     ii.	on a monthly basis. 

  

	 	 ̈     iii.	on a Plan Year quarterly basis. 

  

	 	 ̈     iv.	The Employer elects to true up Safe Harbor Matching Contributions made to the Plan on the above basis. 

If one of the Matching Contribution calculation periods at paragraph (7)(b) above is selected, Matching Contributions must be
deposited to the Plan not later than the last day of the calendar quarter next following the quarter to which they relate. 
  

	 	 ̈       c.	The Employer will only contribute the Safe Harbor Contribution to Non-Highly Compensated Employees. 

 

	x     J.	Matching Employer Contribution: 

 Do not complete this section of the Adoption Agreement if the Plan only offers a Safe Harbor Contribution. A Plan that offers both a Safe Harbor Contribution as well as an additional Employer
Contribution that is specified below, must complete both Sections VI(I) and VI(J) of this Adoption Agreement. 
 Select the
Matching Contribution Formula, Computation Period and special Limitations for each contribution type from the options listed below. Enter the letter of the option(s) selected on the lines provided. Leave the line blank if no election is required.

  

	 	 ̈	The Matching Contribution(s) selected below will be deemed an additional discretionary ACP Test Safe Harbor Matching Contribution in accordance with the selection made
at Section VI(I). The allocation of any additional Matching Contribution made by the Employer will not exceed 4% of eligible Compensation. 

  

	 	x	The Matching Contribution(s) selected below will be deemed a discretionary contribution that will be subject to nondiscrimination testing. 

 

													
	 Type of
 Contribution
	  	Matching
Contribution
(Formula 1)	  	Matching
Computation
Period	  	Limitations	  	Matching
Contribution
(Formula 2)	  	Matching
Computation
Period	  	Limitations
	 Elective Deferrals (including Roth Elective Deferrals, if applicable)
	  	c	  	h	  		  		  		  	
							
	 Voluntary After-tax
	  		  		  		  		  		  	
							
	 Required After-tax
	  		  		  		  		  		  	
							
	 403(b) Deferrals
	  		  		  		  		  		  	

 If any election is made with respect to “403(b) Deferrals” above, and if this Plan is used
to fund any Employer Contributions, Employer Contributions will be based on the Elective Deferrals made to an existing 403(b) plan sponsored by the Employer. 
 Name of corresponding 403(b) plan, as applicable: __________________________ 
  

  

					
		 	18	 	401(k) NS AA #010

 If the Matching Contribution formula selected by the Employer is 100%
vested and may not be distributed to the Participant before the earlier of the date the Participant has a severance from employment, retires, becomes disabled, attains 59 1/2, or dies, it may be treated as a Qualified Matching Contribution.

 Matching Contribution Formulas may be subject to a minimum or maximum dollar or percentage limit.

  

	 	1.	Matching Contribution Formulas: 

 Matching Contribution Formulas for Elective Deferrals and Roth Elective Deferrals: 
  

	 	a.	Percentage of Deferral Match: The Employer shall contribute to each eligible Participant’s account an amount equal to _________% (no more than 500%)
of the Participant’s Elective Deferrals up to a maximum of _________% (no more than the Annual Addition limit for the Plan Year) of Compensation or $_________ [no more than the Annual Addition limit for the Plan Year].

  

	 	b.	Uniform Dollar Match: The Employer shall contribute to each eligible Participant’s account $________ (no more than the Annual Addition limit for the
Plan Year) if the Participant contributes at least ________% (no more than 100%) of Compensation or $__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. The
Employer’s contribution will be made up to a maximum of _____% (no more than the Annual Addition limit for the Plan Year) of Compensation. 

  

	 	c.	Discretionary Match: The Employer shall have the right to make a Discretionary Matching Contribution. The Employer’s Matching Contribution shall be
determined by the Employer with respect to each Plan Year’s eligible Participants. Such contribution shall be in the amount specified and allocated as follows: As determined by the employer and communicated to employees within the time
period prescribed by law. 

  

	 	d.	Tiered Match: The Employer shall contribute to each eligible Participant’s account an amount equal to: 

________% of the first ________% (no more than 500%) of the Participant’s Compensation contributed, and 

________% of the next ________% (no more than 400%) of the Participant’s Compensation contributed, and 

________% of the next ________% (no more than 300%) of the Participant’s Compensation contributed. 

The Employer’s contribution will be made up to the [ ] greater of (may be no more than 500%) [ ] lesser of (may be no less than 1%)
_________% of Compensation, or $__________ (no more than the Annual Addition limit for the Plan Year). 
 The
percentages specified above may not increase as the rate of Elective Deferrals or Employee Contributions increase. This formula must meet Code Section 401(a)(4) and the ACP Test. 

 

	 	e.	Percentage of Compensation Match: The Employer shall contribute to each eligible Participant’s account ________% (no less than 1%) of Compensation if
the eligible Participant contributes at least ________% (no more than 100%) of Compensation. 

 The
Employer’s contribution will be made up to the [ ] greater of (may be no more than 500%) [ ] lesser of (may be no less than 1%) _________% of Compensation or $__________ (no more than the Annual Addition limit for the Plan Year).

  

					
		 	19	 	401(k) NS AA #010

 This formula must meet Code Section 401(a)(4) and the ACP Test. 

 

	 	f.	Proportionate Compensation Match: The Employer shall contribute to each eligible Participant who defers at least ________% (may be no more than
100%) of Compensation, an amount determined by multiplying such Employer Matching Contribution by a fraction, the numerator of which is the Participant’s Compensation and the denominator of which is the Compensation of all Participants eligible
to receive such an allocation. 

 The Employer’s contribution will be made up to the  ̈ greater of (may be no more than 500%)  ̈ lesser of (may be no less than 1%) _________% of Compensation or $__________ (no more than the Annual
Addition limit for the Plan Year). 
 This formula must meet Code Section 401(a)(4) and the ACP Test. 

 

	 	 ̈       g.	Catch-Up Contributions: The Employer elects to match Catch-Up Contributions under the same formula or formulas as elected above. 

In the event that an Excess Contribution is recharacterized as a Catch-up Contribution, any Matching Contribution made thereon may remain
in the Plan if the Matching Contribution Formula is not otherwise exceeded. 
 Additional Matching Contribution Formulas
for Voluntary After-tax Contributions: 
  

	 	h.	Percentage of Deferral Match: The Employer shall contribute to each eligible Participant’s account an amount equal to ______% (no less than 1%) of
the Participant’s Contribution up to a maximum of ______% (may be no more than 500%) of Compensation or $__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable].

  

	 	i.	Uniform Dollar Match: The Employer shall contribute to each eligible Participant’s account $________ (no more than the Annual Addition limit for the
Plan Year) if the Participant contributes at least ________% (may be no more than 100%) of Compensation or $________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. The
Employer’s contribution will be made up to the maximum of _____% (may be no more than 500%) of Compensation. 

  

	 	j.	Discretionary Match: The Employer shall have the right to make a Discretionary Matching Contribution. The Employer’s Matching Contribution shall be
determined by the Employer with respect to each Plan Year’s eligible Participants. Such contribution shall be in the amount specified and allocated as follows:
_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

Additional Matching Contribution Formulas for Required After-tax Contributions: 

 

	 	k.	Percentage of Deferral Match: The Employer shall contribute to each eligible Participant’s account an amount equal to ________% no less than 1%) of
the Participant’s Contribution up to a maximum of ________% (may be no more than 500%) of Compensation or $__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable].

  

	 	l.	Uniform Dollar Match: The Employer shall contribute to each eligible Participant’s account $________ (no more than the Annual Addition limit for the
Plan Year) if the Participant contributes at least _______% (may be no more than 100%) of Compensation or $__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. The
Employer’s contribution will be made up to the maximum of ______% (may be no more than 500%) of Compensation. 

  

					
		 	20	 	401(k) NS AA #010

	 	m.	Discretionary Match: The Employer shall have the right to make a Discretionary Matching Contribution. The Employer’s Matching Contribution shall be
determined by the Employer with respect to each Plan Year’s eligible Participants. Such contribution shall be in the amount specified and allocated as follows: 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

Additional Matching Contribution Formulas for 403(b) Deferrals: 

 

	 	n.	Percentage of Deferral Match: The Employer shall contribute to each eligible Participant’s account an amount equal to ________% (no less than 1%) of
the Participant’s deferral up to a maximum of ________% (may be no more than 500%) of Compensation or $__________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable].

  

	 	o.	Uniform Dollar Match: The Employer shall contribute to each eligible Participant’s account $________ (no more than the Annual Addition limit for the
Plan Year) if the Participant contributes at least ______% (may be no more than 100%) of Compensation or $___________ [may be no more than the Code Section 402(g) limit and Code Section 414(v) limit, if applicable]. The
Employer’s contribution will be made up to the maximum of ______% (may be no more than 500%) of Compensation. 

  

	 	p.	Discretionary Match: The Employer shall have the right to make a Discretionary Matching Contribution. The Employer’s Matching Contribution shall be
determined by the Employer with respect to each Plan Year’s eligible Participants. Such contribution shall be in the amount specified and allocated as follows: 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

 

	 	2.	Matching Contribution Computation Period: The Compensation or any dollar limitation imposed in calculating the Matching Contribution will be based on the period
selected below. Matching Contributions will be calculated on the following basis: 

  

							
	  a.	  	Payroll Based	  	e.	  	Monthly
	  b.	  	Weekly	  	f.	  	Quarterly
	  c.	  	Bi-weekly	  	g.	  	Semi-annually
	  d.	  	Semi-monthly	  	h.	  	Annually

 The calculation of Matching
Contributions based on the Computation Period selected above has no applicability as to when the Employer remits Matching Contributions to the Trust. 
  

	 	3.	Limitations on Matching Formulas: 

  

	 	a.	Contributions to Participants who are not Highly Compensated Employees: Contribution of the Employer’s Matching Contribution will be made only to eligible
Participants who are Non-Highly Compensated Employees. 

  

	 	b.	Deferrals withdrawn prior to the end of the Matching Computation Period: Matching Contributions (whether or not Qualified) will not be made on Employee
contributions withdrawn prior to the end of the  ̈ Matching Computation Period, or  ̈ Plan Year. 

 

	 	 ̈	If elected, this requirement shall apply in the event of a withdrawal occurring as the result of a termination of employment for reasons of retirement, Disability or
death. 

  

					
		 	21	 	401(k) NS AA #010

	 	c.	Maximum Plan Limit for Matching Contributions: In no event will Matching Contributions exceed ______% (no more than 500%) of Compensation, or
$_______ (no more than the Annual Addition limit for the Plan Year). 

  

	 	 ̈	If elected, this limitation applies to the total of all Elective Deferrals, Roth Elective Deferrals, Catch-Up Contributions, Voluntary After-tax Contributions, Required
After-tax Contributions and 403(b) Deferrals made to the Plan for the Plan Year. 

  

	 	d.	True Up of Matching Contributions: The Employer elects to true up Matching Contributions made to the Plan. 

 

	x     K.	Non-Elective Employer Contributions: 

 The Employer shall have the right to make a discretionary contribution. If a discretionary contribution is made, the Employer’s contribution for the Plan Year shall be allocated to the accounts of
eligible Participants as follows (enter the number of the allocation method being used by the Plan): 
  

			
	 Type of Contribution
	  	Allocation Method
	 Non-Elective Formula 1
	  	1
	 Non-Elective Formula 2
	  	

  

	 	1.	Pro-Rata Formula: The Employer’s contribution for the Plan Year shall be allocated to each eligible Participant on a pro-rata basis based on the
Compensation of the Participant to the total Compensation of all Participants. 

  

	 	2.	Uniform Percentage Formula: The Employer’s contribution shall be allocated to each eligible Participant as a uniform percentage of the Employer’s Net
Profit. 

  

	 	3.	Percentage of Compensation Formula: The Employer’s contribution shall be ______% of each Participant’s Compensation allocated on a pro-rata
basis based on the Compensation of the Participant to the total Compensation of all Participants. 

  

	 	4.	Hours of Service Formula: The Employer’s contribution shall be a discretionary amount allocated in the same dollar amount to each eligible Participant based
on each Hour of Service performed or each day that the Participant is entitled to Compensation. 

  

	 	5.	Uniform Dollar Amount Formula: The Employer shall contribute and allocate to the account of each eligible Participant an equal dollar amount. 

  

	 	6.	Excess Integrated Contribution Formula: The Employer’s contribution shall be allocated as an amount taking into consideration amounts contributed to Social
Security using the four-step Excess Integrated Allocation Formula as described in the Basic Plan Document #01; the Integration Level is defined at Section III(E) of this Adoption Agreement. 

 

	 	7.	Base Integrated Contribution Formula: The Employer’s contribution shall be allocated as an amount taking into consideration amounts contributed to Social
Security using the two-step Base Integrated Allocation Formula as described in the Basic Plan Document #01; Employer Contributions shall be allocated as follows: _____% of each eligible Participant’s Compensation, plus _____% of Compensation in
excess of the Integration Level defined at Section III(E) hereof. If the Integration Level selected in Section III(E) is other than the Taxable Wage Base, the maximum disparity rate will be adjusted as follows: (a) if the Integration Level
selected is greater than zero (0) but not more than the greater of $10,000 or 20% of the Taxable Wage Base, the maximum disparity rate will be 5.7%; (b) if the Integration Level selected is more than the greater of $10,000 or 20% but not
more than 80% of the Taxable Wage Base, the maximum disparity rate will be 4.3%; (c) if the Integration Level selected is more than 80% of the Taxable Wage Base, but not more than any amount more than 80% of the Taxable Wage Base, but less than
100% of the Taxable Wage Base, the maximum disparity rate will be 5.4%. 

  

  

					
		 	22	 	401(k) NS AA #010

 Only one Plan maintained by the Employer may be integrated with Social Security. Any
Plan utilizing a Safe Harbor formula as provided in Section VI(I) of this Adoption Agreement may not apply the Safe Harbor Contributions to the integrated allocation formula. 

 

	 	8.	Uniform Points Contribution Formula: The allocation for each eligible Participant will be determined by a uniform points method. Each eligible Participant’s
allocation shall bear the same relationship to the Employer contribution as the Participant’s total points bears to all points awarded. The Employer must grant points for at least age or Service. Each eligible Participant will receive
_____ points for each of the following: 

  

	 	 ̈       a.	_____ year(s) of age. 

  

	 	 ̈       b.	_____ Year(s) of Service determined: 

  

	 	 ̈     i.	In the same manner as determined for eligibility. 

  

	 	 ̈     ii.	In the same manner as determined for vesting. 

  

	 	 ̈     iii.	Points will not be awarded with respect to Year(s) of Service in excess of _____. 

 

	 	 ̈       c.	$_________ (not to exceed $200) of Compensation. 

 The contribution formulas must satisfy the design-based safe harbors described in the Regulations under Code Section 401(a)(4). 

 

	 	L.	Qualified Matching (QMAC) and Qualified Non-Elective (QNEC) Employer Contribution Formulas: 

 

	 	 ̈     1.	QMAC Contribution Formula: The Employer may contribute to each eligible Participant’s Qualified Matching Contribution account an amount equal to (select
one or more of the following): 

  

	 	 ̈       a.	$_________ or ______% of the Participant’s Elective Deferrals (including Roth Elective Deferrals, if applicable). 

 

	 	 ̈       b.	$_________ or ______% of the Participant’s Elective Deferrals (including Roth Elective Deferrals, if applicable) not to exceed ______% of
Compensation. 

  

	 	 ̈       c.	$_________ or ______% of the Participant’s Voluntary After-tax Contributions. 

 

	 	 ̈       d.	$_________ or ______% of the Participant’s Required After-tax Contributions. 

  

					
		 	23	 	401(k) NS AA #010

	 	x     2.	Discretionary QMAC Contribution Formula: The Employer shall have the right to make a discretionary QMAC contribution. The Employer’s Matching Contribution
shall be determined by the Employer with respect to each Plan Year’s eligible Participants. Such contribution shall be in the amount specified and allocated as follows: As determined by the employer and communicated to employees within the
time period prescribed by law. 

 This part of the Employer’s contribution shall be fully vested when
made. 
  

	 	 ̈     3.	QNEC Contribution Formula: The Employer may contribute to each eligible Participant’s Qualified Non-Elective Contribution account an amount equal to (select
one or more of the following): 

  

	 	 ̈       a.	_____% of Compensation of all eligible Participants. This part of the Employer’s contributions shall be fully vested when made. 

 

	 	 ̈       b.	$__________ not to exceed ___% of Compensation. This part of the Employer’s contribution shall be fully vested when made and subject to the
limitations specified in the Basic Plan Document #01. 

  

	 	 ̈     4.	Discretionary Percentage QNEC Contribution Formula: The Employer shall have the right to make a discretionary QNEC contribution which shall be allocated to each
eligible Participant’s account in proportion to his or her Compensation as a percentage of the Compensation of all eligible Participants. This part of the Employer’s contribution shall be fully vested when made. This contribution will be
made to: 

  

	 	 ̈       a.	All eligible Participants. 

  

	 	 ̈       b.	Only eligible Participants who are Non-Highly Compensated Employees. 

  

	 	 ̈     5.	Discretionary Uniform Dollar QNEC Contribution Formula: The Employer shall have the right to make a discretionary QNEC contribution which shall be allocated to
each eligible Participant’s account in a uniform dollar amount to be determined by the Employer and allocated in a nondiscriminatory manner. This part of the Employer’s contribution shall be fully vested when made. This contribution will
be made to: 

  

	 	 ̈       a.	All eligible Participants. 

  

	 	 ̈       b.	Only eligible Participants who are Non-Highly Compensated Employees. 

  

	 	x     6.	Corrective QNEC Contribution Formula: The Employer shall have the right to make a QNEC contribution in the amount necessary to pass the ADP/ACP Test or the
maximum permitted under Code Section 415. This contribution will be allocated to some or all Non-Highly Compensated Participants designated by the Plan Administrator. The allocation will be the lesser of the amount required to pass the ADP/ACP
Test, or the maximum permitted under Code Section 415. This part of the Employer’s contribution shall be fully vested when made. 

  

	 	 ̈     7.	Qualified Matching Contributions (QMAC):  

  

	 	 ̈       a.	For purposes of the ADP and ACP Tests, all Matching Contributions made to the Plan will be deemed “Qualified” for purposes of calculating the Actual Deferral
Percentage and/or Actual Contribution Percentage. All Matching Contributions must be fully vested when made. 

  

	 	 ̈       b.	For purposes of the ADP and ACP Tests, only Matching Contributions made to the Plan that are needed to meet the Actual Deferral Percentage or Actual Contribution
Percentage Test will be deemed “Qualified” for purposes of calculating the Actual Deferral Percentage and/or Actual Contribution Percentage. All such Matching Contributions used must be fully vested when made. 

  

					
		 	24	 	401(k) NS AA #010

	 	 ̈     8.	Qualified Non-Elective Contributions (QNEC):  

  

	 	 ̈       a.	For purposes of the ADP and ACP Tests, all Non-Elective Contributions made to the Plan will be deemed “Qualified” for purposes of calculating the Actual
Deferral Percentage and/or Actual Contribution Percentage. All Non-Elective Contributions must be fully vested when made. 

  

	 	 ̈       b.	For purposes of the ADP and ACP Tests, only the Non-Elective Contributions made to the Plan that are needed to meet the Actual Deferral Percentage or Actual
Contribution Percentage Test will be deemed “Qualified” for purposes of calculating the Actual Deferral Percentage and/or Actual Contribution Percentage. All such Non-Elective Contributions used must be fully vested when made.

  

	 ̈     M.	Additional Adopting Employers: 

  

	 	 ̈     1.	All participating Employers’ contributions and forfeitures, if applicable, attributable to each specific contribution source made by such Employer shall be pooled
together and allocated uniformly among all eligible Participants. 

  

	 	 ̈     2.	Each participating Employer’s contribution and forfeitures, if applicable, attributable to each specific contribution source made by such Employer shall be
allocated only to eligible Participants of the participating Employer. 

 Where contributions and forfeitures
are to be allocated to eligible Participants by participating Employers, each such Employer must maintain data demonstrating that the allocations by group satisfy the nondiscrimination rules under Code Section 401(a)(4). 

 

	VII.	ALLOCATIONS TO PARTICIPANTS 

  

	 	A.	Allocation Accrual Requirements: 

 No Hours of Service or last day requirement may be imposed on any Employer contribution that is subject to the Safe Harbor Plan rules. 

 

	 	x       1.	There are no allocation requirements for Participants to receive any contribution made to the Plan; however, a Participant must have received Compensation from the
Employer to be entitled to an allocation of contributions. 

  

	 	 ̈       2.	Employer contributions will be allocated to all Participants employed on the last day of the Plan Year regardless of hours worked. 

 

	 	 ̈       3.	The Plan is using the Elapsed Time method; contributions will be allocated to all Participants who have completed _____ [not more than twelve (12)] months of
Service regardless of the hours credited. If left blank, the Plan will use twelve (12) months. 

  

	 	 ̈       4.	Employer contributions for a Plan Year will be allocated to all Participants upon completion of the hours and/or employment requirements below.

  

	 	a.	A Year of Service for allocation accrual purposes cannot be less than one (1) Hour of Service nor greater than 1,000 hours by operation of law. If left blank, the
Plan will use 1,000 hours. Enter whole digit numbers only.  

  

					
	 Contribution Type
	  	Hours	 
	 All contributions
	  			
	 Matching Contribution (Formula 1)
	  			
	 Matching Contribution (Formula 2)
	  			
	 Non-Elective Contribution (Formula 1)
	  			
	 Non-Elective Contribution (Formula 2)
	  			
	 QNEC
	  			
	 QMAC
	  			

  

					
		 	25	 	401(k) NS AA #010

	 	b.	Participants must be employed on the last day of each quarter of the Plan Year in order to receive the following contribution(s): 

 

	 	 ̈	All contributions 

  

	 	 ̈	Matching Contribution (Formula 1) 

  

	 	 ̈	Matching Contribution (Formula 2) 

  

	 	 ̈	Non-Elective Contribution (Formula 1) 

  

	 	 ̈	Non-Elective Contribution (Formula 2) 

  

	 	 ̈	QNEC 

  

	 	 ̈	QMAC 

 Note: Use of this
subsection (b) requires that no more than one (1) Hour of Service be required in subsection (a) above for the contribution types selected. 
  

	 	c.	Participants must be employed on the last day of the Plan Year in order to receive the following contribution(s): 

 

	 	 ̈	All contributions 

  

	 	 ̈	Matching Contribution (Formula 1) 

  

	 	 ̈	Matching Contribution (Formula 2) 

  

	 	 ̈	Non-Elective Contribution (Formula 1) 

  

	 	 ̈	Non-Elective Contribution (Formula 2) 

  

	 	 ̈	QNEC 

  

	 	 ̈	QMAC 

  

	 	 ̈       d.	Participants must complete the Hours of Service indicated above or be employed on the last day of the Plan Year to receive the Employer Contribution(s) selected
above. 

  

	 	5.	Employer Contributions for a Plan Year will be allocated to terminated Participants who have met the following allocation accrual requirements (check all applicable
boxes): 

  

															
	 	  	All
Contributions	  	Match
Formula 1	  	Match
Formula 2	  	Non-Elective
Formula 1	  	Non-Elective
Formula 2	  	QNEC	  	QMAC
	
	 a.      The Hours of Service or Period of
Service requirement above will
be
waived if termination is due to:

								
	 i.       Retirement
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 ii.      Disability
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 iii.    Death
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 iv.     Other (must be non-Discriminatory
in operation):
	  		  		  		  		  		  		  	
								
	 —
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
	
	 b.      The last day of employment
requirement above will be
waived if
termination is due to:

								
	 i.       Retirement
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 ii.      Disability
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 iii.    Death
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
								
	 iv.     Other (must be non-Discriminatory in
operation):
	  		  		  		  		  		  		  	
								
		  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈

  

	 ̈     B.	Contributions to Disabled Participants: 

 The Employer will make contributions on behalf of a Participant who is permanently and totally disabled. These contributions will be based on the Compensation each such Participant would have received for
the Limitation Year if the Participant had been paid at the rate of Compensation 

  

					
		 	26	 	401(k) NS AA #010

 
paid immediately before becoming permanently and totally disabled. Such imputed Compensation for the disabled Participant may be taken into account only if the Participant is not a Highly
Compensated Employee. These contributions will be 100% vested when made. 
  

	VIII.    DISPOSITION	OF FORFEITURES 

  

	 	A.	Forfeiture Allocation Alternatives: 

  

	 	 ̈     1.	Not applicable; all contributions are fully vested. 

  

	 	x     2.	Select one or more methods in which forfeitures associated with the contribution type will be allocated (number each item in order of use):

  

					
	 	  	Employer Contribution Type
	 Disposition Method
	  	All Non-Safe Harbor
Matching Contributions	  	All Other
Contributions
			
	 a.      Restoration of Participant’s forfeitures.
	  		  	
			
	 b.      Used to offset Plan expenses.
	  		  	
			
	 c.      Used to reduce the Employer’s Non-Elective Contribution.
	  		  	1
			
	 d.      Used to reduce the Employer’s Matching Contribution.
	  	1	  	
			
	 e.      Added to the Employer’s contribution (other than Matching Contributions or Base
Integration Formula) under the Plan.
	  		  	
			
	 f.       Added to the Employer’s Matching Contribution under the Plan (these
contributions will be subject to ACP Testing).
	  		  	
			
	 g.      Allocate to all Participants eligible to share in the allocations in the same proportion
that each Participant’s Compensation for the year bears to the Compensation of all other Participant’s for such year.
	  	N/A	  	
			
	 h.      Allocate to all NHCEs eligible to share in the allocations in proportion to each such
Participant’s Compensation for the year.
	  	N/A	  	
			
	 i.       Allocate to all NHCEs eligible to share in the allocations in proportion to each such
Participant’s Elective Deferrals for the year.
	  		  	N/A
			
	 j.       Allocate to all Participants eligible to share in the allocations in the same
proportion that each Participant’s Elective Deferrals for the year bears to the Elective Deferrals of all Participants for such year.
	  		  	N/A

 Participants eligible
to share in the allocation of other Employer contributions under Section VI shall be eligible to share in the allocation of forfeitures. The selection of (i) or (j) may require that the Plan be tested for nondiscrimination using a general
test described in Regulations Section 1.410(b). 

  

					
		 	27	 	401(k) NS AA #010

	 	B.	Timing of Allocation of Forfeitures: 

 If no timely distribution or deemed distribution [pursuant to paragraph 6.5(c) of the Basic Plan Document #01] has been made to a former Participant, non-vested portions shall be forfeited at the end of
the Plan Year during which the former Participant incurs his or her fifth consecutive one (1) year Break in Service or Period of Severance for Plans that use the Elapsed Time Method. 

If a former Participant has received the full amount of his or her Vested Account Balance, the non-vested portion of his or her account
shall be forfeited and be disposed of: 
  

	 	 ̈     1.	during the Plan Year following the Plan Year in which the forfeiture arose. 

 

	 	 ̈     2.	as of any Valuation or Allocation Date during the Plan Year (or as soon as administratively feasible following the close of the Plan Year) in which the former
Participant receives full payment of his or her vested benefit. 

  

	 	x     3.	as of the end of the Plan Year during which the former Participant receives full payment of his or her vested benefit. 

 

	 	 ̈     4.	as of the earlier of the first day of the Plan Year, or the first day of the seventh month of the Plan Year following the date on which the former Participant has
received full payment of his or her vested benefit. 

  

	 	 ̈     5.	as of the next Valuation or Allocation Date following the date on which the former Participant receives full payment of his or her vested benefit.

  

	IX.	MULTIPLE PLANS MAINTAINED BY THE EMPLOYER AND TOP-HEAVY CONTRIBUTIONS 

 

	 ̈     A.	Plans Maintained By The Employer: 

 The Employer does maintain another Plan [including a Welfare Benefit Fund or an individual medical account as defined in Code Section 415(l)(2)], under which amounts are treated as Annual Additions
and has completed the proper sections below. If the Participant is covered under another qualified Defined Contribution Plan maintained by the Employer, other than a Master or Prototype Plan [option (1) below shall automatically apply if the
other plan is a Master or Prototype Plan]: 
  

	 	 ̈     1.	The provisions of Article X of the Basic Plan Document #01 will apply as if the other plan were a Master or Prototype Plan. 

 

	 	 ̈     2.	The Employer has specified below the method under which the plans will limit total Annual Additions to the Maximum Permissible Amount, and will properly reduce any
Excess Amounts in a manner that precludes Employer discretion: 

	 	________________________________________________________________________ 

  

	 	B.	Top-Heavy Provisions: 

 In
the event the Plan is or becomes Top-Heavy, the minimum contribution or benefit required under Code Section 416 and paragraph 14.3 of the Basic Plan Document #01 relating to Top-Heavy Plans shall be satisfied in the elected manner: 

 

	 	x     1.	The minimum contribution will be satisfied by this Plan. 

  

	 	 ̈     2.	The minimum contribution will be satisfied by (name of other Qualified Plan): ________ 

Minimum contribution or benefit to be provided (specify interest rates and mortality table, if applicable): ________ 

 

	 	3.	For any Plan Year during which the Plan is Top-Heavy, the sum of the contributions (excluding Elective Deferrals) allocated to non-Key Employees shall not be less than
the amount required under the Basic Plan Document #01. Top-Heavy minimums will be allocated to: 

  

	 	 ̈       a.	all eligible Participants [Plan defaults to this election]. 

  

					
		 	28	 	401(k) NS AA #010

	 	x       b.	only eligible non-Key Employees who are Participants. 

  

	 	 ̈     4.	Matching Contributions shall not be included when satisfying Top-Heavy minimum contributions. 

 

	X.	NONDISCRIMINATION TESTING 

 A Plan may use different testing methods for the ADP and ACP Tests provided the Plan does not permit recharacterization of Excess Contributions, Elective Deferrals to be used in the ACP Test, or Qualified
Matching Contributions to be used in the ADP Test. 
 If no election is made, the Plan will use the Current Year testing
method for both the ADP and ACP Tests. 
  

	 	A.	Testing Elections: 

  

	 	 ̈     1.	The Plan is not subject to ADP or ACP testing. The Plan does not offer Voluntary After-tax or Required After-tax Contributions and it either meets the Safe Harbor
provisions of Section VI(I) of this Adoption Agreement, or it does not benefit any Highly Compensated Employees. 

  

	 	 ̈     2.	This Plan is using the Current Year testing method for purposes of the ADP Test. 

 

	 	 ̈     3.	This Plan is using the Current Year testing method for purposes of the ACP Test. 

 

	 	x     4.	This Plan is using the Prior Year testing method for purposes of the ADP Test. 

 

	 	x     5.	This Plan is using the Prior Year testing method for purposes of the ACP Test. 

 

	 	B.	Testing Elections for the First Plan Year: 

 Complete only when Prior Year testing method election is made and the Employer is not using the “deemed 3%” rule. 

 

	 	 ̈     1.	If this is not a successor Plan, then for the first Plan Year this Plan permits any Participant to make Elective Deferrals, the ADP used in the ADP Test for
Participants who are Non-Highly Compensated Employees shall be such first Plan Year’s ADP. 

  

	 	 ̈     2.	If this is not a successor Plan, then for the first Plan Year this Plan permits (a) any Participant to make Employee contributions, (b) provides for Matching
Contributions or (c) both, the ACP used in the ACP Test for Participants who are Non-Highly Compensated Employees shall be such first Plan Year’s ACP. 

 

	 ̈     C.	Recharacterization: 

Elective Deferrals may be recharacterized as Voluntary After-tax Contributions to the extent so provided by this Plan, to satisfy the ADP
Test. The Employer must have elected to permit Voluntary After-tax Contributions in the Plan for this election to be operable. 
  

	 ̈     D.	Forfeitures of Vested Excess Aggregate Contributions Resulting from ADP Test Failure: 

Forfeitures of Excess Aggregate Contributions resulting from failure of the ADP Test and the inability to distribute corresponding
Matching Contributions will be allocated to the Matching Contribution accounts of Non-Highly Compensated Employees instead of being used to reduce Employer Contributions for the Plan Year in which the failure occurred. 

  

					
		 	29	 	401(k) NS AA #010

	XI.	VESTING 

Participants shall always have a fully vested and nonforfeitable interest in their Employee contributions (including Elective Deferrals,
Catch-Up Contributions, Roth Elective Deferrals, Deemed IRA Contributions, Required After-tax Contributions, and Voluntary After-tax Contributions), Qualified Matching Contributions (“QMACs”), Qualified Non-Elective Contributions
(“QNECs”) or Safe Harbor Contributions, and their investment earnings. 
 Each Participant shall acquire a vested and
nonforfeitable percentage in his or her account balance attributable to Employer contributions and their earnings under the schedule(s) selected below. 
  

	 	A.	Vesting Computation Period: 

 A Year of Service for vesting will be determined on the basis of the (choose one): 
  

	 	 ̈     1.	Not applicable. All contributions are fully vested. 

  

	 	 ̈     2.	Elapsed Time method. 

  

	 	x     3.	Hours of Service method. A Year of Service will be credited upon completion of 500 Hours of Service. A Year of Service for vesting purposes will not be less than
one (1) Hour of Service nor greater than 1,000 hours by operation of law. [If left blank, the Plan will use 1,000 hours.] 

 The computation period for purposes of determining Years of Service and Breaks in Service for purposes of computing a Participant’s nonforfeitable right to his or her account balance derived from
Employer contributions: 
  

	 	 ̈       a.	shall commence on the date on which an Employee first performs an Hour of Service for the Employer and each subsequent twelve (12) consecutive month period shall
commence on the anniversary thereof. 

  

	 	x       b.	shall commence on the first day of the Plan Year during which an Employee first performs an Hour of Service for the Employer and each subsequent twelve
(12) consecutive month period shall commence on the anniversary thereof. 

 A Participant shall receive
credit for a Year of Service if he or she completes the number of hours specified above at any time during the twelve (12) consecutive month computation period. A Year of Service may be earned prior to the end of the twelve
(12) consecutive month computation period and the Participant need not be employed at the end of the twelve (12) consecutive month computation period to receive credit for a Year of Service. 

 

	 	B.	Vesting Schedules: 

The Employer must select either the two-twenty vesting schedule option [(B)(4)] or the three-year cliff vesting schedule [(B)(3)] to
apply in any Plan Year in which the Plan is Top-Heavy. The percentages selected for option (B)(5) may not be less for any year than the percentages shown at option (B)(4). Any switch to a Top-Heavy schedule will remain in effect even if the Plan
later falls out of Top-Heavy status unless the Employer executes an amendment to this Adoption Agreement. If a Participant has at least three (3) Years of Service for vesting purposes at the time of the amendment, the Plan must provide that
Participant the option of remaining on the vesting schedule in effect prior to such amendment. 
 Select the appropriate
schedule for each contribution type and complete the blank vesting percentages from the list below and insert the option number in the vesting schedule chart below. Employer Contributions that are not Safe Harbor Contributions may only choose option
(3) or (4) or a schedule where amounts vest faster than at option (4). 

  

					
		 	30	 	401(k) NS AA #010

																											
	 	    	Years of Service	 	 	 
	 	    	1	 	 	2	 	 	3	 	 	4	 	 	5	 	 	6	 	 	 
		
	 1.
	    	 	Full and immediate Vesting
								
	 2.
	    	 	___	% 	 	 	100	% 	 				 				 				 				 	
								
	 3.
	    	 	0	% 	 	 	0	% 	 	 	100	% 	 				 				 				 	
								
	 4.
	    	 	___	% 	 	 	20	% 	 	 	40	% 	 	 	60	% 	 	 	80	% 	 	 	100	% 	 	
								
	 5.
	    	 	___	% 	 	 	___	% 	 	 	___	% 	 	 	___	% 	 	 	___	% 	 	 	100	% 	 	

  

			
	 Vesting Schedule Chart
	  	 Employer Contribution Type

		
	3	  	All Employer Contributions
		
		  	Matching Contribution (Formula 1)
		
		  	Matching Contribution (Formula 2)
		
		  	Match on Voluntary After-tax Contributions
		
		  	Match on Required After-tax Contributions
		
		  	Match on 403(b) Deferrals
		
		  	Non-Elective Contribution (Formula 1)
		
		  	Non-Elective Contribution (Formula 2)
		
	3	  	Top-Heavy Minimum Contribution

 If a
different Vesting Schedule than that entered above applies to Employer Contributions made prior to the first day of the Plan’s 2007 Plan Year, it should be entered in Schedule B of this Adoption Agreement. 

 

	 	C.	Service Disregarded for Vesting: 

  

	 	 ̈     1.	Not applicable. All Service is recognized. 

  

	 	 ̈     2.	Service prior to the Effective Date of this Plan or a predecessor plan is disregarded when computing a Participant’s vested and nonforfeitable interest.

  

	 	x     3.	Service prior to a Participant having attained age eighteen (18) is disregarded when computing a Participant’s vested and nonforfeitable interest.

  

	 ̈     D.	Full Vesting of Employer Contributions for Current Participants: 

 Notwithstanding the elections above, all Employer contributions made to a Participant’s account shall be 100% fully vested if the Participant is employed on the Effective Date of the Plan (or such
other date as entered herein): _________________. The operation of this provision may not result in the discrimination in favor of Highly Compensated Employees. 
  

	XII.	SERVICE WITH PREDECESSOR ORGANIZATION 

 This option only applies in the situation where the Employer does not or did not maintain the plan of a Predecessor Organization. 

 

	 ̈     A.	Not applicable. The Employer does not maintain the plan of a Predecessor Organization. 

 

	 ̈     B.	The Plan will recognize Service with all Predecessor Organizations. 

  

					
		 	31	 	401(k) NS AA #010

	x     C.	Service with the following organization(s) will be recognized for the Plan purpose indicated: 

 

							
	 	  	Eligibility	  	Allocation
Accrual	  	Vesting
				
	Perpetual Federal Savings & Loan Association	  	x	  	x	  	x
				
	Progressive Federal Savings Bank	  	x	  	x	  	x
				
	Integra Bank N.A.-Milan Branch	  	x	  	x	  	x
				
	Integra Bank N.A.-Osgood Branch	  	x	  	x	  	x
				
	Integra Bank N.A.-Versailles Branch	  	x	  	x	  	x

 Attach additional pages as necessary. 
  

	 ̈     D.	The Plan shall recognize _____ Years of Service with the Employer(s) named in Section XII(C) above. 

 

	XIII.    IN-SERVICE	WITHDRAWALS 

 Distribution restrictions apply in the case of Elective Deferrals (including Roth Elective Deferrals, if applicable), Safe Harbor Contributions, Qualified Matching Contributions and Qualified Non-Elective
Contributions, including the withdrawal restrictions prior to attainment of age 59 1/2. 
 If the Participant could withdraw his or her account in the past,
this right may not be taken away. 
  

	 	A.	In-Service Withdrawals: 

  

	 	 ̈     1.	In-service withdrawals are not permitted in the Plan. 

  

	 	x     2.	In-service withdrawals are permitted in the Plan. Participants may withdraw the following contribution types after meeting the following requirements (select one or
more of the following options): 

  

																	
	 	  	Withdrawal Restrictions
	 Contribution Types
	  	A	  	B	  	C	  	D	  	E	  	F	  	G	  	H
									
	 a.      All Contributions
	  	n/a	  	n/a	  	n/a	  	x	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 b.      Elective Deferrals
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 c.      Roth Elective Deferrals
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 d.      Voluntary After-tax Contributions
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 e.      Required After-tax Contributions
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 f.       Rollover Contributions
	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 g.      Vested Matching (Formula 1)
	  	 ̈	  	n/a	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
									
	 h.      Vested Matching (Formula 2)
	  	 ̈	  	n/a	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
									
	 i.       Vested Non-Elective (Formula 1)
	  	 ̈	  	n/a	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
									
	 j.       Vested Non-Elective (Formula 2)
	  	 ̈	  	n/a	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈	  	 ̈
									
	 k.      Safe Harbor Matching
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 l.       Safe Harbor Non-Elective
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a

  

					
		 	32	 	401(k) NS AA #010

																	
									
	 m.     Qualified Non-Elective
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a
									
	 n.      Qualified Matching
	  	 ̈	  	n/a	  	n/a	  	 ̈	  	 ̈	  	n/a	  	n/a	  	n/a

 Withdrawal
Restriction Key 
  

	 	A.	Not available for in-service withdrawals. 

  

	 	B.	Available for in-service withdrawals without restrictions. 

  

	 	C.	Participants having completed five (5) years of Plan participation may elect to withdraw all or any part of their Vested Account Balance. 

 

	 	D.	 Participants may withdraw all or any part of their Account Balance after having attained the Plan’s Normal Retirement Age (Normal Retirement Age
cannot be less than age 59 1/2 for in-service
withdrawal of Elective Deferrals, Roth Elective Deferrals, Safe Harbor Contributions, QMACs or QNECs). 

  

	 	E.	 Participants may withdraw all or any part of their Vested Account Balance after having attained age ______ (not less than age 59 1/2). 

 

	 	F.	Participants may elect to withdraw all or any part of their Vested Account Balance which has been credited to their account for a period in excess of two
(2) years. 

  

	 	G.	Available for withdrawal only if the Participant is 100% vested (an election at (C), (D), (E) or (F) must also be made). 

 

	 	H.	All requirements selected in (C) through (G) above must be satisfied prior to a distribution being made from the Plan. 

 

	 	 ̈   3.	 In-service withdrawals may be made to Participants who have attained age 70 1/2. 

 

	 	B.	Hardship Withdrawals: 

 Prior to age 59 1/2, a Participant may withdraw balances attributable to Elective Deferrals (including Roth Elective Deferrals, if applicable) for reason of Hardship only. Safe Harbor Contributions, Qualified Matching
Contributions, and Qualified Non-Elective Contributions are not available for Hardship distributions. 
  

	 	 ̈     1.	Hardship withdrawals are not permitted in the Plan. 

  

	 	x     2.	Hardship withdrawals are permitted in the Plan and will be taken from the Participant’s account as follows (select one or more of these options): 

  

	 	x       a.	Participants may withdraw Elective Deferrals. 

  

	 	 ̈       b.	Participants may withdraw Elective Deferrals and any earnings credited as of December 31, 1988 (or if later, the end of the last Plan Year ending before
July 1, 1989). 

  

	 	 ̈       c.	Participants may withdraw Roth Elective Deferrals. 

  

	 	x       d.	Participants may withdraw Rollover Contributions plus their earnings. 

  

	 	x       e.	Participants may withdraw vested Non-Elective Contributions (Formula 1) plus their earnings. 

 

	 	 ̈       f.	Participants may withdraw vested Non-Elective Contributions (Formula 2) plus their earnings. 

 

	 	 ̈       g.	Participants may withdraw fully vested Non-Elective Contributions (Formula 1) plus their earnings. 

  

					
		 	33	 	401(k) NS AA #010

	 	 ̈       h.	Participants may withdraw fully vested Non-Elective Contributions (Formula 2) plus their earnings. 

 

	 	x       i.	Participants may withdraw vested Employer Matching Contributions (Formula 1) plus their earnings. 

 

	 	 ̈       j.	Participants may withdraw vested Employer Matching Contributions (Formula 2) plus their earnings. 

 

	 	 ̈       k.	Participants may withdraw Qualified Matching Contributions and Qualified Non-Elective Contributions plus their earnings, and the earnings on Elective Deferrals which
have been credited to the Participant’s account as of December 31, 1988 (or if later, the end of the last Plan Year ending before July 1, 1989). 

 

	XIV.    LOAN	PROVISIONS 

  

	 ̈     A.	Participant loans are not available from the Plan. 

  

	x     B.	Participant loans are permitted in accordance with the Employer’s established loan procedures. 

 

	x     C.	Loan payments will be suspended under the Plan as permitted under Code Section 414(u) in compliance with the Uniformed Services Employment and Reemployment Rights
Act of 1994. 

  

	XV.    INVESTMENT	MANAGEMENT 

  

	 	A.	Investment Management Responsibility: 

  

	 	 ̈     1.	The Employer shall appoint a discretionary Trustee to manage the assets of the Plan. 

 

	 	 ̈     2.	The Employer shall retain investment management responsibility and/or authority. Unless otherwise appointed, the Trustee shall act in a nondiscretionary capacity.

  

	 	x     3.	The party designated below shall be responsible for the investment of the Participant’s account. By selecting a box, the Employer is making a designation as to who
will have authority to issue investment directives with respect to the specified contribution type (check all applicable boxes): 

  

							
	 	  	Trustee	  	Employer	  	Participant
				
	 a.      All Contributions
	  	n/a	  	n/a	  	x
				
	 b.      Elective Deferrals/Roth Elective Deferrals
	  	 ̈	  	 ̈	  	 ̈
				
	 c.      Voluntary After-tax Contributions
	  	 ̈	  	 ̈	  	 ̈
				
	 d.      Required After-tax Contributions
	  	 ̈	  	 ̈	  	 ̈
				
	 e.      Safe Harbor Contributions
	  	 ̈	  	 ̈	  	 ̈
				
	 f.       Matching Contributions (Formula 1)
	  	 ̈	  	 ̈	  	 ̈
				
	 g.      Matching Contributions (Formula 2)
	  	 ̈	  	 ̈	  	 ̈
				
	 h.      QMACs
	  	 ̈	  	 ̈	  	 ̈
				
	 i.       QNECs
	  	 ̈	  	 ̈	  	 ̈
				
	 j.       Non-Elective Contributions (Formula 1)
	  	 ̈	  	 ̈	  	 ̈
				
	 k.      Non-Elective Contributions (Formula 2)
	  	 ̈	  	 ̈	  	 ̈
				
	 l.       Rollover Contributions
	  	 ̈	  	 ̈	  	 ̈
				
	 m.     Deemed IRA Contributions
	  	 ̈	  	 ̈	  	 ̈

  

					
		 	34	 	401(k) NS AA #010

 To the extent that Participant self-direction was previously permitted, the Employer
shall have the right to either make the assets part of the general fund, or leave them as self-directed subject to the provisions of the Basic Plan Document #01. 
  

	 	B.	Limitations on Participant Directed Investments: 

  

	 	x     1.	Participants are permitted to invest among only those investment alternatives made available by the Employer under the Plan. 

 

	 	 ̈     2.	Participants are permitted to invest in any investment alternative permitted under the Basic Plan Document #01 

 

	 ̈     C.	Insurance: 

 The Plan
permits life insurance as an investment alternative. 
  

	XVI.    DISTRIBUTION	OPTIONS 

  

	 	A.	Timing of Distributions [both (1) and (2) must be completed]: 

 

	 	1.	Distributions payable as a result of termination for reasons other than death, Disability or retirement shall be paid c [select from the list at (A)(3)
below]. 

  

	 	2.	Distributions payable as a result of termination for death, Disability or retirement shall be paid c [select from the list at (A)(3) below].

  

	 	3.	Distribution Options: 

  

	 	a.	As soon as administratively feasible on or after the Valuation Date following the date on which a distribution is requested or is otherwise payable.

  

	 	b.	As soon as administratively feasible following the close of the Plan Year during which a distribution is requested or is otherwise payable. 

 

	 	c.	As soon as administratively feasible following the date on which a distribution is requested or is otherwise payable. (This option is recommended for daily valuation
plans.) 

  

	 	d.	As soon as administratively feasible after the close of the Plan Year during which the Participant incurs ___________ [cannot be more than five (5)] consecutive
one (1) year Breaks in Service. 

  

	 	e.	Only after the Participant has attained the Plan’s Normal Retirement Age or Early Retirement Age, if applicable. 

 

	 	B.	Required Beginning Date: 

The Required Beginning Date of a Participant with respect to the Plan is (select one from below): 

 

	 	 ̈     1.	 The April 1 of the calendar year following the calendar year in which the Participant attains age 70 1/2 

 

	 	x     2.	 The April 1 of the calendar year following the calendar year in which the Participant attains age 70 1/2 except that distributions to a Participant (other than a 5% owner)
with respect to benefits accrued after the later of the adoption of this Plan or Effective Date of the amendment of this Plan must commence no later than the April 1 of the calendar year following the later of the calendar year in which the
Participant attains age 70 1/2 or the calendar year
in which the Participant retires. 

  

					
		 	35	 	401(k) NS AA #010

	 	 ̈     3.	 The later of the April 1 of the calendar year following the calendar year in which the Participant attains age 70 1/2 or retires except that distributions to a 5% owner must commence by
the April 1 of the calendar year following the calendar year in which the Participant attains age
70 1/2. 

Option (3) may only be elected if (i) it corresponds to an amendment previously made to the Plan pursuant to
Regulations Section 1.411(d)-4, Q&A-10(b), or (ii) it does not eliminate an age 70 1/2 distribution option as described in the preceding Regulations because either (A) the Plan is a new Plan or (B) Section XIII(A)(3) is checked or the Plan already offers a pre-retirement
distribution at least as generous as Section XIII(A)(3). 
  

	 	C.	Minimum Distribution Requirements: 

  

	 	 ̈     1.	Election to Apply Five (5) Year Rule to Distributions to Designated Beneficiaries: If the Participant dies before distributions begin and there is a
Designated Beneficiary, distribution to the Designated Beneficiary is not required to begin by the date specified in the Basic Plan Document #01 but the Participant’s entire interest will be distributed to the Designated Beneficiary by
December 31 of the calendar year containing the fifth anniversary of the Participant’s death. 

  

	 	x     2.	Election to Allow Participants or Beneficiaries to Elect Five (5) Year Rule: Participants or Beneficiaries may elect on an individual basis whether the five
(5) year rule or the life expectancy rule described in the Basic Plan Document #01 applies to distributions after the death of a Participant who has a Designated Beneficiary. The election must be made no later than the earlier of
September 30 of the calendar year in which distribution would be required to begin under the Plan, or by September 30 of the calendar year which contains the fifth anniversary of the Participant’s (or, if applicable, surviving
Spouse’s) death. If neither the Participant nor Beneficiary makes an election under this paragraph, distributions will be made in accordance with Article VII of the Basic Plan Document #01 and, if applicable, the elections in Section XVI(C)(1)
above. 

  

	 	D.	Forms of Payment (select all that apply): 

 The normal form of payment is determined at Section III(J) of this Adoption Agreement. If option (1) or no selection is made in Section III(J), then options (4), (5) and (6) in this
section cannot be selected. 
  

	 	x     1.	Lump sum. 

  

	 	x     2.	Installment payments. 

  

	 	 ̈     3.	Partial payments; the minimum amount will be $            . 

 

	 	 ̈     4.	Life annuity. 

  

	 	 ̈     5.	Term certain annuity with payments guaranteed for ________ years [not to exceed twenty (20)]. 

 

	 	 ̈     6.	Joint and [    ] 50%, [    ] 66-2/3%, [    ] 75% or [    ] 100% survivor annuity.

  

	 	E.	Type of Payment (select all that apply): 

  

	 	x     1.	Cash. 

  

	 	x     2.	Employer securities. 

  

	 	 ̈     3.	Other marketable securities. 

  

					
		 	36	 	401(k) NS AA #010

	 	 ̈     4.	Other:
                                         
                                         
                   (fill in the blank with the type of other in-kind distributions allowed under the Plan). 

 

	 	F.	Application of Involuntary Cash-out Provisions: 

  

	 	 ̈     1.	The Plan shall not make involuntary cash-outs to any terminated vested Participant. Distributions will only be made with the consent of the Participant.

  

	 	x     2.	The Plan shall make involuntary cash-outs to a terminated vested Participant as follows: 

 

	 	 ̈       a.	The Plan shall make involuntary cash-out distributions of Vested Account Balances of less than $200. Distribution of amounts $200 or greater shall only be made with the
consent of the Participant. 

  

	 	x       b.	The Plan shall make involuntary cash-out distributions of Vested Account Balances of $1,000 or less. Distribution of amounts greater than $1,000 shall only be made with
the consent of the Participant. 

  

	 	3.	When determining the value of the Participant’s nonforfeitable account balance for purposes of the Plan’s involuntary cash-out rules, the Plan elects to:

  

	 	 ̈       a.	exclude Rollover Contributions. 

  

	 	x       b.	include Rollover Contributions. 

If no selection is made, the Plan will exclude Rollover Contributions when determining the value of the Participant’s
nonforfeitable account balance for involuntary cash-out purposes. Rollover Contributions, if any, will always be included when determining whether the $1,000 threshold has been exceeded. 

 

	 	G.	Automatic Rollovers: 

Do not complete if a selection has been made at Section XVI(F)(1) or (2) above. 

 

	 	 ̈      1.	The Plan shall make automatic rollovers of Vested Account Balances that are greater than $1,000 but are not more than $5,000 in accordance with the provisions of
Article VI of the Basic Plan Document #01. 

  

	 	 ̈      2.	The Plan shall make automatic rollovers of Vested Account Balances that are not more than $5,000 in accordance with the provisions of Article VI of the Basic Plan
Document #01. 

  

	 	H.	Distribution Upon Severance from Employment: 

  

	 	 ̈      1.	Not applicable. 

  

	 	x      2.	Distribution upon severance from employment as described in the Basic Plan Document #01 shall apply for distributions after December 31, 2001 regardless of when
the severance from employment occurred. 

  

	 	 ̈      3.	Distribution upon severance from employment as described in the Basic Plan Document #01 shall apply for distributions after ___________________ (no earlier than
December 31, 2001) for severance from employment occurring after _______________ (enter the Effective Date if different than the Effective Date above). 

  

					
		 	37	 	401(k) NS AA #010

	XVII.    SPONSOR	INFORMATION AND ACCEPTANCE 

 This Plan may not be used and shall not be deemed to be a Prototype Plan unless an authorized representative of the Sponsor has acknowledged the use of the Plan. Such acknowledgment that the Employer is
using the Plan does not represent that the Adoption Agreement (as completed) and Basic Plan Document #01 have been reviewed by a representative of the Sponsor or constitute a qualified retirement plan. 

Acknowledged and accepted by the Sponsor this __________ day of ________________, __________. 

 

					
		  	Name:	 	WILLIAM G. EDWARDS
			
		  	Title:	 	VICE-PRESIDENT
			
		  	Signature:	 	 

 Questions concerning the
language contained in and qualification of the Prototype should be addressed to: 
 WILLIAM G. EDWARDS 

(Position): VICE-PRESIDENT                
(Phone Number): 513-424-5000 
 In the event that the Sponsor amends, discontinues or abandons this Prototype Plan,
notification will be provided to the Employer’s address provided on the first page of this Adoption Agreement. 
  

	XVIII.    SIGNATURES	

 Completion of
this Adoption Agreement requires consideration of complex tax and legal issues. The Employer should consult with or should obtain the advice of its legal counsel and/or tax advisor before executing this Adoption Agreement. By executing this Adoption
Agreement, the Employer acknowledges that it is a legal document with significant tax and legal ramifications. The Employer understands that its failure to properly complete or amend this Adoption Agreement may result in failure of the Plan to
qualify or in disqualification of the Plan. Neither the Sponsor nor any of its agents or affiliates assumes any responsibility for the completion and operation of the Plan established under this Adoption Agreement and Basic Plan Document #01.

  

	 	A.	Employer: 

 This Adoption
Agreement and the corresponding provisions of Basic Plan Document #01 are adopted by the Employer this __________ day of _____________________, ___________. 
  

					
		  	Executed on behalf of the Employer by:	 	E.G. MCLAUGHLIN
			
		  	Title:	 	EXECUTIVE VICE-PRESIDENT
			
		  	Signature:	 	 

 Employer’s
Reliance: The adopting Employer may rely on an Opinion Letter issued by the Internal Revenue Service as evidence that the Plan is qualified under Code Section 401 except to the extent provided in Revenue Procedure 2005-16. The Employer may
not rely on the Opinion Letter in certain other circumstances or with respect to certain qualification requirements, which are specified in the Opinion Letter issued with respect to the Plan and in Revenue Procedure 2005-16. In order to have
reliance in such circumstances or with respect to such qualification requirements, application for a determination letter must be made to Employee Plans Determinations of the Internal Revenue Service. This Adoption Agreement may only be used in
conjunction with Basic Plan Document #01. 

  

					
		 	38	 	401(k) NS AA #010

	 	B.	Trust Agreement/Custodial Agreement: 

  

	 	 ̈	Plan assets will be invested in group annuity contracts and the terms of the contract(s) will apply. 

 

	 	 ̈	Plan assets are held in a tax qualified Trust. The Trust provisions used will be as contained in the Basic Plan Document #01. 

 

	 	x	Plan assets are held in a tax qualified Trust. The Trust provisions used will be as contained in the accompanying pre-approved executed Trust Agreement between the
Employer and the Trustee attached hereto. 

  

	 	 ̈	Plan assets are being held in a Custodial Account arrangement. The Custodial Account provisions used will be as contained in the Basic Plan Document #01.

  

	 	 ̈	Plan assets are being held in a Custodial Account arrangement. The Custodial Account provisions used will be as contained in the accompanying pre-approved executed
Custodial Account Agreement between the Employer and the Custodian attached hereto. 

  

	 	C.	Trustee: 

  

	 	x	The Trustee appointed shall act in the capacity of a non-discretionary directed Trustee. 

 

	 	 ̈	The Trustee appointed shall act in the capacity of a discretionary Trustee. 

 Name and address of Trustee: 
 FRONTIER TRUST COMPANY 

1126 WESTRAC DRIVE 
 FARGO, ND 58103 
 The Employer’s Plan as contained herein is accepted
by the Trustee this ____________ day of ____________________, ___________. 
  

			
	 Accepted on behalf of the Trustee by:
	 	 
		
	 Title:
	 	 
		
	 Signature:
	 	 
		
	 Accepted on behalf of the Trustee by:
	 	 
		
	 Title:
	 	 
		
	 Signature:
	 	 
		
	 Accepted on behalf of the Trustee by:
	 	 
		
	 Title:
	 	 
		
	 Signature:
	 	 

  

					
		 	39	 	401(k) NS AA #010

	 	D.	Custodian: 

 Name and
address of Custodian: 
 ____________________________________________________________________________________________

 ____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

The Employer’s Plan as contained herein is accepted by the Custodian this __________ day of ________________, __________. 

 

			
	Accepted on behalf of the Custodian by:	 	 
		
	 Title:
	 	 
		
	 Signature:
	 	 

  

					
		 	40	 	401(k) NS AA #010

 PARTICIPATION AGREEMENT 
 Each Participating Employer must execute a separate Participation Agreement. If not applicable, do not complete this Participation Agreement. 

By executing this Participation Agreement, the undersigned Employer elects to become a Participating Employer in the Plan and accompanying Adoption
Agreement as if the Participating Employer were a signatory to the Adoption Agreement. The Participating Employer accepts, and agrees to be bound by, all of the elections granted under the provisions of the Prototype Plan as made by the signatory
sponsoring Employer in Section XVIII(A) of the Adoption Agreement. Further, the Participating Employer hereby appoints the signatory sponsoring Employer as its attorney in fact for the purpose of adopting on its behalf of all future amendments
whether required or voluntary and any applicable corresponding documents (e.g., Loan Policy, QDRO procedures, Trust Agreement). This includes the adoption of all future Model Amendments to this Prototype Plan which are required by the U.S.
Department of the Treasury or the Internal Revenue Service as a result of a modification or amendment of applicable Federal laws or regulations that become effective subsequent to the execution of this Participation Agreement. 

 

	A.	PARTICIPATING EMPLOYER: 

 Name and address of any Participating Employer. 

	
	 __________________________________________________________________________________________________

	
	 __________________________________________________________________________________________________

	
	 __________________________________________________________________________________________________

	
	 __________________________________________________________________________________________________

 

							
	Phone Number:	  	 	  	Tax ID Number:	  	 

  

	B.	EFFECTIVE DATE: 

  

			
	          The Effective Date of the Plan for the Participating Employer
is:
                                         
                                         
      

  

	 ̈	This is an adoption of a new plan by the Participating Employer. 

  

	 ̈	This is an adoption of an amendment and/or restatement of a plan currently maintained by the Participating Employer identified as follows: 

 

			
	 Name of Plan:
	  	 
	  

Original Effective Date:
	  	 

  

	C.	SIGNATURES: 

  

					
	 Executed on behalf of the Participating Employer by:
	  	 	 	 
		
	 Title:
	  	 	 	 
		
	 Signature:
	  	 	 	 
		
	 Executed on behalf of the Signatory Sponsoring Employer by:
	  	 	 	 
		
	 Title:
	  	 	 	 
		
	 Signature:
	  	 	 	 
		
	 Executed on behalf of the Trustee by:
	  	 	 	 
		
	 Title:
	  	 	 	 
		
	 Signature:
	  	 	 	 

  

					
		 	41	 	401(k) NS AA #010

 SCHEDULE A 
 PROTECTED BENEFITS 
 This Schedule describes Code Section 411(d)(6) protected benefits
included in the adopting Employer’s prior plan document that are not available in this Prototype Defined Contribution Plan, Basic Plan Document #01. Complete as applicable. 

 

	1.	Plan Provision:  

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	2.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	3.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	4.	Plan Provision:  

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	5.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           

  

					
		 	42	 	401(k) NS AA #010

 SCHEDULE B 
 PRIOR PLAN PROVISIONS 
 This Schedule should be used by the adopting Employer if a prior
plan contains provisions not found in this Prototype Defined Contribution Plan, Basic Plan Document #01, or where the Employer wishes to document transactions or historical provisions of the Employer’s Plan. 

 

	1.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	2.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	3.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	4.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           
  

	5.	Plan Provision: 

	
	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

	
         
__________________________________________________________________________________________________

Effective Date:
                                         
                                         
                           

  

					
		 	43	 	401(k) NS AA #010

 SCHEDULE C 
 SAFE HARBOR ELECTIONS FOR FLEXIBLE NON-ELECTIVE CONTRIBUTION 
 The following elections are
made with regard to the Plan’s Safe Harbor status pursuant to Section VII herein. For Plan Years indicated below, the Plan hereby invokes a Safe Harbor status in accordance with IRS Notices 98-52 and 2000-3. 

For all Plan Years in which this Safe Harbor election is being made, the limitations and restrictions found in Section VII herein apply. 

 

	1.	For the Plan Year beginning _____ and ending _____, the Employer hereby invokes a Safe Harbor status as provided in IRS Notice 2000-3. The Safe Harbor
Contribution will be an amount equal to _____% (not less than 3%) of Compensation. This election is made on this _____ day of _____, _____ (date may not be later than 30 days prior to the end of the Plan Year in which
such election is being made). 

  

	2.	For the Plan Year beginning _____ and ending _____, the Employer hereby invokes a Safe Harbor status as provided in IRS Notice 2000-3. The Safe Harbor
Contribution will be an amount equal to _____% (not less than 3%) of Compensation. This election is made on this _____ day of _____, _____ (date may not be later than 30 days prior to the end of the Plan Year in which such
election is being made). 

  

	3.	For the Plan Year beginning _____ and ending _____, the Employer hereby invokes a Safe Harbor status as provided in IRS Notice 2000-3. The Safe Harbor
Contribution will be an amount equal to _____% (not less than 3%) of Compensation. This election is made on this _____ day of _____, _____ (date may not be later than 30 days prior to the end of the Plan Year in which
such election is being made). 

  

	4.	For the Plan Year beginning _____ and ending _____, the Employer hereby invokes a Safe Harbor status as provided in IRS Notice 2000-3. The Safe Harbor
Contribution will be an amount equal to _____% (not less than 3%) of Compensation. This election is made on this _____ day of _____, _____ (date may not be later than 30 days prior to the end of the Plan Year in which
such election is being made). 

  

	5.	For the Plan Year beginning _____ and ending _____, the Employer hereby invokes a Safe Harbor status as provided in IRS Notice 2000-3. The Safe Harbor
Contribution will be an amount equal to _____% (not less than 3%) of Compensation. This election is made on this _____ day of _____, _____ (date may not be later than 30 days prior to the end of the Plan Year in which
such election is being made). 

  

					
		 	44	 	401(k) NS AA #010

 SCHEDULE D 
 COLLECTIVE AND COMMINGLED FUNDS 
 The Trustee is authorized to invest all or any part of
the Fund in the following Collective and Commingled Funds as provided for in the Basic Plan Document #01: 
 1. 

2. 
 3. 

4. 
 5. 

6. 
 7. 

8. 
 9. 

 

	10.	

  

					
		 	45	 	401(k) NS AA #010

 SCHEDULE E 
 MISCELLANEOUS ADMINISTRATIVE ELECTIONS 
 The following elections are made with regard to
the administration of the Plan: 
  

	x     1.	ERISA Section 404(c): The Employer intends to be covered by the fiduciary liability provisions with respect to Participant-directed investments under ERISA
Section 404(c). Under the terms of this Plan, Participants (or their Beneficiaries) have a reasonable opportunity to give instructions to the Plan Administrator in accordance with the policy set by the Plan Administrator (whether written, oral,
or in electronic form) regarding the choice of investment of their account balance. The Plan Administrator is obligated to comply with the Participant’s or Beneficiary’s investment instructions unless complying with such instructions would
result in a prohibited transaction under the Code, ERISA or the Department of Labor, violate the Plan document, or jeopardize the Plan’s tax-qualified status. 

 

	x     2.	Fees: Listed below are the charges your account will incur as a condition of the receipt of a benefit under the Plan, depending upon the transaction involved.

  

	 	 ̈     a.	Participants have the ability to take a loan from the Plan. [    ] There will be a loan set-up fee of $_____ paid from the account prior to
obtaining a loan from the Plan. [    ] $_____ will be charged on an annual basis until the loan is paid in full. [    ] The loan set-up charge is deducted from the Participant’s account. All other costs
of administering the Plan will be paid by the Employer or from Plan assets. 

  

	 	 ̈     b.	The costs of administering the Plan are shared between Participants and the Employer. 

 

	 	 ̈     c.	A service fee equal to $___ / ___% of a Participant’s account balance will be charged per [    ] Plan quarter [    ] Plan
Year. 

  

	 	 ̈     d.	All costs of administering the Plan will be paid by the Employer or from Plan assets. 

 

	 	 ̈     e.	In order to maintain a self-directed brokerage option, Participants will be charged an initial fee of $_______ [    ] and annual fee of
$            . 

  

	 	 ̈     f.	To obtain a Hardship distribution, Participants will incur a charge of $            .

  

	 	 ̈     g.	Qualified Domestic Relations Order (QDRO) presented to the Plan for payment will be charged $_______ to the Participant’s/Alternate Payee’s account for
processing. 

  

	 	x     h.	Other: 

 See Plan
Administrator for any applicable fees. 
  

	 ̈     3.	Automatic Rollover Of Distributions: If a Plan Participant does not elect to take a distribution and include it in income or have the distribution rolled over to
either a qualified retirement plan or an Individual Retirement Account (“IRA”), the Plan is required to make a Direct Rollover of the distribution to an IRA. The Employer as Plan Sponsor has the authority to execute the documents necessary
to establish the IRA account, and once established, the Trustee/Issuer of the IRA will provide the Participant with a Disclosure Statement detailing the terms and conditions as well as any fees imposed on the IRA, including the procedures regarding
the seven (7) day revocation period. The Plan has selected the following IRA Trustee/Issuer: 

 Name:
                                         
                                         
                                         
                                         
                     

Address: 

     
      
      

Phone:
                                         
                                         
                                         
                                         
                     

The initial IRA setup fee shall be:
                                         
                                         
                                         
                  
 The initial IRA
setup fee shall be paid by:
                                         
                                         
                                         
      

  

					
		 	46	 	401(k) NS AA #010

 The IRA Provider’s annual fee shall be:
                                         
                                         
                                         
          
 The IRA funds shall be invested in: 

  

					
		 	47	 	401(k) NS AA #010

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