Document:

Exhibit 10.28

 

PHILADELPHIA ENERGY SOLUTIONS LLC

1735 Market Street, 10th Floor

Philadelphia, Pennsylvania 19103

 

July    , 2015

 

[NAME]

 

VIA EMAIL

 

Re:          Forfeiture Conditions of PESC Company, LP Interests

 

Dear [NAME]:

 

Reference is made to the Incentive Unit Agreement between you and Philadelphia Energy Solutions LLC (the “Company”), dated [    ], 201[ ] (the “Incentive Unit Agreement”), which governs the Incentive Units granted to you in connection with your employment with the Company.  The Incentive Unit Agreement provides that your Incentive Units vest in 20% increments in accordance with a “time-based” schedule set forth therein and in full upon a Qualified IPO and that, upon vesting, the forfeiture restrictions on the Incentive Units will lapse.  The forfeiture restrictions on the Incentive Units will lapse upon the effective date of the registration statement filed by Philadelphia Energy Solutions Inc. (“PES Inc.”) for the initial public offering of its class A common stock (the “IPO”) and as of that time the terms of the Incentive Unit Agreements will no longer apply and that agreement will have no further force or effect.

 

In connection with the IPO, you agree that your Incentive Units will be contributed (the “Contribution”) to PESC Company, LP (“PESC”) pursuant to a contribution agreement (the “Contribution Agreement”) and you will receive in exchange for those units certain limited partner units in PESC (“PESC Units”).  The number of PESC Units that you receive in the Contribution will be based on the Company’s IPO valuation.  The PESC Units will be governed by and will be subject to the terms of the Limited Partnership Agreement of PESC (as it may be amended and restated from time to time, the “Partnership Agreement”), the Contribution Agreement and this letter agreement.

 

For and in consideration of the transactions occurring in connection with the IPO and for other good and valuable consideration, the receipt of which is hereby acknowledged and confirmed, you, the Company and PESC hereby agree that, if you voluntarily resign your employment with the Company without Good Reason prior to the expiration of the Restricted Period (each as defined below), then you will immediately forfeit for no consideration that percentage of your PESC Units that corresponded to the percentage of your Incentive Units that would not have vested prior to the date of your resignation in accordance with the regular time-based vesting provisions of your Incentive Unit Agreement.  In such event, a number of common units in the Company then held by PESC that is equal to the number of forfeited PESC Units will be cancelled by the Company and forfeited by PESC immediately and for no consideration (and, as a result, a corresponding number of shares of class B common stock of PES Inc. then held by PESC will be cancelled by PES Inc. and forfeited by PESC).

 

 

For purposes of this letter agreement, the “Restricted Period” means the period beginning at the time of the IPO is completed and ending on earlier of (a) 912 days after the pricing date of the IPO and (b) the date on which Carlyle PES, L.L.C., Carlyle CEOF AIV Investors Holdings, L.P., Carlyle CEMOF AIV Investors Holdings, L.P. and their respective permitted affiliate transferees together own less than 25% of the aggregate voting power in PES Inc., whether directly through the ownership of shares of class A Common Stock of PES, Inc. or indirectly through the ownership of PESC Units.

 

In the event you dispose of any PESC Units (including through any redemption or exchange) prior to the expiration of the Restricted Period, such dispositions shall be deemed to come first from the portion of your PESC Units that are not subject to the forfeiture restrictions set forth in this letter agreement.

 

For purposes of this letter agreement, the term “Good Reason” shall have the same meaning as set forth in you employment agreement or severance agreement with Company, as applicable, as such agreement was in effect on the date of the IPO, provided that if on such date you were not a party to such an agreement, then “Good Reason” will mean, without your written consent:  (i) any material diminution in your base salary; (ii) any material diminution in your authority, duties or responsibilities at the Company; or (iii) the Company requiring you to relocate to a primary place of employment that is located more than 50 miles outside of the Philadelphia, Pennsylvania metropolitan area; provided that prior to your termination of employment for Good Reason, you must give written notice to the Company of any Good Reason event within 30 days after you have actual knowledge of the facts or circumstances giving rise thereto and such event must remain uncorrected for 30 days following such written notice.  Any termination for “Good Reason” following such 30 day cure period must occur within 30 days of the expiration of such cure period.

 

You agree that in connection with the Contribution, you will execute the Contribution Agreement and the Partnership Agreement.  In addition, in connection with the Contribution and your execution of this letter agreement, you will file an election under Section 83(b) of the Internal Revenue Code of 1986 in the form set forth on Exhibit A hereto.

 

Please confirm your agreement with the foregoing by returning a countersigned copy of this letter agreement to                  at your earliest convenience.

 

Signature Page Follows

 

 

	
 
    	
Sincerely,
    
	
 
    	
 
    
	
 
    	
PESC   COMPANY, LP
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
PESC   Company GP, LLC, its general partner
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
 
    
	
 
    	
Name:
    	
 
    
	
 
    	
Title:
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
and
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
PHILADELPHIA   ENERGY SOLUTIONS LLC
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
 
    
	
 
    	
Name:
    	
 
    
	
 
    	
Title:
    	
 
    

 

 

	
Accepted   and agreed:
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
[NAME]
    	
 
    	
 
    

 

 

Exhibit A

 

ELECTION PURSUANT TO SECTION 83(b) OF THE
 INTERNAL REVENUE CODE

 

The undersigned taxpayer is receiving the limited partner units (the “LP Units”) of PESC Company, LP (the “Partnership”) described below in exchange for the contribution to the Partnership of Incentive Units of Philadelphia Energy Solutions LLC held by the taxpayer (the “LLC Units”).  The taxpayer previously made an election under Section 83(b) of the Internal Revenue Code of 1986, as amended (the “Code”), to include in the taxpayer’s gross income for the then-current taxable year the amount of any compensation taxable to the taxpayer in connection with the taxpayer’s receipt of the LLC Units.  The taxpayer does not believe the receipt of the LP Units in exchange for the contribution to the Partnership of the taxpayer’s LLC Units is a transfer of property within the meaning of Section 83(a) of the Code.  However, to the extent the receipt of the LP Units is considered to be a transfer of property within the meaning of Section 83(a) of the Code, the taxpayer hereby elects to include in the taxpayer’s gross income for the current taxable year the amount of any compensation taxable to the taxpayer in connection with the taxpayer’s exchange of the LLC Units for the LP Units.

 

1.             The name, address, taxpayer identification number and taxable year of the undersigned are as follows:

 

	
Name:
    	
 
    
	
Address:
    	
 
    
	
 
    	
 
    
	
Social Security No.:
    	
 
    
	
Taxable year:
    	
2015
    

 

2.             The property with respect to which the election is made is [     ] LP Units.

 

3.             The date on which the property was transferred is [           ], 2015.

 

4.             The property is subject to the following restrictions: The LP Units are subject to forfeiture and transfer restrictions contained in agreements between the Partnership and the taxpayer.

 

5.             The fair market value at the time of transfer, determined without regard to any restriction other than a restriction which by its terms will never lapse, of the LP Units is $[             ].

 

6.             The amount (if any) paid for such property is $[             ].

 

The undersigned has submitted a copy of this statement to the person for whom the services were performed in connection with the undersigned’s receipt of the above-described property.  The transferee of such property is the person performing the services in connection with the transfer of said property.  The undersigned understands that the foregoing election may not be revoked except with the consent of the Commissioner.

 

 

	
Dated:                         ,   20
    	
 
    
	
 
    	
TaxpayerExhibit 10.1

 

AMENDMENT TO PARTNERSHIP AGREEMENT
 FOR PREFERRED UNITS

 

Nineteenth Amendment to the
 First Amended and Restated Agreement
 of Limited Partnership
 of SL Green Operating Partnership, L.P.

 

This Amendment is made as of July 22, 2015 by SL Green Realty Corp., a Maryland corporation, as managing general partner (the “Company” or the “Managing General Partner”) of SL Green Operating Partnership, L.P., a Delaware limited partnership (the “Partnership”), and as attorney-in-fact for the Persons named on Exhibit A to the First Amended and Restated Agreement of Limited Partnership of SL Green Operating Partnership, L.P., dated as of August 20, 1997, as amended from time to time (the “Partnership Agreement”), for the purpose of amending the Partnership Agreement.  Capitalized terms used herein and not defined shall have the meanings given to them in the Partnership Agreement.

 

WHEREAS, pursuant to a Purchase, Sale, Exchange and Contribution Agreement (the “Contribution Agreement”), dated as of June 16, 2015, by and among an affiliate of the Partnership (“Member”), the unit recipient (the “Transferor”) and the other parties party thereto, the Transferor transferred its interests in an entity that owned a commercial real estate property to Member in exchange for the applicable consideration specified in the Contribution Agreement, which includes the Series P Preferred Units (as defined herein).

 

WHEREAS, Section 4.02A of the Partnership Agreement grants the Managing General Partner authority to cause the Partnership to issue interests in the Partnership to Persons other than the Managing General Partner in one or more classes or series, with such designations, preferences and relative, participating optional or other special rights, powers and duties as may be determined by the Managing General Partner in its sole and absolute discretion, subject to applicable Delaware law.

 

WHEREAS, the Managing General Partner has determined that, in connection with the issuance of the preferred partnership units contemplated by the Contribution Agreement, it is necessary and desirable to amend the Partnership Agreement to create and set forth the terms of the preferred partnership units having the designations, rights and preferences set forth herein.

 

WHEREAS, solely to the extent necessary to effect the establishment of the Series P Preferred Units (as defined herein) with the terms and conditions described herein, the following shall be deemed to amend Articles V and VI and Section 8.06 of the Partnership Agreement.

 

NOW, THEREFORE, in consideration of the premises and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Managing General Partner hereby amends the Partnership Agreement as follows:

 

1.                                      Article I of the Partnership Agreement is hereby amended by adding the following definition:

 

“Series P Preferred Units” means the series of Partnership Units established pursuant to the Nineteenth to this Partnership Agreement, representing units of Limited Partnership Interest designated as the Series P Preferred Units, with the preferences, rights, voting powers, restrictions, limitations as to distributions, qualifications and terms and conditions of repurchase as described herein.

 

2.                                      In accordance with Section 4.02A of the Partnership Agreement, set forth below are the terms and conditions of the Series P Preferred Units hereby established:

 

 

A.                                    Designation and Number.  A series of Partnership Units, designated as Series P Preferred Units, is hereby established.  The maximum number of Series P Preferred Units shall be 200,000 Series P Preferred Units.

 

B.                                    Rank.  The Series P Preferred Units, with respect to rights to the payment of dividends and the distribution of assets upon the liquidation, dissolution or winding up of the Partnership, rank (a) senior to the Class A Units, the Class B Units (collectively, the “Common Units”), and all Partnership Interests outstanding or issued in the future by the Partnership, the terms of which do not expressly provide that such Partnership Interests rank senior to or on a parity with the Series P Preferred Units, (b) on a parity with the Series F Preferred Units, the Series G Preferred Units, the Series I Preferred Units, the Series J Preferred Units, the Series K Preferred Units, the Series L Preferred Units, the Series M Preferred Units, the Series N Preferred Units, the Series O Preferred Units, the Series Q Preferred Units and all Partnership Interests outstanding or issued in the future by the Partnership, the terms of which expressly provide that such Partnership Interests rank on a parity with the Series P Preferred Units and (c) junior to all Partnership Interests issued in the future by the Partnership, the terms of which expressly provide that such Partnership Interests rank senior to the Series P Preferred Units.

 

C.                                    Distributions.

 

(i)                                     Pursuant to Section 5.01 of the Partnership Agreement but subject to the rights of holders of any Partnership Interests ranking senior to the Series P Preferred Units as to the payment of distributions, the holders of the then outstanding Series P Preferred Units shall be entitled to receive, when, as and if authorized by the Managing General Partner, out of Available Cash, cumulative quarterly preferential cash distributions in an amount per unit equal to 4.00% of the $25.00 liquidation preference per annum (equivalent to a fixed annual amount of $1.00  per unit).  Distributions on the Series P Preferred Units shall accrue and be fully cumulative from the date of original issuance and shall be payable quarterly when, as and if authorized by the Managing General Partner, in equal amounts in arrears on the fifteenth day of each January, April, July and October or, if not a business day, the next succeeding business day (each, a “Series P Preferred Unit Distribution Payment Date”). Any distribution (including the initial distribution) payable on the Series P Preferred Units for any partial distribution period shall be prorated and computed on the basis of a 360-day year consisting of twelve 30-day months. “Distribution Period” shall mean the period from and including the date of original issuance and ending on but excluding the next Series P Preferred Unit Distribution Payment Date, and each subsequent period from and including such Series P Preferred Unit Distribution Payment Date and ending on but excluding the next following Series P Preferred Unit Distribution Payment Date.

 

(ii)                                  No distribution on the Series P Preferred Units shall be authorized by the Managing General Partner or declared or paid or set apart for payment by the Partnership at such time as the terms and provisions of any agreement of the Managing General Partner or the Partnership, including any agreement relating to its indebtedness, prohibits such authorization, declaration, payment or setting apart for payment or provides that such authorization, declaration, payment or setting apart for payment would constitute a breach thereof, or a default thereunder, or if such authorization, declaration, payment or setting apart for payment shall be restricted or prohibited by law.  No interest, or sum of money in lieu of interest, shall be payable in respect of any distribution payment or payments on the Series P Preferred Units which may be in arrears.

 

(iii)                                           Notwithstanding the foregoing, distributions with respect to the Series P Preferred Units shall accumulate whether or not any of the foregoing restrictions exist, whether or not there is sufficient Available Cash for the payment thereof and whether or not such distributions are authorized. Accumulated but unpaid distributions on Series P Preferred Units shall not bear interest and holders of the Series P Preferred Units shall not be entitled to any distributions in excess of full cumulative distributions.  Any distribution payment made on the Series P Preferred Units shall first be credited against the earliest accumulated but unpaid distribution due with respect to such units which remains payable.

 

(iv)                                          Except as provided in section 2.C.(v), unless full cumulative distributions have been or contemporaneously are declared and paid or authorized, declared and a sum sufficient for the payment thereof set apart for such payment on the Series P Preferred Units for all past distribution periods and the then current distribution period, no distributions (other than in Partnership Interests ranking junior to the Series P Preferred Units as to the payment of dividends and the distribution of assets upon any liquidation, dissolution or winding up of the Partnership) shall be authorized, declared or paid or set apart for payment nor shall any other distribution be 

 

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authorized, declared or made upon any other Partnership Interests ranking, as to the payment of distributions or the distribution of assets upon any liquidation, dissolution or winding up of the Partnership, junior to or on a parity with the Series P Preferred Units for any period, nor shall any other Partnership Interests ranking junior to or on a parity with the Series P Preferred Units as to the payment of distributions or the distribution of assets upon any liquidation, dissolution or winding up of the Partnership, be redeemed, purchased or otherwise acquired for any consideration (or any moneys be paid to or made available for a sinking fund for the redemption of any such Partnership Interests) by the Partnership (except by conversion into or exchange for Partnership Interests ranking junior to the Series P Preferred Units as to the payment of distributions and the distribution of assets upon any liquidation, dissolution or winding up of the affairs of the Partnership).

 

(v)                                             When distributions are not paid in full (or a sum sufficient for such full payment is not so set apart) upon the Series P Preferred Units and any other Partnership Interests ranking on a parity as to the payment of distributions with the Series P Preferred Units, all distributions authorized and declared upon the Series P Preferred Units and any other Partnership Interests ranking on a parity as to the payment of distributions with the Series P Preferred Units shall be declared pro rata so that the amount of distributions authorized and declared per Series P Preferred Unit and such other Partnership Interests shall in all cases bear to each other the same ratio that accumulated distributions per each Series P Preferred Unit and such other Partnership Interests (which shall not include any accumulation in respect of unpaid distributions for prior distribution periods if such other Partnership Interests do not have a cumulative distribution) bear to each other.

 

(vi)                                          Holders of Series P Preferred Units shall not be entitled to any distribution, whether payable in cash, property or Partnership Interests, in excess of full cumulative distributions on the Series P Preferred Units as described above.  Accrued but unpaid distributions on the Series P Preferred Units will accumulate as of the Series P Preferred Units Distribution Payment Date on which they first become payable.

 

D.                                    Allocations.  Allocations of the Partnership’s items of income, gain, loss and deduction shall be allocated among holders of Series P Preferred Units in accordance with Article VI of the Partnership Agreement.

 

E.                                     Liquidation Preference.

 

(i)                                     In the event of any voluntary or involuntary liquidation, dissolution or winding up of the Partnership, the holders of the Series P Preferred Units shall be entitled to receive out of the assets of the Partnership available for distribution to the Partners pursuant to Section 13.02.A of the Partnership Agreement a liquidation preference of $25.00 per Series P Preferred Unit, plus an amount equal to any accumulated and unpaid distributions (whether or not earned or authorized) to the date of payment (the “Series P Liquidation Value”), before any distribution of assets is made to holders of any other Partnership Interests that rank junior to the Series P Preferred Units as to the distribution of assets upon the liquidation, dissolution or winding up of the Partnership, but subject to the preferential rights of the holders of Partnership Interests ranking senior to the Series P Preferred Units as to the distribution of assets upon the liquidation, dissolution or winding up of the Partnership.

 

(ii)                                  If upon any such voluntary or involuntary liquidation, dissolution or winding up of the Partnership, the assets of the Partnership legally available for distribution to its Partners are insufficient to make such full payment to the holders of the Series P Preferred Units, and the corresponding amounts payable on all other Partnership Interests ranking on a parity with the Series P Preferred Units as to the distribution of assets upon the liquidation, dissolution or winding up of the Partnership, then the holders of the Series P Preferred Units, and all other holders of such Partnership Interests on a parity with the Series P Preferred Units shall share ratably in any such distribution of assets in proportion to the full liquidating distributions (including, if applicable, accumulated and unpaid distributions) to which they would otherwise be respectively entitled.

 

(iii)                               After payment of the full amount of the Series P Liquidation Value, the holders of the Series P Preferred Units, shall have no right or claim to any of the remaining assets of the Partnership.

 

(iv)                              None of a consolidation or merger of the Partnership with or into another entity, a merger of another entity with or into the Partnership, a statutory unit exchange by the Partnership or a sale, lease or conveyance of all or substantially all of the Partnership’s property or business shall be considered a liquidation, dissolution or winding up of the affairs of the Partnership.

 

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F.                                      Repurchase at the Option of the Holder.

 

(i)                                     Notwithstanding any other provision of the Partnership Agreement to the contrary, the holders of the Series P Preferred Units shall have the right to require the Partnership to repurchase for cash all or a portion of the Series P Preferred Units at any time after the date hereof (the “Cash Repurchase Right”), subject to paragraph (ii) of this Section 2.F. The repurchase price per Series P Preferred Unit upon such repurchase shall be paid by the Partnership in cash and shall be in an amount equal to the Series P Liquidation Value of such Series P Preferred Units to the date of such repurchase (the “Cash Repurchase Consideration”).  From and after the applicable repurchase date, the Series P Preferred Units so repurchased shall no longer be outstanding and all rights hereunder, to distributions or otherwise, with respect to such Series P Preferred Units shall cease.

 

(ii)                                  Each holder of Series P Preferred Units who desires to require the Partnership to repurchase all or a portion of the Series P Preferred Units shall provide notice to the Partnership (with a copy to the Managing General Partner) in the form of the Notice of Repurchase Demand attached as Exhibit A hereto (a “Repurchase Demand Notice”) via facsimile, hand delivery or other mail or messenger service.  The date upon which the Partnership initially receives a Repurchase Demand Notice shall be a “Notice Date.” The Partnership shall pay to such holder of Series P Preferred Units the Cash Repurchase Consideration within ten (10) Business Days after the Notice Date.  A holder of Series P Preferred Units may not request repurchase of less than 10,000 Series P Preferred Units or, if such holder of Series P Preferred Units holds less than 10,000 Series P Preferred Units, for less than all of the Series P Preferred Units held by such holder of Series P Preferred Units.

 

G.                                    Voting Rights.  Except as required by applicable law, the Series P Preferred Units shall have no voting rights, except that no amendment of the Partnership Agreement shall be made that materially adversely affects the rights of the holders of Series P Preferred Units without the consent of a majority of such holders (unless all holders of Partnership Interests are materially adversely affected to the same degree).  For the avoidance of doubt, any amendment to create, establish or amend the rights and designations of a series of Partnership Units shall not require the consent of the holders of the Series P Preferred Units.

 

H.                                   Conversion.  The Series P Preferred Units are not convertible into or exchangeable for any other property or securities of the Partnership.

 

I.                                        Transfer.  In addition to the restrictions set forth in Section 11.03 of the Partnership Agreement, except as set forth in section 2.F above, a holder of the Series P Preferred Units may not Transfer any of the Series P Preferred Units without the consent of the Managing General Partner, which consent may be withheld in the Managing General Partner’s sole discretion.  Any attempt to effect a Transfer of the Series P Preferred Units without the Managing General Partner’s consent shall be void ab initio.

 

For purposes of this Section 2.I, “Transfer” shall have the meaning of “transfer” as defined in 11.01(A) in the Partnership Agreement.  The term “Transfer” as used in this section 2.I or Article XI of the Partnership Agreement shall not include any repurchase of the Series P Preferred Units by the Partnership.

 

J.                                        Restrictions on Ownership.  No person that is not a legal resident of the United States of America shall be permitted to beneficially own, directly or indirectly for U.S. federal income tax purposes, any Series P Preferred Units.  The acquisition of any Series P Preferred Units by any person that is not a legal resident of the United States of America, whether or not in accordance with Section 2.I above, shall be void ab initio.

 

3.                                      Except as modified herein, all terms and conditions of the Partnership Agreement shall remain in full force and effect, which terms and conditions the Managing General Partner hereby ratifies and confirms.

 

4.                                      This Amendment shall be construed and enforced in accordance with and governed by the laws of the State of Delaware, without regard to conflicts of law.

 

5.                                      If any provision of this Amendment is or becomes invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions contained herein shall not be affected thereby.

 

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IN WITNESS WHEREOF, the undersigned has executed this Amendment as of the date first set forth above.

 

 

	
 
    	
SL GREEN REALTY CORP., 
    
	
 
    	
a Maryland corporation,
    
	
 
    	
as Managing General   Partner of 
    
	
 
    	
SL GREEN OPERATING   PARTNERSHIP, L.P., 
    
	
 
    	
a Delaware limited   partnership
    
	
 
    	
and on behalf of   existing Limited Partners
    
	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
/s/ Andrew Levine
    
	
 
    	
 
    	
Name: Andrew Levine
    
	
 
    	
 
    	
Title: Executive Vice President
    

 

 

Exhibit A

 

Notice of Repurchase Demand

 

The undersigned holder of Series P Preferred Units hereby irrevocably requests SL Green Operating Partnership, L.P., a Delaware limited partnership (the “Partnership”), to repurchase the number of Series P Preferred Units stated herein in accordance with the terms of the First Amended and Restated Agreement of Limited Partnership of SL Green Operating Partnership, L.P., as amended from time to time in accordance with its terms, and the Cash Repurchase Right referred to therein; and the undersigned irrevocably (i) surrenders such Series P Preferred Units and all right, title and interest therein and (ii) directs that the Cash Repurchase Consideration deliverable in accordance with this Notice be delivered in the name(s) and at the address(es) specified below.

 

The undersigned hereby represents, warrants, and certifies that the undersigned (a) has good and unencumbered title to the Series P Preferred Units that are the subject of this Notice, free and clear of the rights or interests of any other person or entity, (b) has the full right, power, and authority to demand repurchase and surrender the Series P Preferred Units that are the subject of this Notice and (c) has obtained the consent or approval of all persons or entities, if any, having the right to consent or approve such repurchase and surrender.

 

Number of Series P Preferred Units tendered:

 

	
Dated:
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
Name:
    	
 
    	
 
    
	
 
    	
(Please Print)
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
(Signature)
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
(Street Address)
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
(City)      (State)     (Zip   Code)

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