Document:

stsa-ex46_10.htm

Exhibit 4.6

 DESCRIPTION OF REGISTRANT’S SECURITIES
REGISTERED PURSUANT TO SECTION 12 OF THE
SECURITIES EXCHANGE ACT OF 1934

The following summary describes our capital stock and the material provisions of our amended and restated certificate of incorporation and our amended and restated bylaws, the amended and restated investors’ rights agreement to which we and certain of our stockholders are parties and of the Delaware General Corporation Law. Because the following is only a summary, it does not contain all of the information that may be important to you. For a complete description, you should refer to our amended and restated certificate of incorporation, amended and restated bylaws and amended and restated investors’ rights agreement, copies of which are incorporated by reference as Exhibits 3.1, 3.2 and 4.3, respectively, to our Annual Report on Form 10-K.

 

Common Stock 

 

As of December 31, 2020, Satsuma Pharmaceuticals, Inc. (“Satsuma”) had common stock, $0.0001 par value per share, registered under Section 12 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), and listed on The Nasdaq Global Market under the trading symbol “STSA.”  

 

Shares Outstanding

We are authorized to issue up to 300,000,000 shares of Common Stock. As of December 31, 2020, there are 17,436,978 shares of Common Stock issued and outstanding and   3,162,459 shares are issuable upon the exercise of outstanding options to purchase common stock.

As of December 31, 2020, there were approximately 7 holders of record of our Common Stock. This number does not include beneficial owners whose shares are held by nominees in street name.

The actual number of stockholders is greater than the number of record holders and includes stockholders who are beneficial owners but whose shares are held in street name by brokers and other nominees. This number of holders of record also does not include stockholders whose shares may be held in trust by other entities.

Voting Rights 

Each holder of our common stock is entitled to one vote for each share on all matters submitted to a vote of the stockholders, including the election of directors. Our stockholders do not have cumulative voting rights in the election of directors. Accordingly, holders of a majority of the voting shares are able to elect all of the directors. In addition, the affirmative vote of holders of 66 2⁄3% of the voting power of all of the then outstanding voting stock will be required to take certain actions, including amending certain provisions of our amended and restated certificate of incorporation, such as the provisions relating to amending our amended and restated bylaws, the classified board and director liability. 

Dividends 

Subject to preferences that may be applicable to any then outstanding preferred stock, holders of our common stock are entitled to receive dividends, if any, as may be declared from time to time by our board of directors out of legally available funds. 

Liquidation 

In the event of our liquidation, dissolution or winding up, holders of our common stock will be entitled to share ratably in the net assets legally available for distribution to stockholders after the payment of all of our debts and other liabilities and the satisfaction of any liquidation preference granted to the holders of any then outstanding shares of preferred stock. 

 

 

Rights and Preferences 

Holders of our common stock have no preemptive, conversion, subscription or other rights, and there are no redemption or sinking fund provisions applicable to our common stock. The rights, preferences and privileges of the holders of our common stock are subject to and may be adversely affected by the rights of the holders of shares of any series of our preferred stock that we may designate in the future. 

 

Fully Paid and Nonassessable 

All of our outstanding shares of common stock are, and the shares of common stock to be issued in this offering will be, fully paid and nonassessable. 

Convertible Preferred Stock 

Our board of directors has the authority, without further action by our stockholders, to issue up to 10,000,000 shares of preferred stock in one or more series and to fix the rights, preferences, privileges and restrictions thereof. These rights, preferences and privileges could include dividend rights, conversion rights, voting rights, terms of redemption, liquidation preferences, sinking fund terms and the number of shares constituting, or the designation of, such series, any or all of which may be greater than the rights of our common stock. The issuance of our preferred stock could adversely affect the voting power of holders of common stock and the likelihood that such holders will receive dividend payments and payments upon our liquidation. In addition, the issuance of preferred stock could have the effect of delaying, deferring or preventing a change in control of our company or other corporate action. As of December 31, 2020, no shares of preferred stock were outstanding, and we have no present plan to issue any shares of preferred stock. 

Registration Rights 

Under our amended and restated investors’ rights agreement, based on the number of shares outstanding as of December 31, 2020, the holders of approximately 4.7 million shares of common stock, or their transferees, have the right to require us to register their shares under the Securities Act so that those shares may be publicly resold, and to include their shares in any registration statement we file, in each case as described below. 

Demand Registration Rights 

Based on the number of shares outstanding as of December 31, 2020, the holders of approximately 4.7 million shares of our common stock (on an as-converted basis), or their transferees, are entitled to certain demand registration rights. The holders of at least 20% of these shares can, on not more than two occasions, request that we register all or a portion of their shares if the aggregate price to the public of the shares offered is at least $10.0 million (before deductions of underwriters’ commissions and expenses). 

Piggyback Registration Rights 

Based on the number of shares outstanding as of December 31, 2020, after the consummation of this offering, in the event that we determine to register any of our securities under the Securities Act (subject to certain exceptions), either for our own account or for the account of other security holders, the holders of approximately 4.7 million shares of our common stock (on an as-converted basis), or their transferees, are entitled to certain “piggyback” registration rights allowing the holders to include their shares in such registration, subject to certain marketing and other limitations. As a result, whenever we propose to file a registration statement under the Securities Act, other than with respect to a registration related to employee benefit plans, the offer and sale of debt securities, or corporate reorganizations or certain other transactions, the holders of these shares are entitled to notice of the registration and have the right, subject to limitations that the underwriters may impose on the number of shares included in the registration, to include their shares in the registration. In an underwritten offering, the managing underwriter, if any, has the right, subject to specified conditions, to exclude or limit the number of shares such holders may include. 

 

 

 

 

Form S-3 Registration Rights 

Based on the number of shares outstanding as of December 31, 2020, the holders of approximately 4.7 million shares of our common stock (on an as-converted basis), or their transferees, are entitled to certain Form S-3 registration rights. The holders of at least 20% of these shares can make a written request that we register their shares on Form S-3 if we are eligible to file a registration statement on Form S-3 and if the aggregate price to the public of the shares offered is at least $1.0 million (before deductions of underwriters’ commissions and expenses). These stockholders may make an unlimited number of requests for registration on Form S-3, but in no event shall we be required to file more than two registrations on Form S-3 in any given twelve-month period. 

Expenses of Registration 

We will pay the registration expenses of the holders of the shares registered pursuant to the demand and Form S-3 registration rights described above. 

Expiration of Registration Rights 

The demand, piggyback and Form S-3 registration rights described above will expire, with respect to any particular stockholder, upon the earlier of five years after the consummation of our initial public offering or when that stockholder can sell all of its shares under Rule 144 of the Securities Act during any 90-day period (and without the requirement for the Company to be in compliance with the current public information required under Section c(1) of Rule 144 of the Securities Act). 

Anti-Takeover Effects of Provisions of our Amended and Restated Certificate of Incorporation, our Amended and Restated Bylaws and Delaware Law 

Certain provisions of Delaware law and our amended and restated certificate of incorporation and our amended and restated bylaws contain provisions that could make the following transactions more difficult: acquisition of us by means of a tender offer; acquisition of us by means of a proxy contest or otherwise; or removal of our incumbent officers and directors. It is possible that these provisions could make it more difficult to accomplish or could deter transactions that stockholders may otherwise consider to be in their best interest or in our best interests, including transactions that might result in a premium over the market price for our shares. 

These provisions, summarized below, are expected to discourage coercive takeover practices and inadequate takeover bids. These provisions are also designed to encourage persons seeking to acquire control of us to first negotiate with our board of directors. We believe that the benefits of increased protection of our potential ability to negotiate with the proponent of an unfriendly or unsolicited proposal to acquire or restructure us outweigh the disadvantages of discouraging these proposals because negotiation of these proposals could result in an improvement of their terms. 

Delaware Anti-Takeover Statute 

We are subject to Section 203 of the Delaware General Corporation Law, which prohibits persons deemed “interested stockholders” from engaging in a “business combination” with a publicly-held Delaware corporation for three years following the date these persons become interested stockholders unless the business combination is, or the transaction in which the person became an interested stockholder was, approved in a prescribed manner or another prescribed exception applies. Generally, an “interested stockholder” is a person who, together with affiliates and associates, owns, or within three years prior to the determination of interested stockholder status did own, 15% or more of a corporation’s voting stock. Generally, a “business combination” includes a merger, asset or stock sale, or other transaction resulting in a financial benefit to the interested stockholder. The existence of this provision may have an anti-takeover effect with respect to transactions not approved in advance by the board of directors, such as discouraging takeover attempts that might result in a premium over the market price of our common stock. 

 

 

 

Undesignated Preferred Stock 

The ability to authorize undesignated preferred stock makes it possible for our board of directors to issue preferred stock with voting or other rights or preferences that could impede the success of any attempt to change control of us. These and other provisions may have the effect of deterring hostile takeovers or delaying changes in control or management of our company. 

Special Stockholder Meetings 

Our amended and restated bylaws provide that a special meeting of stockholders may be called at any time by our board of directors, or our President or Chief Executive Officer, but such special meetings may not be called by the stockholders or any other person or persons. 

Requirements for Advance Notification of Stockholder Nominations and Proposals 

Our amended and restated bylaws establish advance notice procedures with respect to stockholder proposals and the nomination of candidates for election as directors, other than nominations made by or at the direction of the board of directors or a committee of the board of directors. 

Elimination of Stockholder Action by Written Consent 

Our amended and restated certificate of incorporation and our amended and restated bylaws eliminate the right of stockholders to act by written consent without a meeting. 

Classified Board; Election and Removal of Directors; Filling Vacancies 

Our board of directors is divided into three classes. The directors in each class serve for a three-year term, with one class being elected each year by our stockholders, with staggered three-year terms. Only one class of directors will be elected at each annual meeting of our stockholders, with the other classes continuing for the remainder of their respective three-year terms. Because our stockholders do not have cumulative voting rights, our stockholders holding a majority of the shares of common stock outstanding will be able to elect all of our directors. Our amended and restated certificate of incorporation will provide for the removal of any of our directors only for cause and requires a stockholder vote by the holders of at least a 66 2/3% of the voting power of the then outstanding voting stock. For more information on the classified board, see “Management—Board Composition.” Furthermore, any vacancy on our board of directors, however occurring, including a vacancy resulting from an increase in the size of the board, may only be filled by a resolution of the board of directors unless the board of directors determines that such vacancies shall be filled by the stockholders. This system of electing and removing directors and filling vacancies may tend to discourage a third party from making a tender offer or otherwise attempting to obtain control of us, because it generally makes it more difficult for stockholders to replace a majority of the directors. 

 

Choice of Forum 

 

Our amended and restated certificate of incorporation and our amended and restated bylaws provide that the Court of Chancery of the State of Delaware shall be the sole and exclusive forum for (i) any derivative action or proceeding brought on behalf us, (ii) any action asserting a claim of breach of a fiduciary duty owed by any of our directors or officers to us or our stockholders, (iii) any action asserting a claim against us arising pursuant to any provision of the Delaware General Corporation Law or our amended and restated certificate of incorporation or amended and restated bylaws or (iv) any action asserting a claim against us governed by the internal affairs doctrine. As a result, any action brought by any of our stockholders with regard to any of these matters will need to be filed in the Court of Chancery of the State of Delaware and cannot be filed in any other jurisdiction; provided that, the exclusive forum provision will not apply to suits brought to enforce any liability or duty created by the Securities Act, the Exchange Act or any other claim for which the federal courts have exclusive jurisdiction; and provided further that, if and only if the Court of Chancery of the State of Delaware dismisses any such action for lack of subject matter jurisdiction, such action may be brought in another state or federal court sitting in the State of Delaware. Nothing in our amended and restated certificate of incorporation or amended and restated bylaws precludes stockholders that assert claims under the Securities Act or the Exchange Act from bringing such claims in state or federal court, subject to applicable law. 

 

 

This choice of forum provision may limit a stockholder’s ability to bring a claim in a judicial forum that it finds favorable for disputes with us or any of our directors, officers, other employees or stockholders, which may discourage lawsuits with respect to such claims, although our stockholders will not be deemed to have waived our compliance with federal securities laws and the rules and regulations thereunder. 

Amendment of Charter and Bylaws Provisions 

The amendment of any of the above provisions in our amended and restated certificate of incorporation, except for the provision making it possible for our board of directors to issue undesignated preferred stock would require approval by a stockholder vote by the holders of at least a 66 2/3% of the voting power of the then outstanding voting stock. 

The provisions of the Delaware General Corporation Law, our amended and restated certificate of incorporation and our amended and restated bylaws could have the effect of discouraging others from attempting hostile takeovers and, as a consequence, they may also inhibit temporary fluctuations in the market price of our common stock that often result from actual or rumored hostile takeover attempts. These provisions may also have the effect of preventing changes in our management. It is possible that these provisions could make it more difficult to accomplish transactions that stockholders may otherwise deem to be in their best interests. 

Limitations of Liability and Indemnification Matters 

Our amended and restated certificate of incorporation contains provisions that limit the liability of our directors for monetary damages to the fullest extent permitted by Delaware law. Consequently, our directors are not personally liable to us or our stockholders for monetary damages for any breach of fiduciary duties as directors, except liability for:

	
 
	
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any breach of the director’s duty of loyalty to us or our stockholders;

	
 
	
•
	
any act or omission not in good faith or that involves intentional misconduct or a knowing violation of law;

	
 
	
•
	
unlawful payments of dividends or unlawful stock repurchases or redemptions as provided in Section 174 of the Delaware General Corporation Law; or

	
 
	
•
	
any transaction from which the director derived an improper personal benefit.

Each of our amended and restated certificate of incorporation and amended and restated bylaws provide that we are required to indemnify our directors and officers, in each case to the fullest extent permitted by Delaware law. Our amended and restated bylaws also obligates us to advance expenses incurred by a director or officer in advance of the final disposition of any action or proceeding, and permit us to secure insurance on behalf of any officer, director, employee or other agent for any liability arising out of his or her actions in that capacity regardless of whether we would otherwise be permitted to indemnify him or her under Delaware law. We have entered and expect to continue to enter into agreements to indemnify our directors, executive officers and other employees as determined by our board of directors. With specified exceptions, these agreements provide for indemnification for related expenses including, among other things, attorneys’ fees, judgments, fines and settlement amounts incurred by any of these individuals in any action or proceeding. We believe that these bylaw provisions and indemnification agreements are necessary to attract and retain qualified persons as directors and officers. We also maintain directors’ and officers’ liability insurance.

The limitation of liability and indemnification provisions in our amended and restated certificate of incorporation and amended and restated bylaws may discourage stockholders from bringing a lawsuit against our directors and officers for breach of their fiduciary duty. They may also reduce the likelihood of derivative litigation against our directors and officers, even though an action, if successful, might benefit us and our stockholders. Further, a stockholder’s investment may be adversely affected to the extent that we pay the costs of settlement and damages.

 

Transfer Agent and Registrar 

The transfer agent and registrar for our common stock is American Stock Transfer and Trust Company, LLC. The transfer agent and registrar’s address is 6201 15th Avenue, Brooklyn, New York 11219.Exhibit 10.1

 

[FORM OF AGREEMENT]

 

COMMUNITY BANKERS TRUST CORPORATION

2019 Stock Incentive Plan

 

Performance-Based

Restricted Stock Unit Award Agreement

 

THIS AWARD AGREEMENT dated
as of the _____ day of __________, ____, between COMMUNITY BANKERS TRUST CORPORATION, a Virginia corporation (the “Company”)
and ____________ (“Participant”), is made pursuant and subject to the provisions of the Company’s 2019 Stock Incentive
Plan (the “Plan”). All terms used herein that are defined in the Plan have the same meaning given them in the Plan.

 

1.            Award
of Restricted Stock Units. The Company hereby grants to Participant on ________ __, _____, subject to the terms and conditions
of the Plan and subject further to the terms and conditions of this Award Agreement, __________ Restricted Stock Units (the “Restricted
Stock Units”). Each Restricted Stock Unit represents the right to receive one share of Company Stock, subject to vesting and the
other terms, conditions and restrictions set forth in this Award Agreement and in the Plan.

 

2.            Vesting.

 

(a)            Except
as otherwise provided in Section 3, provided Participant remains an employee of the Company or an Affiliate through the Vesting Date
(as defined herein), and the Company satisfies the applicable performance target set forth in Section 2(b) as determined by
the Committee as soon as practicable on or before ________ __, _____ (the date of such determination, the “Vesting Date”),
the Restricted Stock Units will vest in accordance with Section 2(b). The period during which the restrictions in this Award Agreement
apply, which is the Date of Grant through the Vesting Date, is referred to as the “Restricted Period”. Once vested, the Restricted
Stock Units become “Vested Units” and shares of Company Stock representing the Vested Units will be issued in accordance with
the settlement procedures set forth in Section 6. To the extent Participant’s vested percentage of Restricted Stock Units exceeds
100%, any additional shares of Company Stock to which Participant is entitled in accordance with Section 2(b) will be issued
to Participant on the Vesting Date.

 

(b)            The
Restricted Stock Units shall become Vested Units, subject to the provisions of this Award Agreement relating to continued employment,
in accordance with the table immediately below on the date the Committee determines ____________________ (“_____”) for the
Company, and the _____ rank, expressed as a percentile, based on Company _____ versus _____ of peers selected by the Committee (“_____
Rank”), for the period from ________ __, _____, through ________
__, _____ (the “Performance Period”). Any Restricted Stock Units outstanding on the Vesting Date that do not become
Vested Units on the Vesting Date will immediately be forfeited.

 

    

     

    

 

	ROA Rank	
    Number of Vested 

Units *
	Percentage Represented by 

Number of Vested Units 

(“Payout Percentage”) *
	_____ percentile or higher	 	 
	At least _____ percentile, but less than _____ percentile (“Target Performance”)	 	 
	At least _____ percentile, but less than _____ percentile	 	 
	Less than _____ percentile	 	 

 

*The applicable Number of Vested Units
and Payout Percentage shall be determined using straight-line interpolation of (i) Payout Percentages between _____ and _____, for
_____ Rank between _____ percentile and _____ percentile; and (ii) Payout Percentages between _____ and _____ for _____ Rank between
_____ percentile and _____ percentile.

 

(c)            The
vesting of the Restricted Stock Units is subject to the determination of the Committee, in its discretion, that the Company has satisfied
the applicable performance target.

 

3.            Effect
of Termination of Employment.

 

(a)            Except
as set forth in the following sentence and Sections 3(b) and 3(c), if Participant’s employment terminates for any reason during
the Restricted Period, all the Restricted Stock Units that are not then vested shall be automatically forfeited upon such termination
of employment, and the Company shall not have any further obligation to Participant under this Award Agreement. The Committee may, in
its discretion, on or before the date of termination of employment, determine that all or a portion of the Restricted Stock Units that
are not then vested shall become Vested Units as of the date of Participant’s termination of employment.

 

(b)            If
Participant dies or become Disabled while employed with the Company or an Affiliate during the Restricted Period, a pro rata portion of
the Restricted Stock Units that are not vested shall become Vested Units of the date of Participant’s death or the termination of
Participant’s employment due to Disability. Such vested portion will equal (i) the number of Restricted Stock Units that represent
Target Performance (i.e., a 100% Payout Percentage) multiplied by (ii) a fraction, (x) the numerator of which
is the number of days during the Performance Period in which Participant was employed with the Company or an Affiliate and (y) the
denominator of which is the number of days in the Performance Period.

 

    2

     

    

 

(c)            If
a Change in Control of the Company occurs during the Restricted Period and Participant has remained employed with the Company or an Affiliate
until immediately prior to the Change in Control, a pro rata portion of the Restricted Stock Units that are not vested shall become Vested
Units as of the date of the Change in Control. Such vested portion will equal (i) the number of Restricted Stock Units that represent
Target Performance (i.e., a 100% Payout Percentage) multiplied by (ii) a fraction, (x) the numerator of which
is the number of days during the Performance Period prior to the date of the Change in Control and (y) the denominator of
which is the number of days in the Performance Period.

 

4.            Restrictions.
Subject to any exceptions set forth in this Award Agreement or the Plan, during the Restricted Period and until such time as the Restricted
Stock Units are settled in accordance with Section 6, the Restricted Stock Units or the rights relating thereto may not be sold,
assigned, alienated, pledged or otherwise transferred or encumbered by Participant, whether voluntary or involuntary. Any attempt to sell,
assign, alienate, pledge or otherwise transfer or encumber the Restricted Stock Units or the rights relating thereto shall be wholly ineffective
and, if any such attempt is made, the Restricted Stock Units will be forfeited and all of Participant’s rights to such Restricted
Stock Units shall immediately terminate without any payment or consideration by the Company.

 

5.            Shareholder
Rights.

 

(a)            Participant
shall not have any rights of a shareholder with respect to the shares of Company Stock underlying the Restricted Stock Units unless and
until the Restricted Stock Units vest and are settled by the issuance of shares of Company Stock. Notwithstanding the foregoing, an amount
equal to the cash or stock dividends paid from the Date of Grant through the applicable Vesting Date, on the number of shares of Company
Stock for which this Award is settled under Section 6, will be paid to Participant, in cash (or in shares of Company Stock at the
discretion of the Committee) within five days of the applicable Vesting Date. Any shares of Company Stock so issued shall be subject to
the provisions of this Award Agreement applicable to Company Stock issued in settlement of Vested Units.

 

(b)            Upon
and following the settlement of the Restricted Stock Units, Participant shall be the record owner of the shares of Company Stock issued
to Participant (unless and until such shares are sold or otherwise disposed of), and as record owner shall be entitled to all rights of
a shareholder of the Company.

 

6.            Settlement
of Vested Units. Subject to Section 7, on the Vesting Date (or, if sooner, on the date the Restricted Stock Units become
vested under Section 3) the Company shall issue and deliver to Participant (or issue via book entry) the number of shares of Company
Stock, if any, equal to the Number of Vested Units and enter Participant’s name on the books of the Company as the shareholder of
record with respect to the shares of Company Stock issued to Participant.

 

    3

     

    

 

7.            Tax
Liability and Income Tax Withholding. Participant agrees, as a condition of receiving this Award, to pay to the Company or an
Affiliate, or make arrangements satisfactory to the Company or the Affiliate regarding the payment of, all Applicable Withholding Taxes
with respect to the Award. Until the Applicable Withholding Taxes have been paid or arrangements satisfactory to the Company or the Affiliate
have been made, no stock certificates or book-entry shares shall be issued to Participant. As an alternative to making a cash payment
to the Company or the Affiliate to satisfy Applicable Withholding Tax obligations, the Committee may establish procedures permitting Participant
to elect to (a) deliver shares of already owned Company Stock or (b) have the Company retain that number of shares of Company
Stock from the shares otherwise deliverable under the Award, in either case with respect to which the Company has a statutory obligation
to withhold taxes. Any such election shall be made only in accordance with procedures established by the Committee to avoid a charge to
earnings for financial accounting purposes and in accordance with Rule 16b-3.

 

8.            Fractional
Shares. Fractional shares shall not be issuable hereunder and, when any provision hereof may entitle Participant to a fractional
share, such fraction shall be disregarded.

 

9.            No
Right to Continued Employment. This Award does not confer upon Participant any right with respect to continuance of employment
with the Company or an Affiliate, nor shall it interfere in any way with the right of the Company or any Affiliate to terminate Participant’s
employment at any time.

 

10.            Change
in Capital Structure. In accordance with Section 12 of the Plan, the number of Restricted Stock Units and shares of Company
Stock that may be issued hereunder shall be proportionately adjusted for changes in the outstanding shares of Company Stock or in the
capital structure of the Company by reason of any stock or extraordinary cash dividend, stock split, reverse stock split, an extraordinary
corporate transaction such as any recapitalization, reorganization, merger, spin-off of a subsidiary, or other relevant change in capitalization
occurring after the Date of Grant.

 

11.            Governing
Law. This Award Agreement shall be governed by and construed and enforced in accordance with the laws of the Commonwealth of Virginia,
excluding any choice of law rules or principles that might otherwise refer construction or interpretation of any provision of the
Plan or this Award Agreement to the substantive law of another jurisdiction.

 

12.            Conflicts.
In the event of any conflict between the provisions of the Plan and the provisions of this Award Agreement, the provisions of the Plan
shall govern.

 

13.            Participant
Bound by Plan; Definitions. Participant hereby acknowledges receipt of a copy of the Plan and agrees to be bound by all the terms
and provisions thereof. Unless otherwise noted, defined terms used in this Award Agreement have the same meaning as provided in the Plan.

 

14.            Binding
Effect. Subject to the limitations stated above and in the Plan, this Award Agreement shall be binding upon and inure to the benefit
of the legatees, distributees, and personal representatives of Participant and the successors of the Company.

 

[Signatures on Next Page]

 

    4

     

    

 

IN
WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date first written above.

 

 

	 	community
    bankers trust corporation
	 	 
	 	 
	 	By:	                   
	 	 	 
	 	Its:	 
	 	 

 

	 	[participant
    name]
	 	 
	 	 
	 	Signature: 	               

 

    5

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