Document:

Exhibit 10.12

 

AGREEMENT

 

THIS AGREEMENT is made effective as of July 18, 2018 and between,
Alliance MMA, Inc. (“Alliance” or the “Company”), with an address at 590 Madison Ave, 21st Floor,
New York, New York, 10022, Robert J. Haydak (sometimes hereinafter “Haydak”), CFFC Promotions, LLC, of which Haydak
is a Manager (“CFFC”), Maria Haydak (someties hereinafter “M. Haydak”), and Hoss Promotions, LLC, of which
M. Haydak is a Manager (“Hoss”).

 

RECITALS

 

WHEREAS, Haydak, CFFC and the Company (among others) entered
into that certain asset purchase agreement dated February 23, 2016, as amended by amendment no.1 dated July 16, 2016 (“APA”),
under which the Company acquired certain assets from CFFC, all as described in the APA;

 

WHEREAS, Hoss and the Company entered into that certain fight
library copyright purchase agreement dated February 23, 2016 (“FLPA”), under which the Company acquired certain copyrights
from Hoss, all as described in the FLPA (the “Fight Library”)

 

WHEREAS, in connection with the APA, Haydak and the Company
entered into that certain employment agreement dated September 30, 2016 pursuant to which Haydak became President of the Company
(“Employment Agreement”);

 

WHEREAS, the Company and Haydak desire (i) to separate and terminate
the Employment Agreement and (ii) transfer to Haydak those Assets listed on Schedule A hereto;

 

WHEREAS, the Company, Haydak and CFFC desire to terminate the
APA.

 

WHEREAS, the Company, M. Haydak and Hoss desire to terminate
the FLPA

 

AGREEMENT

 

Now, therefore, the parties hereto, for good and valuable
consideration, the receipt and sufficiency of which are hereby acknowledged, agree as follows:

 

		1.	Recitals. The foregoing recitals are hereby incorporated
into this Agreement.

 

		2.	Transfer of Acquired Assets. The Company does hereby convey to Haydak all of its right, title and interest in and to
(i) the assets listed on Schedule A and (ii) the CFFC and Caged Fury Fighting Championship tradenames and any associated fight
libraries, trademarks, service marks, copyrights, trade names, be they current or pending, along with the domain and social media
accounts under said names, and the Fight Library (“Assets”). Haydak acknowledges that as of the execution hereof, he
has dominion and control over the Assets and he accepts them as is, where is. The Company makes no warranty, express or implied
regarding the Assets, other than said Assets are not subject to any liens. The company shall provide reasonable cooperation to
Haydak regarding any action he may bring against third parties regarding any of the Assets..

 

     

     

    

 

		3.	Retention of AMMA Shares. Haydak shall retain any cash already paid and all shares of stock already issued to him pursuant
to the APA. The employment of Haydak terminated effective February 7, 2018 (“Termination Date”).  Accordingly,
after the Termination Date, Haydak is no longer an employee of the Company.  The shares of Common Stock currently owned by
Haydak are no longer subject to any restriction resulting from his status as an employee/officer of the Company.  Accordingly,
Haydak may sell the Common Stock owned by him, subject to compliance with applicable federal and state securities laws, including
laws related to insider trading.

 

		4.	Termination of APA/FLPA. Each of the APA and FLPA is hereby terminated and none of the parties thereto shall have any
further rights or obligations thereunder.

 

		5.	Termination of Employment Agreement. The Employment Agreement is hereby terminated and neither Company nor Haydak shall
have any further rights or obligations thereunder.

 

		6.	Payment to Haydak. In consideration of the releases and covenants contained herein, the company shall, on or before
September 30, 2018, Pay Haydak the sum of $50,000 by wire transfer in accordance with the instructions set forth on Schedule B
hereto.

 

		7.	Voting Agreement.  Haydak agrees at the Company’s option to either give Company management a proxy to vote or
to directly vote all shares of Company common stock over which Haydak has voting control in favor of any transaction as to which
the Company’s Board of Directors recommends approval.

 

		8.	Cooperation. Each of Haydak and M. Haydak shall cooperate with the Company and its auditors and provide such information
as the auditors require in connection with the preparation of interim and annual financial statements for the year ended December
31, 2018 and will respond to these requests within 24 hours.

 

		9.	Release of Company and Related Persons. In consideration of the above, Each of Haydak, CFFC, M. Haydak and Hoss, including
their respective affiliates, spouses, officers, directors, partners, shareholders, employees, agents and attorneys, hereby release
and forever discharge Ivy Equity Investors, LLC, the Company and its subsidiaries, and their respective current and former founders,
promoters, officers, directors, partners, members, shareholders, employees, agents and attorneys in their official and individual
capacities from all actions, causes of action, suits, debts, covenants, contracts, agreements, promises, trespasses, damages, payments,
judgments, claims and demands whatsoever, known or unknown, which such persons ever had, now have or hereafter may have for, upon
or by reason of any matter, cause or thing whatsoever from the beginning of the world to the date of this Agreement, including
without limitation under the APA, FLPA and Employment Agreement. Nothing in this release shall prevent the enforcement of the provisions
of this Settlement Agreement.

 

     

     

    

 

		10.	Release of Haydak/CFFC/M. Haydak/Hoss and Related Persons. In consideration of the above, the Company, including its
affiliates, subsidiaries, officers, directors, employees, agents and attorneys, hereby release and forever discharge each of Haydak,
CFFC, M. Haydak and Hoss, and their respective current and former founders, promoters, officers, spouses, directors, partners,
shareholders, members, employees, agents and attorneys in their official and individual capacities from all actions, causes of
action, suits, debts, covenants, contracts, agreements, promises, trespasses, damages, payments, judgments, claims and demands
whatsoever, known or unknown, which the such persons ever had, now have or hereafter may have for, upon or by reason of any matter,
cause or thing whatsoever from the beginning of the world to the date of this Agreement, including without limitation under the
APA, FLPA and Employment Agreement.. Nothing in this release shall prevent the enforcement of the provisions of this Settlement
Agreement.

  

		11.	Dismissal of Action/Consent Order. Promptly following the execution hereof, Haydak shall file a consent order (in ofrm
and substance reasonably satisfactory to the Company dismissing with prejudice the lawsuit captioned Robert J. Haydak V. Alliance
MMA, Inc. Docket #1:18–CV-10822, and incorporating the terms of this agreement. The parties agree that the court shall retain
jurisdiction over enforcement of this agreement.

  

		12.	Non-Disparagement. The Parties agree that from this time forward
each Party will refrain from making to a third party any defamatory, derogatory, or disparaging statements about the other, or
any person or entity associated with or representing the other.

  

		13.	Entire Agreement. The Agreement represents the entire agreement and understanding between the Parties concerning the
subject matter of this Agreement and supersedes any and all prior agreements or understandings. No materials outside the body of
this Agreement, either written or oral, shall constitute a part of the terms or conditions of this Agreement, except where otherwise
stated herein.

  

		14.	Applicable Law. This Agreement shall be construed and interpreted
in accordance with the laws of the State of New York. Any disputes or litigation arising out of this Settlement Agreement shall
be governed by New York law.

  

		15.	Binding Effect. This Agreement shall be binding on, and shall be enforceable against, and shall inure to the benefit
of the Parties to this Agreement and their respective past and present officers, directors, affiliates, member firms, subsidiaries,
parents, successors, shareholders, members, partners, general partners, limited partners, principals, participating principals,
managing members or other agents, management personnel, attorneys, servants, employees, representatives of any other kind (and
any officers, directors, members or shareholders of any of the foregoing which are not natural persons), spouses, estates, executors,
estate administrators, heirs, and assigns.

  

		16.	Waiver and Amendment. No provision of or rights under this
Settlement Agreement may be waived or modified unless in writing and signed by the Party whose rights are thereby waived or modified.
Waiver of any one provision herein shall not be deemed to be a waiver of any other provision herein (whether similar or not), nor
shall such waiver constitute a continuing waiver unless otherwise expressly so provided.

   

     

     

    

 

		17.	Disputes. In case any dispute shall arise under this agreement, the prevailing party shall be entitled to prompt reimbursement
of reasonable legal fees incurred in connection with the enforcement of this Agreement.

 

 

		18.	Confidentiality. The Parties and their respective counsel agree to maintain in the strictest confidence and not disclose
to the public, media, or any third parties (except upon order of a court or governmental body, or as required by law or for reporting
to their auditors, investors or similarly interested parties under an obligation to maintain confidentiality) the contents and
terms of this Agreement, provided that it is agreed that Haydak may disclose publicly that he has resumed operating under the CFFC/Caged
Fury Fighting Championship tradenames.

 

 

 

The Parties hereto have executed this Agreement as an instrument
under seal as of the date written above.

 

Alliance MMA, Inc.

 

/s/ John Price

 

John Price, Co-President/CFO, duly authorized

 

 

 /s/ Robert J. Haydak

 

Robert J. Haydak

 

 

 

CFFC Promotions, LLC

 

/s/ Robert J. Haydak

 

Robert J. Haydak, duly authorized

 

 

/s/ Maria Haydak

 

Maria Haydak

 

 

  

Hoss Promotions, LLC

 

/s/ Maria Haydak

 

Maria Haydak, duly authorized

 

     

     

    

 

Schedule A

List of Assets

 

	Asset Number	Assignment
    Date	Assigned To	Owner	Title	Description	Serial Number	STATUS
	 	 	Digital	 	@CFFCmma Instagram Account	 	 	Jason Robinett
	 	 	Digital	 	@CFFCmma Snapchat Account	 	 	Jason Robinett
	 	 	Digital	 	@CFFCmma Twitter Account	 	 	Jason Robinett
	197	 	Brad Boulton	Alliance MMA, Inc.	16TB G-RAID Thunderbolt Enclosure	16tb G-Raid Hard Drive	DC0173100904	Good
	198	 	Mark Chmielinski	Alliance MMA, Inc.	16TB G-RAID Thunderbolt Enclosure	16tb G-Raid Hard Drive	DC0173100260	Good
	199	 	Mark Chmielinski	Alliance MMA, Inc.	16TB G-RAID Thunderbolt Enclosure	16TB G-RAID Thunderbolt Enclosure hard drive	DC0171300791	Good
	200	 	Mark Chmielinski	Alliance MMA, Inc.	16TB G-RAID Thunderbolt Enclosure	16TB G-RAID Thunderbolt Enclosure hard drive	DC0171300460	Good
	118	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	AAS HD-SDE-122 SDI Extender	AAS HD-SDE-122 SDI Extender	N/A	Good
	178	 	Mark Chmielinski	Alliance MMA, Inc.	AC Adapter for CHARGER - CLEARCOM HME Lithium Ion Battery	AC Adapter for CHARGER - CLEARCOM HME Lithium Ion Battery	N/A	Good
	201	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	AJA 1X6 SDI DBA 	SDI Distributor and Booster	K0088525	Good
	208	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	AJA HDTV SDI DBA	SDI Booster	K0108401	Good
	187	 	Mark Chmielinski	Alliance MMA, Inc.	Alienware 17 R4 Laptop	Alienware 17 R4 Laptop for Streaming	5TMLBH2	Good
	 	 	Devon	 	Apparel	 	 	Good w / Devon
	11001	 	Devon	 	Apparel Table Cover	 	 	Good w / Devon
	202	 	Mark Chmielinski	Alliance MMA, Inc.	Black Magic Mini Converter SDI DBA	SDI DBA	2871507	Good
	104	 	Mark Chmielinski	Alliance MMA, Inc.	Black Magic UltraStudio Mini Recorder	SDI/HDMI to Thunderbolt converter for live streaming using a thunderbolt
    laptop.	3652042	Good
	 	 	Storage	 	Cables / Wiring	 	 	All Good
	 	 	Digital	 	Cage Fury Fighting Championships Facebook Page	 	 	Jason Robinett
	 	 	Digital	 	Cage Fury MMA Youtube Account	 	 	Jason Robinett
	11002	 	Devon	 	Cage Girl Outfits	 	 	Good w / Devon
	106	 	Mark Chmielinski	Alliance MMA, Inc.	Canon 24-70mm Lens	Canon 24-70 mm lens for Sony FS7	4755004986	Good
	119	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	CCTV HD-SDE-122-OEM SDI Distributor	CCTV HD SDI Distribution Amplifier & Extender	N/A	Good
	 	 	Digital	 	CFFC Broadcast Graphics Package	 	 	Good
	 	 	Digital	 	CFFC Complete Video Library	 	 	Good. Hard copies are safe but the Amazon back ups should be secured
    for redundancy.
	 	 	Digital	 	CFFC Event Marketing Folder (Dropbox)	 	 	Possibly good. Need to confirm.
	 	 	Digital	 	CFFC Google Analytics Account	 	 	Jason Robinett
	 	 	Digital	 	CFFC Mailchimp Account	 	 	Jason Robinett
	 	 	Digital	 	CFFC Stripe Account	 	 	Jason Robinett
	 	 	Digital	 	CFFC.tv and associated Domain Names	 	 	Jason Robinett
	 	 	Digital	 	CFFC.tv Hosting (Squarespace)	 	 	Jason Robinett
	11003	 	Devon	 	Champion Banners	 	 	Good w/ Devon
	177	 	Mark Chmielinski	Alliance MMA, Inc.	CHARGER - CLEARCOM HME Lithium Ion Battery	CHARGER - CLEARCOM HME Lithium Ion Battery	N/A	Good
	169	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0097 2017-06	Good
	170	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0094 2017-06	Good
	171	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0084 2017-06	Good
	172	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0019 2017-06	Good
	173	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0096 2017-06	Good
	174	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0085 2017-06	Good
	175	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0095 2017-06	Good
	176	 	Mark Chmielinski	Alliance MMA, Inc.	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset	Clear-Com CC-15-MD4 Single-Ear/Noise-Cancelling Headset with Mini
    DIN Connector for DX Series Wireless Intercom	N23W0010 2017-06	Good
	145	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08084 2017-08	Good
	146	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W06902 2017-08	Good
	147	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W06384 2017-08	Good
	148	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08090 2017-08	Good
	149	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08088 2017-08	Good
	150	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08086 2017-08	Good
	151	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08087 2017-08	Good
	152	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	CLEARCOM DX410 SYTEM BELT PACK (WIRELESS)	36W08093 2017-08	Good
	179	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM DX410 WIRELESS COMM SYSTEM	CLEARCOM DX410 WIRELESS COMM SYSTEM	N/A	Good
	153	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15320	Good
	154	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15546	Good
	155	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15088	Good
	156	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG18632	Good
	157	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG13354	Good
	158	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15503	Good
	159	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15257	Good
	160	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15531	Good
	161	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15303	Good
	162	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG13262	Good
	163	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG18536	Good
	164	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG13250	Good
	165	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15379	Good
	166	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15341	Good
	167	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG15533	Good
	168	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM HME Lithium Ion Battery	CLEARCOM HME Lithium Ion Battery for DX410 Beltpacks	B17AUG13086	Good
	181	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM MA-704	CLEARCOM MA-704 for IFB control	N/A	Good
	180	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM MS-704 MAIN STATION	CLEARCOM MS-704 MAIN STATION	N/A	Good
	182	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM PIC-4744 IFB ROUTER	CLEARCOM PIC-4744 IFB ROUTER	N/A	Good
	183	 	Mark Chmielinski	Alliance MMA, Inc.	CLEARCOM PS-702 Power Supply	CLEARCOM PS-702 Power Supply	N/A	Good
	209	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Connect Cable Test System	Multiple Cables Test System	N/A	Good
	 	 	Storage	 	Dell Monitor	 	 	Good
	223	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Dell Monitor P2715Q	Dell Flat Panel Monitor	CN0X24K1WS20076K249L	Good
	20	22/7/2017	Jason Robinett	Jason Robinett	Dell PowerEdge R620 Server	Vmware ESXi Hypervisor	 	TRASHED
	 	 	Storage	 	Drone	 	 	HAVE IT BUT BROKEN
	 	 	Storage 	 	Editing Room TV	 	 	Good
	120	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	eSYNiC SDI/HDMI Converter	eSYNiC SDI/HDMI Converter	N/A	Good
	210	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	eSYNiC SDI/HDMI Converter	SDI to HDMI Converter	N/A	Good
	11004	 	Burt Watson	 	Existing Glove Inventory	 	 	Burt Watson
	11005	 	Storage	 	Fog Machine	 	 	? POSSIBLY IN STORAGE. NEED TO CONFIRM.
	189	 	Mark Chmielinski	Alliance MMA, Inc.	FUJINON XA16x8A-XB8 LENS	FUJINON XA16x8A-XB8 LENS 8 - 128 mm	A62003329	Good
	190	 	Mark Chmielinski	Alliance MMA, Inc.	FUJINON XA16x8A-XB8 LENS	FUJINON XA16x8A-XB8 LENS 8 - 128mm	A62003505	Good
	191	 	Mark Chmielinski	Alliance MMA, Inc.	FUJINON XA16x8A-XB8 LENS	FUJINON XA16x8A-XB8 LENS 8 - 128mm	A62004796	Good
	134	 	Brandon Harris	Alliance MMA, Inc.	G-RAID 16TB Drive	G-RAID 16TB Drive for Content backup and archiving	B475K00304	Good
	225	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Genaray Overhead Camera Light	Overhead Camera Light	N/A	Good
	206	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	HD CCTV SDI DBA	SDI Booster	N/A	Good
	93	 	Mark Chmielinski	Alliance MMA, Inc.	IKAN LED Light	LED light for field and studio shooting.	408007590	Good
	94	 	Mark Chmielinski	Alliance MMA, Inc.	IKAN LED Light	LED light for field and studio shooting.	411000222	Good 
	95	 	Mark Chmielinski	Alliance MMA, Inc.	IKAN LED Light	LED light for field and studio shooting.	410006802	Good
	96	 	Mark Chmielinski	Alliance MMA, Inc.	IKAN LED Light	LED light for field and studio shooting.	411000219	Good
	101	 	Mark Chmielinski	Alliance MMA, Inc.	IKAN LED Light	LED Light for field & studio shooting.	N/A  Ineligible	BROKEN | TRASHED
	184	 	Jamie Sims	Alliance MMA, Inc.	iMac Retina 5K 27 inch 2017	iMac Retina 5K 27 inch 2017	D25VH0VHJ1GQ	AT JAMIE SIMS HOME
	185	 	Mark Chmielinski	Alliance MMA, Inc.	iMac Retina 5K 27 inch 2017	iMac Retina 5K 27 inch 2017	D25VH0GQJ1GQ	Good
	11006	 	Storage	 	Large TV + Stand (70inch?)	 	 	Good
	227	 	Sharon Carpenter	Alliance MMA, Inc.	Laser Jet Pro M402dn	Laser Jet Pro M402dn check printer	PHBQD72830	Good
	196	 	Mark Chmielinski	Alliance MMA, Inc.	LECTROSONICS IFB RECEIVER	R1a IFB RECEIVER 	40602	Good
	204	 	Mark Chmielinski	Alliance MMA, Inc.	LECTROSONICS IFB RECEIVER	IFB Receiver for Talent queuing.	40505	Good
	195	 	Mark Chmielinski	Alliance MMA, Inc.	LECTROSONICS IFB TRANSMITTER	IFBT4 UHF Transmitter	11606	Good
	203	 	Mark Chmielinski	Alliance MMA, Inc.	LECTROSONICS IFB TRANSMITTER	IFB Transmitter for queuing talent.	11608	Good
	140	27/7/2017	Mark Chmielinski	Alliance MMA, Inc.	mac OS Sierra	Mac OS Sierra Computer	D25TH0DXGQ17	Good
	141	27/7/2017	Mark Chmielinski	Alliance MMA, Inc.	mac OS Sierra	mac OS Sierra Mac Pro computer	CMVHX0HWF4MG	Good
	142	27/7/2017	Mark Chmielinski	Alliance MMA, Inc.	Mac OS X Yosemite	Mac OS X Yosemite Computer	H01480ECEUH	Good
	139	27/7/2017	Mark Chmielinski	Alliance MMA, Inc.	Mac Pro (Early 2008)	Mac Pro (Early 2008) computer	G88421F312K	Good
	143	27/7/2017	Mark Chmielinski	Alliance MMA, Inc.	Mac Pro (mid 2012)	mac OS Sierra computer	CMVHX0HTF4MG	Good
	11008	 	(Former Matt Cassidy)	 	Macbook Air	 	 	Good w/ Jason
	11009	 	(Former Dalton Lanoza)	 	Macbook Air	 	 	Good
	11010	 	(Former Brad Boulton)	 	Macbook Pro	 	 	Good w / Jason
	11011	 	Storage	 	Macbook Pro (Audio ISO Recording Laptop)	 	 	Good
	98	 	Mark Chmielinski	Alliance MMA, Inc.	MacBook Pro (Retina, 15-inch, Mid 2015)	2015 Macbook Pro	C02SV29DG8WL	Good
	186	 	Mark Chmielinski	Alliance MMA, Inc.	MacBook Pro 15-inch Mid 2015	MacBook Pro 15-inch Mid 2015	C02S43NBG8WP	Good
	11012	 	Devon	 	Mannequins	 	 	Good w / Devon
	19	22/7/2017	Brandon Harris	Brandon Harris	Mevo Battery	Extended battery for Mevo wireless camera	 	Good
	136	 	David Oblas	Alliance MMA, Inc.	Mevo Battery	Battery extender for MEVO unit	AA00308599	MISSING | Last known possesor was David Oblas
	18	22/7/2017	David Oblas	Brandon Harris	Mevo Unit	Mevo wireless camera unit	 	Good
	135	 	Mark Chmielinski	Alliance MMA, Inc.	Mevo Unit	Camera for Live streaming to facebook.	AA00148488	MISSING | Last known possesor was David Oblas
	 	 	Devon	 	Mic Flags / Covers	 	 	CFFC Mic Flags are good.
	 	 	Storage	 	Mice + keyboards	 	 	All Good
	 	 	Storage	 	Misc Hard Drives	 	 	All Good
	 	 	Storage	 	Misc Memory Cards	 	 	All Good
	 	 	Storage	 	Mixing Boards	 	 	All Good
	121	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	MSC HD/SDI Distribution Amp	MSC HD/SDI Distribution Amplifier 	MSC-9597	Good
	 	 	Storage	 	Multiple Apple Cinema Displays (3?)	 	 	2 Are Good. 1 is with JAMIE SIMS
	 	 	Storage	 	News Desk	 	 	Good
	125	 	Mark Chmielinski	Alliance MMA, Inc.	NewTek 3Play 425	3Play 425 Instant Replay Unit	M1AF16490221150	Good
	126	 	Mark Chmielinski	Alliance MMA, Inc.	NewTek 3Play 425 Control Surface	Control Surface for NewTek 3Play 425	61zzz3537255426	Good
	124	 	Mark Chmielinski	Alliance MMA, Inc.	NewTek Tricaster 860	NewTek Tricaster 860 Live Production Switcher	NA3019019503559	Good
	123	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	NewTek TriCaster TCX0850 CS	NewTek TriCaster System	J1N019847920080	Good
	 	 	Storage	 	Office Inkjet Printer	 	 	Good
	 	 	(Former Rob Haydak)	 	Office Inkjet Printer	 	 	Good w/ Burt
	 	 	Storage	 	Office Laser Printer	 	 	Good
	 	 	Storage	 	Older iMacs (x2?)	 	 	MARK
	 	 	Storage	 	Other new iMac	 	 	? Possibly thrown out due to it being broken. This was not new.
	 	 	Devon Mathiesen	 	Past Event Poster Memorabilia 	 	 	Discared during office move out.
	226	 	Mark Chmielinski	Alliance MMA, Inc.	Pelican Case 1600	Pelican case for streaming laptop and related gear.	N/A	Good
	 	 	Devon Mathiesen	 	Pop Up Banners	 	 	Good w / Devon
	224	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	PreSonus Headset Monitor	PreSonus Audio and Headset System	HP4C12061188	Good
	 	 	VFC Trailer / ryan stoddard	 	Production Trailer purchased for Cage Transfer	 	 	Good w / Ryan Stoddard
	108	13/7/2017	Mark Chmielinski	Alliance MMA, Inc.	RODE NTG-2 Shotgun Microphone	RODE NTG-2 Shotgun Mic	0255292	Good
	109	13/7/2017	Mark Chmielinski	Alliance MMA, Inc.	RODE NTG-2 Shotgun Microphone	RODE NTG-2 Shotgun Mic	0255293	Good
	83	 	Mark Chmielinski	Alliance MMA, Inc.	SACHTLER DV 12TB TRIPOD	SACHTLER DV 12TB TRIPOD	N/A	Good
	84	 	Mark Chmielinski	Alliance MMA, Inc.	SACHTLER DV 12TB TRIPOD	SACHTLER DV 12TB TRIPOD	N/A	Good
	85	 	Mark Chmielinski	Alliance MMA, Inc.	SACHTLER VIDEO 18P TRIPOD	SACHTLER VIDEO 18P TRIPOD	N/A	Good
	 	 	Devon Mathiesen	 	Scale	 	 	Good w / Devon
	122	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SDI Splitter	SDI Splitter & Distribution Amp	N/A	Good
	205	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	SDI Splitter DBA	SDI Splitter and Booster	14090000000000422	Good
	212	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	SDI01 SDI to HDMI Converter	SDI to HDMI Converter	1226011393	Good
	216	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Butt Plug	Microphone Wireless Transmitter	N/A	Good
	219	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Butt Plug	Wireless Mic Transmitter	N/A	Good
	211	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Receiver	Wireless Mic Receiver	4274049880	Good
	218	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Receiver	Wireless microphone receiver	4244049346	Good
	110	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Transmitter	Sennheiser ew 100 G3 Lav Mic	4284088771	Good
	111	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser ew 100 G3 Wireless Transmitter	Sennheiser ew 100 G3 Lav Mic	4284088769	Good
	89	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser HMD 26-II-600 Announcer Headset Mic	Commentator Headset Mic for live broadcasts	1037108907	Good
	90	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser HMD 26-II-600 Announcer Headset Mic	Commentator Headset Mic for live broadcasts	1097109329	Good
	91	 	Mark Chmielinski	Alliance MMA, Inc.	Sennheiser HMD 26-II-600 Announcer Headset Mic	Commentator Headset Mic for live broadcasts	1037108904	Good
	92	 	Mark Chmielinski	Alliance MMA, Inc.	Shiny Bow 4x Video DBA	4x DBA for Composite video signal	N/A	Good
	207	 	Mark Chmielinski	Alliance MMA, Inc.	Shure SM-58 Microphone	Stick Microphone	N/A	Good
	102	 	Brad Boulton	Alliance MMA, Inc.	Sony A7S II Mirrorless DSLR	4K DLSR for cinematic video and photos.	3398320	Good
	129	 	Mark Chmielinski	Alliance MMA, Inc.	Sony AC Adaptor/Charger	Charger for Sony BP-U batteries	16073003984	Good
	74	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BC-L70 BATTERY CHARGER	SONY BC-L70 BATTERY CHARGER for PMW-350 batteries	0100289	Good
	75	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BC-L70 BATTERY CHARGER	SONY BC-L70 BATTERY CHARGER for PMW-350 batteries	0100621	Good
	76	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BC-L70 BATTERY CHARGER	SONY BC-L70 BATTERY CHARGER for PMW-350 batteries	0100623	Good
	64	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019309	Good
	65	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019392	Good
	66	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019306	Good
	67	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019399	Good
	68	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019310	Good
	69	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019400	Good
	70	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019395	Good
	71	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019393	Good
	72	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019397	Good
	73	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-GL95 LITHIUM ION BATTERY PACK	SONY BP-GL95 LITHIUM ION BATTERY PACK for PMW-350 Camera	0019307	Good
	61	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-L90 LITHIUM ION BATTERY PACK	SONY BP-L90 LITHIUM ION BATTERY PACK for Sony PMW-350	 	Good
	62	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-L90 LITHIUM ION BATTERY PACK	SONY BP-L90 LITHIUM ION BATTERY PACK for PMW-350 camera	 	Good
	63	 	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-L90 LITHIUM ION BATTERY PACK	SONY BP-L90 LITHIUM ION BATTERY PACK for PMW-350 Camera	 	Good
	128	 	Mark Chmielinski	Alliance MMA, Inc.	Sony BP-U30 Battery	Sony BP-U30 Battery for Sony FS7	0427750	Good
	220	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Sony BP-U30 Battery	Lithium Ion Battery Pack	20080207	Good
	221	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Sony BP-U30 Battery	Lithium Ion Battery Pack	20071126	Good
	222	17/1/2018	Mark Chmielinski	Alliance MMA, Inc.	Sony BP-U30 Battery	Lithium Ion Battery Pack	20120125	Good
	213	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-U60 Lithium ION Battery	Lithium ION Converter	20071001	Good
	215	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	SONY BP-U60 Lithium ION Battery	Lithium Ion Battery	20080424	Good
	 	 	Storage	 	Sony EX3 Cameras (3-5?)	 	 	3 EX3's Good
	103	 	Brad Boulton	Alliance MMA, Inc.	Sony FE 2.8 / 24 - 70 Lens	Lens for Sony A7S II	1842366	Good
	194	 	Mark Chmielinski	Alliance MMA, Inc.	SONY PMW-350 BROADCAST CAMERA	SONY PWM-350 BROADCAST CAMERA for TV & Web Productions by ASM	110708	Good
	193	 	Mark Chmielinski	Alliance MMA, Inc.	SONY PMW-350 BROADCAST CAMERA	SONY PWM-350 BROADCAST CAMERA	112624	Good
	192	 	Mark Chmielinski	Alliance MMA, Inc.	SONY PMW-350 BROADCAST CAMERA	SONY PWM-350 BROADCAST CAMERA	111960	Good
	107	13/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY PXW-FS7 CAMERA	SONY PXW-FS7 CAMERA	0028731	Good
	114	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS PRO Memory Card	SONY SxS PRO Memory Card	N/A	Good
	112	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS-1 Memory Card	SONY SxS-1 Memory Card	N/A	Good
	113	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS-1 Memory Card	SONY SxS-1 Memory Card	N/A	Good
	115	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS-1 Memory Card	SONY SxS-1 Memory Card	N/A	Good
	116	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS-1 Memory Card	SONY SxS-1 Memory Card	N/A	Good
	117	18/7/2017	Mark Chmielinski	Alliance MMA, Inc.	SONY SxS-1 Memory Card	SONY SxS-1 Memory Card	N/A	Good
	77	 	Mark Chmielinski	Alliance MMA, Inc.	SONY VCT-14 TRIPOD PLATE	Tripod Plate for PMW-350 Cameras	4112001508	Good
	78	 	Mark Chmielinski	Alliance MMA, Inc.	SONY VCT-14 TRIPOD PLATE	Tripod Plate for PMW-350 Camera	4112001763	Good
	79	 	Mark Chmielinski	Alliance MMA, Inc.	SONY VCT-14 TRIPOD PLATE	Tripod Plate for PMW-350 Camera	4112001507	Good
	80	 	Mark Chmielinski	Alliance MMA, Inc.	SONY WRT-822 WIRELESS MIC TRANSMITTER	SONY WRT-822 WIRELESS MIC TRANSMITTER for PMW-350 Cameras	300502	Good
	81	 	Mark Chmielinski	Alliance MMA, Inc.	SONY WRT-822 WIRELESS MIC TRANSMITTER	SONY WRT-822 WIRELESS MIC TRANSMITTER for PMW-350 Camera	300476	Good
	82	 	Mark Chmielinski	Alliance MMA, Inc.	SONY WRT-822 WIRELESS MIC TRANSMITTER	SONY WRT-822 WIRELESS MIC TRANSMITTER for PMW-350 Camera	300501	Good
	130	 	Mark Chmielinski	Alliance MMA, Inc.	SONY XQD 128GB CARD	SONY XQD 128GB CARD for Sony FS7	N/A	Good
	131	 	Mark Chmielinski	Alliance MMA, Inc.	SONY XQD 128GB CARD	SONY XQD 128GB CARD for Sony FS7	N/A	Good
	132	 	Mark Chmielinski	Alliance MMA, Inc.	SONY XQD 64GB CARD	SONY XQD 64GB CARD for Sony FS7	N/A	Good
	133	 	Mark Chmielinski	Alliance MMA, Inc.	SONY XQD 64GB CARD	SONY XQD 64GB CARD for Sony FS7	N/A	Good
	127	 	Mark Chmielinski	Alliance MMA, Inc.	Sony XQD/SD Card Reader	Sony XQD/SD Card Reader	30010119701631	Good
	11014	 	Devon	 	Step and Repeat	 	 	Good w/ N. Harmeier
	11013	 	Storage	 	Studio Light Piping / Rigging	 	 	Good
	11015	 	Storage	 	Studio Lighting (multiple)	 	 	Good
	86	 	Mark Chmielinski	Alliance MMA, Inc.	Studio Technologies Model 210 Announcer's Console	On Air Announcer cough box for live broadcasts.	M210-02038	Good
	87	 	Mark Chmielinski	Alliance MMA, Inc.	Studio Technologies Model 210 Announcer's Console	On Air announcer cough box for live broadcasts	M210-02039	Good
	88	 	Mark Chmielinski	Alliance MMA, Inc.	Studio Technologies Model 210 Announcer's Console	On Air announcer cough box for live broadcasts.	M210-02049	Good
	188	 	Mark Chmielinski	Alliance MMA, Inc.	Tascam DR-60DmkII	Tascam DR-60DmkII 4-Channel Portable Recorder	1720082	Good
	 	 	Storage	 	Teleprompter	 	 	Mark C. owns
	 	 	storage	 	Tracking Lights in office lobby (4 pieces)	 	 	Good
	 	 	Storage	 	Various Pelican travel Cases	 	 	All Good
	 	 	Storage	 	Various Sets of Speakers	 	 	All Good
	 	 	Storage	 	Video Wall	 	 	Good
	568	 	Burt Watson	 	Warm Up Mats	 	 	Good w / Devon or Burt
	214	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	WATSON B-4232 Battery	Lithium ION Battery	N/A	Good
	217	16/1/2018	Mark Chmielinski	Alliance MMA, Inc.	WATSON B-4232 Battery	Lithium ION Battery	N/A	Good
	569	 	Devon Mathiesen	 	Windows Laptop	 	 	Good w/Devon
	570	 	(Former Rob Haydak)	 	Windows Laptop	 	 	Good
	580	 	Burt Watson	 	Windows Laptop 	 	 	Good w/ Burt
	600	 	Scott Sheeley / ohio	40' Lighting Trust	 	Purchased by Mark C as part of production studio buyout	N/A	Good / w S. Sheeley

 

     

     

    

 

Schedule B

Wire InstructionsEX-10.1

 Exhibit 10.1 

Mid Penn Bank 

Supplemental Executive Retirement Plan Agreement 

This Supplemental Executive Retirement Plan Agreement (this “Agreement”) is adopted this      day of
            , 2018, by and between Mid Penn Bank, a Pennsylvania bank and trust company headquartered in Millersburg, Pennsylvania (the “Bank”), and
                     (the “Executive”). 

The purpose of this Agreement is to provide specified benefits to the Executive, a member of a select group of management or highly
compensated employees who contribute materially to the continued growth, development and future success of the Bank. This Agreement shall be unfunded for tax purposes and for purposes of Title I of the Employee Retirement Income Security Act of 1974
(“ERISA”), as amended from time to time. 
 Article 1 

Definitions 
 Whenever used
in this Agreement, the following words and phrases shall have the meanings specified: 
 1.1    “Accrued
Benefit” means the dollar value of the liability that should be accrued by the Bank, under generally accepted accounting principles, for the Bank’s obligation to the Executive under this Agreement, calculated by applying Accounting
Standards Codification 710-10 (or any successor thereto) and the Discount Rate. 

1.2    “Affiliate” means any business entity with whom the Bank would be considered a single employer
under Code Section 414(b) and 414(c). Such term shall be interpreted in a manner consistent with the definition of “service recipient” contained in Code Section 409A. 

1.3    “Beneficiary” means each designated person or entity, or the estate of the deceased Executive,
entitled to any benefits upon the death of the Executive pursuant to Article 3. 
 1.4    “Beneficiary
Designation Form” means the form established from time to time by the Plan Administrator that the Executive completes, signs and returns to the Plan Administrator to designate one or more Beneficiaries. 

1.5    “Board” means the Board of Directors of the Bank as from time to time constituted. 

1.6    “Change in Control” means a change in the ownership or effective control of the Bank, or in the
ownership of a substantial portion of the assets of the Bank, as such change is defined in Code Section 409A and regulations thereunder. 

 1.7    “Code” means the Internal Revenue Code of 1986,
as amended, and all regulations and guidance thereunder, including such regulations and guidance as may be promulgated after the Effective Date. 

1.8    “Competing Business” means a business or enterprise (other than the Corporation, the Bank and
their Affiliates) that is engaged in the commercial banking, financial services, investment or insurance business in which the Corporation, the Bank or any of their Affiliates is engaged. 

1.9    “Corporation” means Mid Penn Bancorp, Inc. 

1.10    “Disability” means a condition of the Executive whereby the Executive either: (i) 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 can be expected to last for a continuous period of not less than twelve (12) months;
or (ii) is, by reason of any medically determinable physical or mental impairment which can be expected to result in death or can be expected to last for a continuous period of not less than twelve (12) months, receiving income replacement
benefits for a period of not less than three (3) months under an accident and health plan covering employees or directors of the Bank. Medical determination of Disability may be made by either the Social Security Administration or by the
provider of disability insurance covering employees or directors of the Bank, provided that the definition of “disability” applied under such insurance program complies with the requirements of the preceding sentence. Upon the request of
the Plan Administrator, the Executive must submit proof to the Plan Administrator of the Social Security Administration’s or the provider’s determination. 

1.11    “Discount Rate” means the rate used by the Plan Administrator for determining the Accrued
Benefit. The initial Discount Rate is four percent (4%). The Plan Administrator may adjust the Discount Rate to maintain the rate within reasonable standards according to generally accepted accounting principles and applicable bank regulatory
guidance. 
 1.12    “Early Termination” means Separation from Service before attainment of Normal
Retirement Age, except when such Separation from Service occurs within twenty-four (24) months following a Change in Control or due to death, Disability or Termination for Cause. 

1.13    “Effective Date” means              ,
2018. 
 1.14    “Normal Retirement Age” means age seventy (70). 

1.15    “Normal Retirement Date” means the later of Normal Retirement Age or Separation from Service.

 1.16    “Participant” means any other director or employee of the Bank who is a party to an
agreement providing for benefits substantially similar to this Agreement. 
 1.17    “Person” shall
have the meaning ascribed to such term in Section 3(9) of ERISA. 

  
 2 

 1.18    “Plan Administrator” means the Compensation
Committee of the Board, or such other committee or person as the Board shall appoint. 
 1.19    “Plan
Year” means each twelve (12) month period commencing on January 1st and ending on December 31st of such year. The initial Plan
Year shall commence on the Effective Date and end on the following December 31st. 

1.20    “Schedule A” means the schedule attached to this Agreement and made a part hereof. Schedule A
shall be updated upon a change in any of the benefit amounts under Article 2. 
 1.21    “Separation from
Service” means termination of the Executive’s employment with the Bank and its Affiliates for reasons other than death or Disability. Whether a Separation from Service has occurred shall be determined in accordance with the
requirements of Code Section 409A based on whether the facts and circumstances indicate that the Bank and Executive reasonably anticipated that no further services would be performed after a certain date or that the level of bona fide services
the Executive would perform after such date (whether as an employee or as an independent contractor) would permanently decrease to no more than twenty percent (20%) of the average level of bona fide services performed (whether as an employee or an
independent contractor) over the immediately preceding thirty-six (36) month period (or the full period of services to the Bank if the Executive has been providing services to the Bank less than thirty-six (36) months). A Separation from Service will not be deemed to have occurred while the Executive is on military leave, sick leave, or other bona fide leave of absence if the period of such leave does
not exceed six (6) months or, if longer, the period for which a statute or contract provides the Executive with the right to reemployment with the Bank. If the Executive’s leave exceeds six (6) months, but the Executive is not
entitled to reemployment under a statute or contract, the Executive incurs a Separation from Service on the next day following the expiration of such six (6) month period. In determining whether a Separation from Service occurs the Plan
Administrator shall take into account, among other things, the definition of “service recipient” and “employer” set forth in Treasury regulation §1.409A-l(h)(3). The Plan
Administrator shall have full and final authority to determine conclusively whether a Separation from Service occurs and the date of such Separation from Service. 

1.22    “Specified Employee” means an employee who at the time of Separation from Service is a key
employee of the Bank or its Affiliates, if any stock of the Bank or its Affiliates is publicly traded on an established securities market or otherwise. For purposes of this Agreement, an employee is a “key employee” if the employee meets
the requirements of Code Section 416(i)(1)(A)(i), (ii), or (iii) (applied in accordance with the regulations thereunder and disregarding section 416(i)(5)) at any time during the twelve (12) month period ending on December 31 (the
“identification period”). If the employee is a key employee during an identification period, the employee is treated as a key employee for purposes of this Agreement during the twelve (12) month period that begins on the first day of
April following the close of the identification period. 

  
 3 

 1.23    “Termination for Cause” means Separation from
Service for “Cause,” as such term is defined in [Executive’s Employment Agreement/Change in Control Severance Agreement] with the Corporation and the Bank dated November 3, 2016, as the same may be amended from time to time. 

  
 4 

 Article 2 

Distributions 

2.1    Normal Retirement Benefit. Upon Separation from Service after attaining Normal Retirement Age, the Bank
shall distribute to the Executive the benefit described in this Section 2.1 in lieu of any other benefit under this Article. 
  

	 	2.1.1	 Amount of Benefit. The initial annual benefit under this Section 2.1 is
                                        
 Dollars ($                    ). The Bank may increase the annual benefit under this Section 2.1 at the sole and absolute
discretion of the Board. Any such discretionary increase shall require the recalculation of all the amounts on Schedule A attached hereto. 

  

	 	2.1.2	 Distribution of Benefit. The Bank shall distribute the annual benefit to the Executive in twelve
(12) equal monthly installments commencing on the first day of the month following the Normal Retirement Date. The annual benefit shall be distributed to the Executive for fifteen (15) years. 

2.2    Early Termination Benefit. If Early Termination occurs, the Bank shall distribute to the Executive the
benefit described in this Section 2.2 in lieu of any other benefit under this Article. 
  

	 	2.2.1	 Amount of Benefit. The annual benefit under this Section 2.2 is the Early Termination Annual
Benefit set forth on Schedule A for the Plan Year ended immediately prior to the date on which the Early Termination occurs. Additionally, the annual benefit amount shall be increased by a pro-rated amount
relative to the Executive’s service during the partial Plan Year in which the Early Termination occurs. This amount will be added to the annual benefit amount at the end of the preceding Plan Year on Schedule A. For example, assuming that Early
Termination occurs on January 31, 2023, the Early Termination Annual Benefit would be the sum of the Early Termination Annual Benefit for the January 1 – December 31, 2022 Plan Year, plus a pro-rated portion of the Early Termination Annual Benefit for the January 1 – December 31, 2023 Plan Year). 

 

	 	2.2.2	 Distribution of Benefit. The Bank shall distribute the annual benefit to the Executive in twelve
(12) equal monthly installments commencing on the first day of the month following the Separation from Service. The annual benefit shall be distributed to the Executive for fifteen (15) years. 

2.3    Disability Benefit. If the Executive experiences a Disability prior to Normal Retirement Age, the
Bank shall distribute to the Executive the benefit described in this Section 2.3 in lieu of any other benefit under this Article. 
  

	 	2.3.1	 Amount of Benefit. The annual benefit under this Section 2.3 is the Disability Annual
Benefit set forth on Schedule A for the Plan Year ended immediately prior to the date on which the Disability occurs. Additionally, the annual benefit 

  
 5 

	 	
amount shall be increased by a pro-rated amount relative to the Executive’s service during the partial Plan Year in which the Separation from Service
occurs. This amount will be added to the annual benefit amount at the end of the preceding Plan Year on Schedule A, consistent with the example in Section 2.2.1. 

 

	 	2.3.2	 Distribution of Benefit. The Bank shall distribute the annual benefit to the Executive in twelve
(12) equal monthly installments commencing on the first day of the month following the Disability. The annual benefit shall be distributed to the Executive for fifteen (15) years. 

2.4    Change in Control Benefit. If a Change in Control occurs prior to Normal Retirement Age followed by
Separation from Service within twenty-four (24) months following the Change in Control, the Bank shall distribute to the Executive the benefit described in this Section 2.4 in lieu of any other benefit under this Article. 

 

	 	2.4.1	 Amount of Benefit. The annual benefit under this Section 2.4 shall be equal to the
amount of the benefit payable under Section 2.1.1, as the same may be increased from time to time in accordance with the terms thereof. 

  

	 	2.4.2	 Distribution of Benefit. The Bank shall distribute the annual benefit to the Executive in twelve
(12) equal monthly installments commencing on the first day of the month following Separation from Service. The annual benefit shall be distributed to the Executive for fifteen (15) years. 

2.5    Death Prior to Commencement of Benefit Payments. If the Executive dies prior to Separation from Service and
Normal Retirement Age, the Bank shall distribute to the Beneficiary the benefit described in this Section 2.5. This benefit shall be distributed in lieu of any other benefit under this Article. 

 

	 	2.5.1	 Amount of Benefit. The benefit under this Section 2.5 is the
Pre-retirement Death Benefit amount set forth on Schedule A for the Plan Year ended immediately prior to the date on which the Separation from Service due to death occurs. Additionally, the annual benefit
amount shall be increased by a pro-rated amount relative to the Executive’s service during the partial Plan Year in which the Separation from Service due to death takes place. This amount will be added to
the annual benefit amount at the end of the preceding Plan Year on Schedule A, consistent with the example in Section 2.2.1. 

  

	 	2.5.2	 Distribution of Benefit. The Bank shall distribute the annual benefit to the Beneficiary in twelve
(12) equal monthly installments commencing within sixty (60) days of receipt by the Bank of the Executive’s death certificate. The annual benefit shall be distributed to the Beneficiary for fifteen (15) years. The Beneficiary
shall be required to provide to the Bank the Executive’s death certificate as a condition precedent to receiving payments hereunder. 

2.6    Death During Distribution of a Benefit. If the Executive dies after benefit payments have commenced under
this Agreement, but before receiving all such payments, the 

  
 6 

 
Bank shall pay the remaining benefits to the Executive’s Beneficiary at the same time and in the same amounts they would have been paid to the Executive had the Executive survived. The
Beneficiary shall be required to provide to the Bank the Executive’s death certificate as a condition precedent to receiving payments hereunder. 

2.7    Restriction on Commencement of Distributions. Notwithstanding any provision of this Agreement to the
contrary, if the Executive is considered a Specified Employee, the provisions of this Section 2.7 shall govern all distributions hereunder. If benefit distributions which would otherwise be made to the Executive due to Separation from Service
are limited by Code Section 409A and regulations thereunder because the Executive is a Specified Employee, then such distributions shall not be made during the first six (6) months following Separation from Service. Rather, any
distribution which would otherwise be paid to the Executive during such period shall be accumulated and paid to the Executive in a lump sum on the first day of the seventh month following Separation from Service. All subsequent distributions shall
be paid in the manner specified. 
 2.8    Distributions Upon Taxation of Amounts Deferred. If, pursuant to Code
Section 409A, the Federal Insurance Contributions Act or other state, local or foreign tax, the Executive becomes subject to tax on the amounts deferred hereunder, then the Bank may make a limited distribution to the Executive in a manner that
conforms to the requirements of Code Section 409A. Any such distribution will decrease the Executive’s benefits distributable under this Agreement. 

2.9    Acceleration of Payments. Except as specifically permitted herein, no acceleration of the
time or schedule of any payment may be made hereunder. Notwithstanding the foregoing, payments may be accelerated, in accordance with the provisions of Treasury Regulation §1.409A-3(j)(4) in the
following circumstances: (i) as a result of certain domestic relations orders; (ii) in compliance with ethics agreements with the federal government; (iii) in compliance with the ethics laws or conflicts of interest laws; (iv) in
limited cashouts (but not in excess of the limit under Code Section 402(g)(l)(B)); (v) to pay employment-related taxes; or (vi) to pay any taxes that may become due at any time that the Agreement fails to meet the requirements of Code
Section 409A. 
 2.10    Delays in Payment by Bank. A payment may be delayed to a date
after the designated payment date under any of the circumstances described below, and the provision will not fail to meet the requirements of establishing a permissible payment event. The delay in the payment will not constitute a subsequent
deferral election, so long as the Bank treats all payments to similarly situated Participants on a reasonably consistent basis. 
  

	 	2.10.1	 Payments subject to Code Section 162(m). If the Bank reasonably anticipates that the
Bank’s deduction with respect to any distribution under this Agreement would be limited or eliminated by application of Code Section 162(m), then to the extent deemed necessary by the Bank to ensure that the entire amount of any
distribution from this Agreement is deductible, the Bank may delay payment of any amount that would otherwise be distributed under this Agreement. The delayed amounts shall be distributed to the Executive (or the Beneficiary in the event of the
Executive’s death) at the earliest date the Bank reasonably anticipates that the deduction of the payment of the amount will not be limited or eliminated by application of Code Section 162(m).

  
 7 

	 	2.10.2	 Payments that would violate Federal securities laws or other applicable law. A payment may be delayed
where the Bank reasonably anticipates that the making of the payment will violate Federal securities laws or other applicable law provided that the payment is made at the earliest date at which the Bank reasonably anticipates that the making of the
payment will not cause such violation. The making of a payment that would cause inclusion in gross income or the application of any penalty provision of the Code is not treated as a violation of law. 

 

	 	2.10.3	 Solvency. A payment may be delayed where the payment would jeopardize the ability of the Bank to
continue as a going concern. 

 2.11     Treatment of Payment as Made on Designated Payment
Date. Solely for purposes of determining compliance with Code Section 409A, any payment under this Agreement made after the required payment date shall be deemed made on the required payment date provided that such
payment is made by the latest of: (i) the end of the calendar year in which the payment is due; (ii) the 15th day of the third calendar month following the payment due date;
(iii) if the Bank cannot calculate the payment amount on account of administrative impracticality which is beyond the Executive’s control, the end of the first calendar year which payment calculation is practicable; and (iv) if the
Bank does not have sufficient funds to make the payment without jeopardizing the Bank’s solvency, in the first calendar year in which the Bank’s funds are sufficient to make the payment.

2.12     Facility of Payment. If a distribution is to be made to a minor, or to a person
who is otherwise incompetent, then the Plan Administrator may make such distribution: (i) to the legal guardian, or if none, to a parent of a minor payee with whom the payee maintains his or her residence; or (ii) to the conservator or
administrator or, if none, to the person having custody of an incompetent payee. Any such distribution shall fully discharge the Bank and the Plan Administrator from further liability on account thereof.

2.13     Excise Tax Payment. Anything contained in this Agreement to the contrary notwithstanding, if
any of the payments or benefits received or to be received by Executive pursuant to this Agreement (which the parties agree will not include any portion of payments allocated to the non-solicitation and non-competition provisions of Section 4.5 that are classified as payments of reasonable compensation for purposes of Code Section 280G), when taken together with payments and benefits payable to or on
behalf of Executive under any other plans, contracts or arrangements with the Corporation or the Bank (all such payments and benefits, the “Total Payments”), will be subject to excise tax imposed under Code Section 4999 (the
“Excise Tax”), then Executive shall receive an additional payment in an amount equal to the amount of the Excise Tax actually payable by Executive, without regard to any additional tax, interest or penalty payable by Executive on such
additional amount. For example, if the Total Payments would result in an Excise Tax payable by Executive of $300,000, then Executive will be entitled to receive an additional payment of $300,000; however, Executive shall be solely responsible for

  
 8 

 
any additional tax, interest or penalties resulting from the additional $300,000 payment. All calculations required to be made under this Section, including the portion of any payments to be
allocated to the restrictive covenants set forth in Section 4.5 (or any payments to be allocated to a separate restrictive covenant agreement, if any) will be made by the Corporation’s independent public accountants, subject to the right
of Executive’s representative to review the same. All amounts required to be paid pursuant to this Section shall be paid at the time any withholding may be required (or, if earlier, the time Executive shall be required to pay such amounts)
under applicable law, and any additional amounts to which Executive may be entitled shall be paid or reimbursed no later than fifteen (15) days following confirmation of such amount by the Corporation’s independent public accountants;
provided, however, that any payments to be made under this Section shall in all events be made no later than the end of Executive’s taxable year next following the taxable year in which the Executive remits such Excise Tax payment. The parties
recognize that the actual implementation of the provisions of this Section are complex and agree to deal with each other in good faith to resolve any questions or disagreements arising hereunder. 

2.14    Change in Form or Timing of Distributions. For distribution of benefits under this Article 2, the
Executive and the Bank may, subject to the terms of Section 7.1, amend this Agreement to delay the timing or change the form of distributions. Any such amendment (a) may not accelerate the time or schedule of any distribution, except
as provided in Code Section 409A; (b) must, for benefits distributable under Section 2.2 be made at least twelve (12) months prior to the first scheduled distribution; (c) must, for benefits distributable under Sections 2.1,
2.2, and 2.4, delay the commencement of distributions for a minimum of five (5) years from the date the first distribution was originally scheduled to be made; and (d) must take effect not less than twelve (12) months after the
amendment is made. 
 Article 3 

Beneficiaries 

3.1    In General. The Executive shall have the right, at any time, to designate a Beneficiary to receive any
benefit distributions under this Agreement upon the death of the Executive. The Beneficiary designated under this Agreement may be the same as or different from the beneficiary designated under any other plan of the Bank in which the Executive
participates. 
 3.2    Designation. The Executive shall designate a Beneficiary by completing and signing the
Beneficiary Designation Form and delivering it to the Plan Administrator or its designated agent. If the Executive names someone other than the Executive’s spouse as a Beneficiary, the Plan Administrator may, in its sole discretion, determine
that spousal consent is required to be provided in a form designated by the Plan Administrator, executed by the Executive’s spouse and returned to the Plan Administrator. The Executive’s beneficiary designation shall be deemed
automatically revoked if the Beneficiary predeceases the Executive or if the Executive names a spouse as Beneficiary and the marriage is subsequently dissolved. The Executive shall have the right to change a Beneficiary by completing, signing and
otherwise complying with the terms of the Beneficiary Designation Form and the Plan Administrator’s rules and procedures. Upon the acceptance by the Plan Administrator of a new Beneficiary Designation Form, all Beneficiary designations
previously filed shall be cancelled. The Plan Administrator shall be entitled to rely on the last Beneficiary Designation Form filed by the Executive and accepted by the Plan Administrator prior to the Executive’s death. 

  
 9 

 3.3    Acknowledgment. No designation or change in designation of
a Beneficiary shall be effective until received, accepted and acknowledged in writing by the Plan Administrator or its designated agent. 

3.4    No Beneficiary Designation. If the Executive dies without a valid beneficiary designation, or if all
designated Beneficiaries predecease the Executive, then the Executive’s spouse shall be the designated Beneficiary. If the Executive has no surviving spouse, any benefit shall be paid to the Executive’s estate. 

3.5    Facility of Distribution. If the Plan Administrator determines in its discretion that a benefit is to be
distributed to a minor, to a person declared incompetent or to a person incapable of handling the disposition of that person’s property, the Plan Administrator may direct distribution of such benefit to the guardian, legal representative or
person having the care or custody of such minor, incompetent person or incapable person. The Plan Administrator may require proof of incompetence, minority or guardianship as it may deem appropriate prior to distribution of the benefit. Any
distribution of a benefit shall be a distribution for the account of the Executive and the Beneficiary, as the case may be, and shall completely discharge any liability under this Agreement for such distribution amount. 

Article 4 
 General
Limitations 
 4.1    Termination for Cause. Notwithstanding any provision of this Agreement to the contrary,
the Bank shall not distribute any benefit under this Agreement if the Executive’s employment with the Bank is terminated by the Bank due to a Termination for Cause. 

4.2    Misstatement. No benefit shall be distributed if an insurance company which issued a life insurance policy
covering the Executive and owned by the Bank denies coverage (i) for material misstatements of fact made by the Executive on an application for such life insurance, or (ii) for any other reason. 

4.3    Removal. Notwithstanding any provision of this Agreement to the contrary, the Bank shall not
distribute any benefit under this Agreement if the Executive is subject to a final removal or prohibition order issued by an appropriate federal banking agency pursuant to Section 8(e) of the Federal Deposit Insurance Act. 

4.4    Regulatory Restrictions. Notwithstanding anything herein to the contrary, any payments made to the Executive
pursuant to this Agreement, or otherwise, shall be subject upon compliance with 12 U.S.C. Section 1828 and FDIC Regulation 12 CFR Part 359, Golden Parachute Indemnification Payments and any other regulations or guidance promulgated thereunder.

  
 10 

 4.5    Competition after Separation from Service. The Executive
shall forfeit, for the Executive and the Beneficiary, any unpaid benefits payable hereunder, if the Executive: 
  

	 	(a)	 directly or indirectly, and whether as principal or investor or as an employee, officer, director, manager,
partner, consultant, agent, or otherwise, alone or in association with any other Person, becomes involved in a Competing Business (as defined below) in any county in the Commonwealth of Pennsylvania in which the Corporation, the Bank or any of their
Affiliates has maintained a branch or other office during the period of Executive’s employment (excluding an ownership interest of $100,000 or less in the stock of one or more publicly-traded companies); or 

 

	 	(b)	 directly or indirectly, whether alone or in association with any other Person, for the purpose of conducting or
engaging in any Competing Business, calls upon, solicits, or advises any Person who is, or was, during the then most recent 12-month period, a customer of the Corporation, the Bank or any of their Affiliates,
or takes away or interferes or attempts to take away or interfere with any custom, trade, business, patronage, or affairs of the Corporation, the Bank or any of their Affiliates, or hires or attempts to hire, or otherwise engages or attempts to
engage as an independent contractor or otherwise any Person who is, or was during the then most recent 12-month period, an employee, officer, representative, or agent of the Corporation, the Bank or any of
their Affiliates, or solicits, induces, or attempts to solicit or induce any Person who is an employee, officer, representative, or agent of the Corporation, the Bank or any of their Affiliates to leave the employ of the Corporation, the Bank or any
of their Affiliates or cease their business relationship with Corporation, the Bank or any of their Affiliates (as the case may be), or violate the terms of their contracts, or any employment arrangements, with the Corporation, the Bank or any of
their Affiliates. 

 The restrictive provisions set forth in this Section 4.5 are intended to operate independently of, and not
replace or be superseded by, any similar provisions contained in any other agreement between Executive and the Bank or Corporation. Although Executive and the Corporation and the Bank consider the restrictions contained in this
Section 4.5 to be the minimum restriction reasonable for the purposes of preserving the Corporation’s and the Bank’s goodwill and other proprietary rights, if a final determination is made by a court that the time or
territory, or any other restriction contained in this Section 4.5 is an unreasonable or otherwise unenforceable restriction against the Executive, the provisions of this Section 4.5 will not be rendered void, but will
be deemed amended to apply as to such maximum time and territory and to such other extent as the court may determine to be reasonable. Notwithstanding the foregoing, this Section 4.5 shall not apply following: (i) a Separation of Service
after attaining Normal Retirement Age if such Separation of Service is the result of an involuntary termination of Executive’s employment by the Bank (other than a Termination for Cause); (ii) a Change in Control; or (iii) a Separation of
Service prior to attaining Normal Retirement Age if such Separation of Service is the result of an involuntary termination of Executive’s employment by the Bank (other than a Termination for Cause); provided, however, that in the event of an
involuntary termination as described in clause (iii), the provisions of Section 4.5(b) shall be effective for one (1) year following the Separation of Service. 

  
 11 

 Article 5 

Administration of Agreement 

5.1    Plan Administrator Duties. The Plan Administrator shall be responsible for the management, operation, and
administration of the Agreement. When making a determination or calculation, the Plan Administrator shall be entitled to rely on information furnished by the Bank, Executive or Beneficiary. No provision of this Agreement shall be construed as
imposing on the Plan Administrator any fiduciary duty under ERISA or other law, or any duty similar to any fiduciary duty under ERISA or other law. 

5.2    Authority of Plan Administrator. The Plan Administrator shall enforce this Agreement in accordance with its
terms, shall be charged with the general administration of this Agreement, and shall have all powers necessary to accomplish its purposes. 

5.3    Binding Effect of Decisions. The decision or action of the Plan Administrator with respect to any question
arising out of or in connection with the administration, interpretation or application of this Agreement and the rules and regulations promulgated hereunder shall be final, conclusive and binding upon all persons having any interest in this
Agreement. 
 5.4    Compensation and Indemnity of Plan Administrator. The Plan Administrator shall serve without
compensation for services rendered hereunder. The Plan Administrator is authorized at the expense of the Bank to employ such legal counsel and/or recordkeeper as it may deem advisable to assist in the performance of its duties hereunder. Expenses
and fees incurred in connection with the administration of this Agreement shall be paid by the Bank. 
 5.5    Bank
Information. To enable the Plan Administrator to perform its functions, the Bank shall supply full and timely information to the Plan Administrator on all matters relating to the date and circumstances of the Executive’s death, Disability
or Separation from Service, and such other pertinent information as the Plan Administrator may reasonably require. 

5.6    Termination of Participation. If the Plan Administrator determines in good faith that the
Executive no longer qualifies as a member of a select group of management or highly compensated employees, as determined in accordance with ERISA, the Plan Administrator shall have the right, in its sole discretion, to cease further benefit accruals
hereunder. 
 Article 6 

Claims and Review Procedures 

6.1    Claims Procedure. An Executive or Beneficiary (“claimant”) who has not received benefits under
this Agreement that he or she believes should be distributed shall make a claim for such benefits as follows: 
  

	 	6.1.1	 Initiation – Written Claim. The claimant initiates a claim by submitting to the Plan Administrator
a written claim for the benefits. If such a claim relates to the contents of a notice received by the claimant, the claim must be made within sixty (60) days after such notice was received by the claimant. All other claims must be made within
one hundred eighty (180) days of the date on which the event that caused the claim to arise occurred. The claim must state with particularity the determination desired by the claimant. 

  
 12 

	 	6.1.2	 Timing of Plan Administrator Response. The Plan Administrator shall respond to such claimant
within thirty (30) days after receiving the claim. If the Plan Administrator determines that special circumstances require additional time for processing the claim, the Plan Administrator can extend the response period by an additional thirty
(30) days by notifying the claimant in writing, prior to the end of the initial thirty (30) day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date by which the Plan
Administrator expects to render its decision. 

  

	 	6.1.3	 Notice of Decision. If the Plan Administrator denies part or all of the claim, the Plan Administrator
shall notify the claimant in writing of such denial. The Plan Administrator shall write the notification in a manner calculated to be understood by the claimant. The notification shall set forth: 

 

	 	(a)	 The specific reasons for the denial; 

 

	 	(b)	 A reference to the specific provisions of this Agreement on which the denial is based; 

 

	 	(c)	 A description of any additional information or material necessary for the claimant to perfect the claim and an
explanation of why it is needed; 

  

	 	(d)	 An explanation of this Agreement’s review procedures and the time limits applicable to such procedures;
and 

  

	 	(e)	 A statement of the claimant’s right to bring a civil action under ERISA Section 502(a) following an
adverse benefit determination on review. 

 6.2    Review Procedure. If the Plan Administrator
denies part or the entire claim, the claimant shall have the opportunity for a full and fair review by the Plan Administrator of the denial as follows: 
  

	 	6.2.1	 Initiation – Written Request. To initiate the review, the claimant, within sixty (60) days
after receiving the Plan Administrator’s notice of denial, must file with the Plan Administrator a written request for review. 

  

	 	6.2.2	 Additional Submissions – Information Access. The claimant shall then have the opportunity to submit
written comments, documents, records and other information relating to the claim. The Plan Administrator shall also provide the claimant, upon request and free of charge, reasonable access to, and copies of, all documents, records and other
information relevant (as defined in applicable ERISA regulations) to the claimant’s claim for benefits. 

  

	 	6.2.3	 Considerations on Review. In considering the review, the Plan Administrator shall take into account all
materials and information the claimant submits relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. 

  
 13 

	 	6.2.4	 Timing of Plan Administrator Response. The Plan Administrator shall respond in writing to such claimant
within thirty (30) days after receiving the request for review. If the Plan Administrator determines that special circumstances require additional time for processing the claim, the Plan Administrator can extend the response period by an
additional thirty (30) days by notifying the claimant in writing, prior to the end of the initial thirty (30) day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date
by which the Plan Administrator expects to render its decision. 

  

	 	6.2.5	 Notice of Decision. The Plan Administrator shall notify the claimant in writing of its decision on
review. The Plan Administrator shall write the notification in a manner calculated to be understood by the claimant. The notification shall set forth: 

  

	 	(a)	 The specific reasons for the denial; 

 

	 	(b)	 A reference to the specific provisions of this Agreement on which the denial is based; 

 

	 	(c)	 A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to,
and copies of, all documents, records and other information relevant (as defined in applicable ERISA regulations) to the claimant’s claim for benefits; and 

 

	 	(d)	 A statement of the claimant’s right to bring a civil action under ERISA Section 502(a).

 Article 7 

Amendments and Termination 

7.1    Amendments, Generally. Except as provided in Section 7.2, this Agreement may be amended only by a
written agreement signed by both the Bank and the Executive. 
 7.2    Amendment to Ensure Proper Characterization of
Agreement. Notwithstanding anything in this Agreement to the contrary, this Agreement may be amended by the Bank at any time, if found necessary in the opinion of the Bank: (i) to ensure that the Agreement is characterized as a
plan of deferred compensation maintained for a select group of management or highly compensated employees as described under ERISA; (ii) to conform the Agreement to the requirements of any applicable law; or (iii) to comply with the
written instructions of the Bank’s auditors or banking regulators. 
 7.3    Agreement Termination,
Generally. Except as provided in Section 7.4, this Agreement may be terminated only by a written agreement signed by the Bank and the 

  
 14 

 
Executive. Such termination shall not cause a distribution of benefits under this Agreement. Rather, upon such termination, benefit distributions will be made at the earliest distribution event
permitted under Article 2. 
 7.4    Effect of Complete Terminations. Notwithstanding anything to the contrary in
Section 7.3, and subject to the requirements of Code Section 409A and Treasury Regulations §1.409A-3(j)(4)(ix), at certain times the Bank may completely terminate and liquidate the
Agreement. In the event of such a complete termination in accordance with subsections 7.4.1 or 7.4.3 below, the Bank shall pay the Executive the Accrued Benefit. In the event of such a complete termination in accordance with subsection
7.4.2 below, the Bank shall pay the Executive the present value, determined using the Discount Rate, of the benefit described in Section 2.4 hereof. In either event, such complete termination of the Agreement shall occur only under the
following circumstances and conditions: 
  

	 	7.4.1	 Corporate Dissolution or Bankruptcy. The Bank may terminate and liquidate this Agreement within twelve
(12) months of a corporate dissolution taxed under Code Section 331, or with the approval of a bankruptcy court pursuant to 11 U.S.C.§503(b)(1)(A), provided that all benefits paid under the Agreement are included in the
Executive’s gross income in the latest of: (i) the calendar year which the termination occurs; (ii) the calendar year in which the amount is no longer subject to a substantial risk of forfeiture; or (iii) the first calendar year
in which the payment is administratively practicable. 

  

	 	7.4.2	 Change in Control. The Bank may terminate and liquidate this Agreement by taking irrevocable action to
terminate and liquidate within the thirty (30) days preceding or the twelve (12) months following a Change in Control. This Agreement will then be treated as terminated only if all substantially similar arrangements sponsored by the Bank
which are treated as deferred under a single plan under Treasury Regulations §1.409A-l(c)(2) are terminated and liquidated with respect to each participant who experienced the Change in Control so that
the Executive and any participants in any such similar arrangements are required to receive all amounts of compensation deferred under the terminated arrangements within twelve (12) months of the date the Bank takes the irrevocable action to
terminate the arrangements. 

  

	 	7.4.3	 Discretionary Termination. The Bank may terminate and liquidate this Agreement provided that:
(i) the termination does not occur proximate to a downturn in the financial health of the Bank; (ii) all arrangements sponsored by the Bank and Affiliates that would be aggregated with any terminated arrangements under Treasury Regulations
§1.409A-l(c) are terminated; (iii) no payments, other than payments that would be payable under the terms of this Agreement if the termination had not occurred, are made within twelve
(12) months of the date the Bank takes the irrevocable action to terminate this Agreement; (iv) all payments are made within twenty-four (24) months following the date the Bank takes the irrevocable action to terminate and liquidate
this Agreement; and (v) neither the Bank nor any of its Affiliates adopts a new arrangement that would be aggregated with any terminated arrangement under Treasury
Regulations §1.409A-l(c) if the Executive participated in both arrangements at any time within three (3) years following the date the Bank takes the irrevocable action to terminate this
Agreement. 

  
 15 

 Article 8 

Miscellaneous 

8.1    Binding Effect. This Agreement shall bind the Executive, Beneficiary and the Bank and their respective
successors, heirs, executors and administrators. 
 8.2    No Effect on Other Rights. This Agreement constitutes
the entire agreement between the Bank and the Executive as to the subject matter hereof. No rights are granted to the Executive by virtue of this Agreement other than those specifically set forth herein. Nothing contained herein will confer upon the
Executive the right to be retained in the service of the Bank nor limit the right of the Bank to discharge or otherwise deal with the Executive without regard to the existence hereof. 

8.3    Non-Transferability. Benefits under this Agreement cannot be sold,
transferred, assigned, pledged, attached or encumbered in any manner. 
 8.4    Tax Withholding and Reporting.
The Bank shall withhold any taxes that are required to be withheld, including but not limited to taxes owed under Code Section 409A from the benefits provided under this Agreement. The Executive acknowledges that the Bank’s sole liability
regarding taxes is to forward any amounts withheld to the appropriate taxing authorities. The Bank shall satisfy all applicable reporting requirements, including those under Code Section 409A. 

8.5    Applicable Law. This Agreement and all rights hereunder shall be governed by the laws of the Commonwealth of
Pennsylvania, except to the extent preempted by the laws of the United States of America. 
 8.6    Unfunded
Arrangement. The Executive and the Beneficiary are general unsecured creditors of the Bank for the distribution of benefits under this Agreement. The benefits represent the mere promise by the Bank to distribute such benefits. The rights to
benefits are not subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, attachment or garnishment by creditors. Any insurance on the Executive’s life or other informal funding asset is a general
asset of the Bank to which the Executive and Beneficiary have no preferred or secured claim. 

8.7    Reorganization. The Bank shall not merge or consolidate into or with another bank, or reorganize, or
sell substantially all of its assets to another bank, firm or person unless such succeeding or continuing bank, firm or person agrees to assume and discharge the obligations of the Bank under this Agreement. Upon the occurrence of such an event, the
term “Bank” as used in this Agreement shall be deemed to refer to the successor or survivor entity. 

  
 16 

 8.8    Entire Agreement. This Agreement constitutes the
entire agreement between the Bank and the Executive as to the subject matter hereof. No rights are granted to the Executive by virtue of this Agreement other than those specifically set forth herein. 

8.9    Interpretation. Wherever the fulfillment of the intent and purpose of this Agreement requires and the
context will permit, the use of the masculine gender includes the feminine and use of the singular includes the plural. 

8.10    Alternative Action. In the event it shall become impossible for the Bank or the Plan Administrator to
perform any act required by this Agreement due to regulatory or other constraints, the Bank or Plan Administrator may perform such alternative act as most nearly carries out the intent and purpose of this Agreement and is in the best interests of
the Bank, provided that such alternative act does not violate Code Section 409A. 
 8.11    Headings.
Article and section headings are for convenient reference only and shall not control or affect the meaning or construction of any provision herein. 

8.12    Validity. If any provision of this Agreement shall be illegal or invalid for any reason, said illegality or
invalidity shall not affect the remaining parts hereof, but this Agreement shall be construed and enforced as if such illegal or invalid provision had never been included herein. 

8.13    Notice. Any notice, consent or demand required or permitted to be given to the Bank or Plan Administrator
under this Agreement shall be sufficient if in writing and hand-delivered or sent by registered or certified mail to the Bank’s principal business office. Any notice or filing required or permitted to be given to the Executive or Beneficiary
under this Agreement shall be sufficient if in writing and hand-delivered or sent by mail to the last known address of the Executive or Beneficiary, as appropriate. Any notice shall be deemed given as of the date of delivery or, if delivery is made
by mail, as of the date shown on the postmark or on the receipt for registration or certification. 

8.14    Coordination with Other Benefits. The benefits provided for the Executive or the
Beneficiary under this Agreement are in addition to any other benefits available to the Executive under any other plan or program for employees of the Bank. This Agreement shall supplement and shall not supersede, modify, or amend any other such
plan or program except as may otherwise be expressly provided herein. 
 8.15    Aggregation of
Agreement. If the Bank offers other non-qualified deferred compensation plans, this Agreement and those plans shall be treated as a single plan to the extent required under
Code Section 409A. 
 8.16    Compliance with Section 409A. This Agreement shall be
interpreted and administered consistent with Code Section 409A. The Bank and the Executive intend that the Agreement comply with the provisions of Code Section 409A to prevent the inclusion in gross income of any amounts deferred
hereunder in a taxable year prior to the year in which amounts are actually paid to the Executive or Beneficiary. This Agreement shall be construed, administered and governed in a manner that affects such intent, and the Administrator shall not take
any action that would be inconsistent therewith. 
 [signature page follows] 

  
 17 

 IN WITNESS WHEREOF, the Executive and a duly authorized representative of the Bank have
signed this Agreement. 
  

							
	EXECUTIVE	 		 	MID PENN BANK
				
	  
	 		 	By:	 	
                     
                    

		 		 	Title:	 	
                     
                    

 [Signature Page to Supplemental Executive Retirement Plan Agreement] 

  
 18 

 SCHEDULE A 

[EXECUTIVE] 
  

													
	 	  	Early
Termination	 	  	Disability	 	  	 Pre-Retirement

Death
	 
	 Plan Year
	  	Annual Benefit	 	  	Annual Benefit	 	  	Annual Benefit	 
	 Plan Years Commencing on the Effective Date and Ending on December 31, 2021
	  	$	0	 	  	$	0	 	  	$	0	 
	January 1 – December 31, 2022	  	$	                 	 	  	$	                 	 	  	$	                 	 
	January 1 – December 31, 2023	  	$	                 	 	  	$	                 	 	  	$	                 	 
	January 1 – December 31, 2024	  	$	                 	 	  	$	                 	 	  	$	                 	 
	January 1 – December 31, 2025	  	$	                 	 	  	$	                 	 	  	$	                 	 
	January 1 – December 31, 2026	  	$	                 	 	  	$	                 	 	  	$	                 	 
	January 1 – December 31, 2027 and All Subsequent Plan Years	  	$	                 	 	  	$	                 	 	  	$	                 	 

 BENEFICIARY DESIGNATION FORM 

{ }    New Designation 
 {
}    Change in Designation 
 I,
                    , designate the following as Beneficiary under this Agreement: 

 

			
	 Primary: 
  

                          
                                         
                                         
                                         
       
  

                          
                                         
                                         
                                         
       
  
	  	
    % 
  

    %
  

	 Contingent:

  

                          
                                         
                                         
                                         
       
  

                          
                                         
                                         
                                         
       
  
	  	     % 

 
     %

 

 Notes: 
  

	 	•	 	 Please PRINT CLEARLY or TYPE the names of the beneficiaries. 

 

	 	•	 	 To name a trust as Beneficiary, please provide the name of the trustee(s) and the exact name and date
of the trust agreement. 

  

	 	•	 	 To name your estate as Beneficiary, please write “Estate of [your name]”.

  

	 	•	 	 Be aware that none of the contingent beneficiaries will receive anything unless ALL of the primary
beneficiaries predecease you. 

 I understand that I may change these beneficiary designations by delivering a new written designation
to the Plan Administrator, which shall be effective only upon receipt and acknowledgment by the Plan Administrator prior to my death. I further understand that the designations will be automatically revoked if the Beneficiary predeceases me, or, if
I have named my spouse as Beneficiary and our marriage is subsequently dissolved. 
 Name:      

Signature:                        
                                         
                                         
  Date                     
 Received
by the Plan Administrator this      day of             , 20     

 

			
	By:	 	  

		
	Title:	 	  

  
 1

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