Document:

EXHIBIT 10.23(b)
	 

	 
		FORM OF RESTRICTED STOCK
		AGREEMENT
	 

	 
		UNDER THE 2007 LONG TERM
		INCENTIVE PLAN
	 

	 
		OF FINLAY ENTERPRISES,
		INC.
	 

	 
		(for awards granted after
		termination of 
	 

	 
		Stockholders’ Agreement
		and Registration Rights Agreement)
	 

	 
		AGREEMENT, made as of ___________, 20__, between
		FINLAY ENTERPRISES, INC., a Delaware corporation (the “Company”), and
		________________ (the “Grantee”).
	 

	 
		1. Purpose. The purpose of this Restricted Stock Agreement (the
		“Agreement”) is to provide an incentive and reward to the Grantee,
		who, through employment and by the Grantee’s industry and exceptional
		service, will continue to contribute to the growth and development of the
		Company.
	 

	 
		2. Shares Awarded.
	 

	 
		(a) Subject to the terms of
		this Agreement, provided that the Grantee is at such time employed by the
		Company or its Subsidiaries (as defined in the Plan), the Company shall issue
		to the Grantee, on _____________, 20__ (the “Vesting Date”) or as
		soon thereafter as is reasonably practicable but in no event later than 60 days
		after the Vesting Date, __________ shares of common stock, $.01 par value
		(“Common Stock”), of the Company (the “Shares”), which
		Shares shall be fully vested on the Vesting Date but shall be subject to the
		restrictions set forth herein.
	 

	 
		(b) The Shares are granted
		pursuant to the Company’s 2007 Long Term Incentive Plan (the
		“Plan”). The Shares are subject to all of the applicable provisions
		of the Plan which are incorporated herein by reference, and any conflict
		between the terms of this Agreement and those of the Plan shall be resolved in
		favor of the terms of the Plan.
	 

	 
		(c) Notwithstanding anything to
		the contrary herein contained, in the event (i) that the Grantee’s
		employment is terminated by reason of the Grantee’s death or Disability
		(as such term is defined in the Plan), or (ii) upon the occurrence of a Change
		in Control (as defined below), then in any such case, all of the Shares shall
		be deemed immediately vested and the Shares shall be distributed to the Grantee
		or his or her estate (as applicable) as promptly as possible thereafter but in
		no event later than 60 days following the vesting date.
	 

	 
		(d) A “Change in
		Control” shall be deemed to have occurred if: (i) the stockholders of the
		Company shall have approved: (A) any consolidation or merger of the Company in
		which the Company is not the continuing or surviving corporation or pursuant to
		which shares of Common Stock would be converted into cash, securities or other
		property, other than a merger of the Company in which the holders of Common
		Stock immediately prior to the merger have the same proportionate ownership of
		common stock of the surviving corporation immediately after the merger; (B) any
		sale, lease, exchange or other transfer (in one transaction or a series of
		related transactions) of all, or substantially all, of the assets of the
		Company; or (C) the adoption of any plan or proposal for the liquidation or
		dissolution of the Company; (ii) any person (as defined in Sections 13(d)(3)
		and 14(d)(2) of the Exchange Act), corporation or other entity (other than
		the
	 

	 
		 
	 

	 
		 
	 

	 
		-1-
	 

	 
		 
	 

	 
	 

	 

	 
		Company or any employee benefit
		plan sponsored by the Company or any subsidiary) shall have become the
		“beneficial owner” (as defined in Rule 13d-3 of the Exchange Act),
		directly or indirectly, of securities of the Company representing 30% or more
		of the issued and outstanding Common Stock; or (iii) individuals who on the
		date of the adoption of the Plan constituted the entire Board of Directors
		shall have ceased for any reason to constitute a majority unless the election,
		or the nomination for election by the Company’s stockholders, of each new
		director was approved by a vote of at least a majority of the directors then
		still in office.
	 

	 
		3. Certificates.
	 

	 
		(a) Certificates. Upon issuance by the Company to the Grantee of the
		Shares in accordance with Section 2 hereof, the Company shall deliver to the
		Grantee or his or her estate (as applicable) a certificate covering such
		Shares, which shall be in the name of the Grantee or such estate and shall have
		stamped thereon the legend set forth in Section 5 hereof.
	 

	 
		(b) Adjustments. In the event that any stock dividend, stock split,
		recapitalization, merger, reorganization, exchange of shares or similar event
		occurs in which the number or class of shares of Common Stock is changed
		without the receipt or payment of consideration by the Company, the number
		and/or type of securities issuable to the Grantee pursuant to Section 2 hereof
		after the effective date of such event shall be proportionately and equitably
		adjusted in such manner as the Committee shall determine in order to retain the
		economic value or opportunity to the Grantee under this Agreement. 
	 

	 
		4. Restrictions on
		Transfer.
		The Grantee hereby
		represents and warrants to and agrees with the Company as follows:
	 

	 
		The Shares (and any other
		securities issued to the Grantee pursuant to Section 3(b) hereof) will not be
		sold, exchanged, pledged, hypothecated, transferred or otherwise disposed of by
		the Grantee in any manner, directly or indirectly, (i) without registration
		thereof under the Securities Act of 1933, as amended, and any applicable state
		“Blue Sky” laws unless an exemption from such registration is
		available and, if the Company so requests, the Grantee causes counsel
		satisfactory to the Company to deliver to
		the Company a written opinion of such counsel in form and substance
		satisfactory to the Company; or (ii) in violation of any law.
	 

	 
		5. Restrictive Legend. All certificates representing Shares issued hereunder
		(and all certificates representing any other securities issued to the Grantee
		pursuant to Section 3(b) hereof) shall bear a restrictive legend thereon
		substantially as follows:
	 

	 
		“THE SHARES REPRESENTED
		BY THIS CERTIFICATE ARE HELD BY AN AFFILIATE OF THE COMPANY (AS DEFINED IN RULE
		144 OF THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”)), AND MAY
		ONLY BE TRANSFERRED (i) TO THE EXTENT APPLICABLE, PURSUANT TO RULE 144 UNDER
		THE ACT (OR ANY SIMILAR RULE UNDER SUCH ACT RELATING TO THE DISPOSITION OF
		SECURITIES), OR (ii) UPON THE DELIVERY BY THE HOLDER TO THE COMPANY OF AN
		OPINION OF COUNSEL, SATISFACTORY TO COUNSEL TO THE COMPANY, STATING THAT
		COMPLIANCE WITH RULE 144 IS UNNECESSARY.”
	 

	 
		6. General Provisions. Nothing contained in this Agreement shall confer upon
		the Grantee any right to continue in the employ of the Company or shall in any
		way affect the right and power of the Company to dismiss or otherwise terminate
		the employment of the Grantee at any time for any reason with or without cause.
		This Agreement shall be governed and construed in accordance with the laws of
		the State of Delaware. Any dispute arising hereunder shall be brought 
	 

	 
		 
	 

	 
		 
	 

	 
		-2-
	 

	 
		 
	 

	 
	 

	 

	 
		before a court of competent
		jurisdiction in the City, County and State of New York. This Agreement shall be
		binding upon the heirs, executors, administrators and successors of the parties
		hereto.
	 

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

	 
		 
	 

	 
		 
	 

	 
			
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  FINLAY ENTERPRISES,
				  INC.
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  
 By 
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  Name: Arthur E.
				  Reiner
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  Title: Chairman and
				  CEO
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  
 THE
				  GRANTEE:
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  Signature
				

			 

 

	 
		 
	 

	 
		 
	 

	 
		-3-EXHIBIT 10.23(c)
	 

	 
		FORM OF AGREEMENT AND
		CERTIFICATE OF OPTION
	 

	 
		PURSUANT TO THE 2007 LONG
		TERM INCENTIVE PLAN 
	 

	 
		OF FINLAY ENTERPRISES,
		INC.
	 

	 
		(for awards granted prior to
		termination of 
	 

	 
		Stockholders’ Agreement
		and Registration Rights Agreement)
	 

	 
		Agreement and Certificate of
		Option (this “Agreement”) dated ________, 20__ (the “Date of
		Grant”), between FINLAY ENTERPRISES, INC. (the “Corporation”)
		and _______________ (the “Grantee”):
	 

	 
			
				
				   
				

			 	
				
				  1.
				

			 	
				
				  The
				  Option.
				

			 

 

	 
		(a) Subject to the provisions
		of this Agreement, the Corporation hereby grants to the Grantee a stock option
		(the “Option”) to purchase, on the terms and conditions herein set
		forth, up to ________ shares of the Corporation’s fully paid,
		non-assessable shares of Common Stock, par value $0.01 per share (the
		“Shares”), at the option price set forth in Section 2 below.
	 

	 
		(b) The Option is granted
		pursuant to the Corporation’s 2007 Long Term Incentive Plan (the
		“Plan”), a copy of which is delivered herewith by the Corporation and
		receipt thereof is acknowledged by the Grantee. The Option is subject in its
		entirety to all of the applicable provisions of the Plan which are incorporated
		herein by reference, and any conflict between the terms of this Agreement and
		those of the Plan shall be resolved in favor of the terms of the Plan. The
		Option is a “Nonqualified Stock Option” as that term is defined in
		the Plan.
	 

	 
			
				
				   
				

			 	
				
				  2.
				

			 	
				
				  Exercise
				  Price.
				

			 

 

	 
		The purchase price of the
		Shares shall be $_______ per Share (the “Exercise Price”).
	 

	 
			
				
				   
				

			 	
				
				  3.
				

			 	
				
				  Exercise of
				  Option.
				

			 

 

	 
		(a) Except as otherwise
		provided in the Plan and this Agreement, the Option is exercisable over a
		period of ten (10) years from the date hereof (the “Option Period”)
		in accordance with the following schedule (the portion of the Option
		exercisable in accordance with such schedule being referred to herein as
		“Vested”):
	 

	 
		 
	 

	 
		 
	 

	 
		-1-
	 

	 
		 
	 

	 
	 

	 

	 
			
				
				  Date
				

			 	
				
				   
				

			 	
				
				  Percent of Shares
				  Subject 
 to Option
				  Exercisable
				

			 	
				
				   
				

			 
	
				
				  Commencing on the first
				  anniversary of the Date of Grant until (but not including) the second
				  anniversary of the Date of Grant
				

			 	
				
				   
				

			 	

				
				  [__]%
				

			 	
				
				   
				

			 
	
				
				  Commencing on the
				  second anniversary of the Date of Grant until (but not including) the third
				  anniversary of the Date of Grant
				

			 	
				
				   
				

			 	
				
				  [__]%
				

			 	
				
				   
				

			 
	
				
				  Commencing on the third
				  anniversary of the Date of Grant until (but not including) the fourth
				  anniversary of the Date of Grant
				

			 	
				
				   
				

			 	
				
				  [__]%
				

			 	
				
				   
				

			 
	
				
				  Commencing on the
				  fourth anniversary of the Date of Grant until (but not including) the fifth
				  anniversary of the Date of Grant
				

			 	
				
				   
				

			 	
				
				  [__]%
				

			 	
				
				   
				

			 
	
				
				  Commencing on the fifth
				  anniversary of the Date of Grant until (but not including) the tenth
				  anniversary of the Date of Grant
				

			 	
				
				   
				

			 	
				
				  [__]%
				

			 	
				
				   
				

			 

 

	 
		Subject to the terms hereof,
		the Option may be exercised from time to time during the Option Period as to
		the total number of Shares allowable under this Section 3, or any lesser amount
		thereof, as long as the Grantee is employed by the Corporation. For purposes of
		this Agreement, employment by the Corporation or any Subsidiary (as defined in
		the Plan) shall be deemed to be employment by the Corporation.
	 

	 
		(b) In the event that the
		Grantee’s employment is terminated other than by reason of Retirement,
		death or Disability (as such terms are defined in the Plan), (1) any portion of
		the Option not yet Vested shall thereupon expire and terminate and (2) any
		portion of the Option that has Vested may be exercised during the period ending
		twenty-one (21) days following such termination, after which period any
		unexercised portion of the Option shall expire and terminate; provided, however, that in the event that the Grantee’s
		employment is terminated for Cause (as hereinafter defined), the Option or any
		unexercised portion thereof shall immediately upon such termination be
		permanently cancelled. 
	 

	 
		(c) In the event that the
		Grantee’s employment is terminated by reason of death, the entire Option
		(or any unexercised portion thereof) shall thereupon be deemed Vested and may
		be exercised during the period ending on (but not including) the first
		anniversary of such termination, and in the event that the Grantee’s
		employment is terminated by reason of Retirement or Disability, the entire
		Option (or any unexercised portion thereof) shall thereupon be deemed Vested
		and may be exercised during the period ending twenty-one (21) days following
		such termination, after which period any unexercised portion of the Option
		shall expire and terminate.
	 

	 
		(d) If this Option shall extend
		to one hundred (100) or more Shares, then this Option may not be exercised for
		less than one hundred (100) Shares at any one time, and if this Option shall
		extend to less than one hundred (100) Shares, then this Option must be
		exercised for all such Shares at one time.
	 

	 
		 
	 

	 
		 
	 

	 
		-2-
	 

	 
		 
	 

	 
	 

	 

	 
		(e) The number of Shares to
		which the Grantee shall be entitled and the Exercise Price shall be
		proportionately and equitably adjusted in such manner as the Committee shall
		determine to maintain the economic value of the Option in the event any stock
		dividend, stock split, recapitalization, merger, reorganization, exchange of
		shares or similar event occurs in which the number or class of shares of Common
		Stock is changed without the receipt or payment of consideration by the
		Corporation. Nothing contained herein shall be deemed to require the
		Corporation to issue any fractional Shares, and any fractional Shares issuable
		upon exercise of the Option may, at the discretion of the Corporation, be
		settled in cash or otherwise or shall be forfeited or otherwise
		eliminated.
	 

	 
		(f) At such time as the Grantee
		desires to exercise the Option granted hereby, in whole or in part, the Grantee
		shall provide to the Corporation an Exercise Form in the form of Annex A hereto
		or in such other form authorized by the Corporation’s General Counsel. The
		Grantee’s signature at the place provided on said Exercise Form will
		evidence the Grantee’s election to purchase Shares of Common Stock
		pursuant to the terms and subject to the conditions and limitations contained
		in the Plan, in this Agreement and in said Exercise Form. The Option shall be
		considered exercised (in full or part, as the case may be) on the date such
		Exercise Form is received by the Secretary, together with payment of the
		Exercise Price for the Shares to be purchased plus any withholding tax required
		under any federal, state and local statutes. The Grantee may elect to have the
		amount of any withholding tax withheld from the Shares of Common Stock
		purchased. 
	 

	 
		(g) The Exercise Price shall be
		paid in full at the time of purchase of the Shares in cash or by check [ONLY
		INCLUDE FOR NON-EXECUTIVE OFFICERS: or by cashless exercise in accordance with
		the Corporation’s cashless exercise procedures as in effect from time to
		time]. If the Option is exercised in accordance with the provisions of the Plan
		and this Agreement, then the Corporation shall deliver to the Grantee
		certificates representing the number of Shares in respect of which the Option
		is being exercised, which Shares shall be registered in the Grantee’s
		name.
	 

	 
			
				
				   
				

			 	
				
				  4.
				

			 	
				
				  Stockholders’
				  and Registration Rights Agreements; Additional Repurchase
				  Provisions.
				

			 

 

	 
		(a) It is a condition to the
		grant of the Option that the Grantee execute and deliver to the Corporation,
		simultaneously with the execution and delivery of this Agreement by the
		Grantee, counterparts of the Amended and Restated Stockholders’ Agreement
		dated as of March 6, 1995 and the Registration Rights Agreement, dated as of
		May 26, 1993, as amended (respectively the “Stockholders’
		Agreement” and the “Registration Rights Agreement”), by and
		among the Corporation, David B. Cornstein, Arthur E. Reiner and certain other
		parties. Upon the Grantee’s execution and delivery of such agreements, the
		Grantee will be deemed to be a “Management Holder” under the
		Stockholders’ Agreement and a “Management Stockholder” under the
		Registration Rights Agreement, and as such the Grantee will be subject, in
		addition to the provisions of this Agreement, to all of the terms, conditions
		and obligations of such agreements, including, without limitation, restrictions
		on the transferability of the Option and any Shares purchased upon exercise
		thereof. Two copies of each of such agreements are enclosed herewith.
		Capitalized terms used but not otherwise defined herein are used as defined in
		the Stockholders’ Agreement.
	 

	 
		(b) Notwithstanding anything to
		the contrary contained herein or in the Stockholders’ Agreement, in the
		event that the Grantee’s employment is terminated for Cause, the
		Corporation shall have the right, exercisable by written notice within
		twenty-one (21) days of such termination of employment, to repurchase from the
		Grantee (and any of Grantee’s Permitted Transferees, if applicable), any
		and all Shares theretofore purchased by the Grantee hereunder at a price per
		Share equal to the Exercise Price in respect of such Shares. For purposes of
		this Agreement, termination for “Cause” shall mean termination by
		reason of the Grantee’s fraud, dishonesty or commission of a crime,
		whether or not in the course of his or her employment. 
	 

	 
		 
	 

	 
		 
	 

	 
		-3-
	 

	 
		 
	 

	 
	 

	 

	 
			
				
				   
				

			 	
				
				  5.
				

			 	
				
				  Transferability of
				  Option and Shares.
				

			 

 

	 
		(a) The Option is not
		transferable other than by will or by the laws of descent and distribution and
		during a Grantee’s lifetime is exercisable only by the Grantee. Any
		assignment in violation of this Section 5(a) shall be void and of no force or
		effect.
	 

	 
		(b) The transferability of the
		Option and the Shares is limited by the terms of the Stockholders’
		Agreement and the Registration Rights Agreement and by applicable law.
	 

	 
		(c) Without limiting the
		generality of the foregoing, no purported sale, assignment or other transfer of
		the Shares shall be effective unless and until the transferee of the Shares so
		transferred executes and delivers to the Corporation its agreement, in form and
		substance satisfactory to the Corporation, to be bound by the provisions of
		this Agreement.
	 

	 
			
				
				   
				

			 	
				
				  6.
				

			 	
				
				  Covenants of the
				  Grantee.
				

			 

 

	 
		The Grantee’s exercise of
		the Option shall be subject to the Grantee acknowledging and agreeing to the
		following at the time of such exercise:
	 

	 
		(a) The Shares may not be sold
		or otherwise disposed of except in compliance with the Securities Act of 1933,
		as amended (the “Act”), and any applicable securities or “Blue
		Sky” laws of any state.
	 

	 
		(b) The Shares will not be
		sold, hypothecated, transferred or otherwise disposed of by the Grantee in any
		manner, directly or indirectly, (i) without registration thereof under the Act
		and any applicable Blue Sky laws unless an exemption from such registration is
		available and, if the Corporation so requests, the Grantee causes counsel
		satisfactory to the Corporation to deliver to the Corporation a reasoned
		written opinion of such counsel in form and substance satisfactory to the
		Corporation; or (ii) in violation of any law; or (iii) in violation of the
		Stockholders’ Agreement or the Registration Rights Agreement.
	 

	 
		(c) The certificate or
		certificates representing the Shares shall have an appropriate legend referring
		to the terms of this Option.
	 

	 
		(d) The Grantee acknowledges
		that in the event of termination of his or her employment with the Corporation,
		his or her rights to exercise this Option are restricted as set forth in
		Section 3 above.
	 

	 
			
				
				   
				

			 	
				
				  7.
				

			 	
				
				  General
				  Provisions.
				

			 

 

	 
		This Agreement is subject in
		all respects to the terms and conditions of the Plan, which terms and
		conditions the Grantee is deemed to accept and consent to by the Grantee’s
		acceptance of the Option. Nothing contained in this Agreement shall confer upon
		the Grantee any right to continue in the employ of the Corporation or any of it
		Subsidiaries or shall in any way affect the right and power of the Corporation
		or any of its Subsidiaries to dismiss or otherwise terminate the employment of
		the Grantee at any time for any reason with or without cause. This Agreement
		shall be governed and construed in accordance with the laws of the State of
		Delaware. Any dispute arising hereunder shall be brought before a court of
		competent jurisdiction in the City, County and State of New York.
	 

	 
		If the foregoing is in
		accordance with the Grantee’s understanding and accepted and agreed to by
		the Grantee, the Grantee may so confirm by signing and returning the duplicate
		of this Agreement delivered for that purpose, as well as one copy of the
		enclosed Stockholders’ Agreement and Registration Rights Agreement.

	 

	 
		 
	 

	 
		 
	 

	 
		-4-
	 

	 
		 
	 

	 
	 

	 

	 
		 
	 

	 
			
				
				   
				

			 	
				
				   
				

			 	
				
				  FINLAY ENTERPRISES,
				  INC.
				

			 
	
				
				   
				

			 	
				
				

			 	
				
				   
				

			 	
				
				  
 By 
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  Arthur E.
				  Reiner
 Chairman and
				  CEO
				

			 

 

	 
		The foregoing is in accordance
		with my understanding and is hereby accepted and agreed.
	 

	 
		 
	 

	 
			
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  GRANTEE
				

			 
	 	 	 	 
	
				
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  Date:_______________________
				

			 

 

	 
		 
	 

	 
		 
	 

	 
		-5-
	 

	 
		 
	 

	 
	 

	 

	 
		ANNEX A
	 

	 
		EXERCISE FORM
	 

	 
		The undersigned hereby
		irrevocably exercises, pursuant to the Agreement and Certificate of Option
		dated as of _________________, _____ (the “Option”), by and between
		Finlay Enterprises, Inc. (the “Corporation”) and the undersigned, the
		option to purchase ________ Shares of Common Stock (the “Subject
		Shares”) of the Corporation at the exercise price of $ _______ per Subject
		Share. Payment of the exercise price shall be made as follows:
	 

	 
		o
		cash for $_______ enclosed herewith
	 

	 
		[INCLUDE ONLY FOR NON-EXECUTIVE
		OFFICERS:
	 

	 
		and/or
	 

	 
			
				
				   
				

			 	
				
				  o
				

			 	
				
				  by cashless exercise in
				  accordance with the Corporation’s cashless exercise procedures as in
				  effect from time to time.]
				

			 

 

	 
		The undersigned o does
		o does not [select one] elect to have the Corporation
		withhold the number of Subject Shares needed to satisfy the undersigned’s
		tax withholding obligations. If the undersigned does not elect to have
		withholding taxes paid with Subject Shares, the undersigned further agrees to
		pay to the Corporation any withholding tax required by any federal, state and
		local statutes and regulations.
	 

	 
		Dated:________________,
		_____
	 

	 
		 
	 

	 
			
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 
	
				
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  (Name of Option Grantee
				  -
				

				
				  Please Type or
				  Print)
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 
	
				
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  (Signature of Option
				  Grantee)
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 
	
				
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  (Address-Please Type or
				  Print)
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 
	
				
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				

			 
	
				
				   
				

			 	
				
				   
				

			 	
				
				   
				

			 	
				
				  (Social Security
				  No.)
				

			 

 

	 
		 
	 

	 
		 
	 

	 
		-6-

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