Document:

<PAGE>
                                                          EXHIBIT 10.15(b)

                                                            (DELTA LOGO)

                                                            INTERNAL MEMORANDUM

                                                            DATE: MARCH 15, 2006

TO:         Delta Officers and Directors

FROM:       Rob Kight, Vice President -- Compensation and Benefits

SUBJECT:    NEW DELTA SEVERANCE PLAN FOR OFFICERS AND DIRECTORS

On February 22nd, the bankruptcy court approved the Delta Air Lines, Inc.
Director and Officer Severance Plan (the "SEVERANCE PLAN") which had previously
been adopted by the Delta Air Lines, Inc. Board of Directors. This memo serves
as your notification that, based on your current status, you are designated as
eligible to participate in the Severance Plan, subject to the terms of this memo
and the terms of the Severance Plan, a copy of which is attached.

Under the terms of the Severance Plan, your eligibility to participate in the
Severance Plan is conditioned on your relinquishment and release of claims to
any other severance arrangements to which you may be a party or for which you
may be otherwise eligible. This memo, signed by you and promptly returned as set
forth below, creates your contractual entitlement to participate in the
Severance Plan, subject to its terms. Because your right, if any, to receive
benefits under the Severance Plan will be determined at the time a potentially
qualifying event occurs, and will be based on the terms of the Severance Plan,
your submission of this memo does not guarantee that you will receive benefits
under the Severance Plan. In order to receive benefits under the Severance Plan,
you must also meet all other criteria of the Plan.

By signing this memo, (i) you acknowledge that you have carefully reviewed this
memo and the terms of the Severance Plan, asked for any clarifications that you
deemed necessary to make an informed decision from the authorized Delta human
resources personnel listed below in this memo and sought any necessary advice
from your personal legal or financial advisors and (ii) notwithstanding anything
in any other agreement, understanding, plan or program to the contrary, you
hereby relinquish and fully release any rights or claims to any other severance
benefit to which you may be or may become entitled pursuant to any arrangement,
plan or program of a Delta Employer (as defined in the Severance Plan) in effect
as of the date hereof, including, without limitation, any benefits under an
Executive Retention Protection Agreement, if applicable.

<PAGE>

New Delta Severance Plan for Officers and Directors
Page 2
March 15, 2006

PLEASE INDICATE YOUR ELECTION TO BECOME ELIGIBLE TO PARTICIPATE IN THE SEVERANCE
PLAN AND YOUR AGREEMENT TO THE ACKNOWLEDGEMENT, RELINQUISHMENT AND RELEASE SET
FORTH ABOVE BY PRINTING, SIGNING, DATING AND RETURNING ONE COPY OF THIS MEMO AS
SOON AS POSSIBLE, AND NO LATER THAN MARCH 24, 2006. You should send the memo via
inter-office mail to the attention of Craig Whipple, Department 936, or to
Melinda Graves, Department 948. You should retain a copy for your records.

If you have any questions regarding the Severance Plan or your eligibility to
participate in it, please do not hesitate to call me, Cynthia Per-Lee or Beth
Johnston as soon as possible.

ACKNOWLEDGEMENT, RELINQUISHMENT AND RELEASE:

-----------------------------------
Signature

-----------------------------------
Name (Please print)

-----------------------------------
Date<PAGE>
                                                                EXHIBIT 10.15(c)

                                                            (DELTA LOGO)

                                                            INTERNAL MEMORANDUM

                                                            DATE: MARCH 15, 2006

TO:           Delta Officers and Directors

FROM:         Rob Kight, Vice President -- Compensation and Benefits

SUBJECT:      NEW DELTA SEVERANCE PLAN FOR OFFICERS AND DIRECTORS

On February 22nd, the bankruptcy court approved the Delta Air Lines, Inc.
Director and Officer Severance Plan (the "SEVERANCE PLAN") which had previously
been adopted by the Delta Air Lines, Inc. Board of Directors. This memo serves
as your notification that, based on your current status, you are designated as
eligible to participate in the Severance Plan, subject to the terms of this memo
and the terms of the Severance Plan, a copy of which is attached.

Under the terms of the Severance Plan, your eligibility to participate in the
Severance Plan is conditioned on your relinquishment and release of claims to
any other severance arrangements to which you may be a party or for which you
may be otherwise eligible. This memo, signed by you and promptly returned as set
forth below, creates your contractual entitlement to participate in the
Severance Plan, subject to its terms. Because your right, if any, to receive
benefits under the Severance Plan will be determined at the time a potentially
qualifying event occurs, and will be based on the terms of the Severance Plan,
your submission of this memo does not guarantee that you will receive benefits
under the Severance Plan. In order to receive benefits under the Severance Plan,
you must also meet all other criteria of the Plan.

By signing this memo, (i) you acknowledge that you have carefully reviewed this
memo and the terms of the Severance Plan, asked for any clarifications that you
deemed necessary to make an informed decision from the authorized Delta human
resources personnel listed below in this memo and sought any necessary advice
from your personal legal or financial advisors and (ii) notwithstanding anything
in any other agreement, understanding, plan or program to the contrary, you
hereby relinquish and fully release any rights or claims to any other severance
benefit to which you may be or may become entitled pursuant to any arrangement,
plan or program of a Delta Employer (as defined in the Severance Plan) in effect
as of the date hereof, including, without limitation, any benefits under an
Executive Retention Protection Agreement, if applicable. You also acknowledge
that to the extent you are eligible for any furlough pay under the pilot working
agreement, such amount will be offset against any amounts to be paid under the
Severance Plan.

<PAGE>

New Delta Severance Plan for Officers and Directors
Page 2
March 15, 2006

PLEASE INDICATE YOUR ELECTION TO BECOME ELIGIBLE TO PARTICIPATE IN THE SEVERANCE
PLAN AND YOUR AGREEMENT TO THE ACKNOWLEDGEMENT, RELINQUISHMENT AND RELEASE SET
FORTH ABOVE BY PRINTING, SIGNING, DATING AND RETURNING ONE COPY OF THIS MEMO AS
SOON AS POSSIBLE, AND NO LATER THAN MARCH 24, 2006. You should send the memo via
inter-office mail to the attention of Craig Whipple, Department 936, or to
Melinda Graves, Department 948. You should retain a copy for your records.

If you have any questions regarding the Severance Plan or your eligibility to
participate in it, please do not hesitate to call me, Cynthia Per-Lee or Beth
Johnston as soon as possible.

ACKNOWLEDGEMENT, RELINQUISHMENT AND RELEASE:

-----------------------------------
Signature

-----------------------------------
Name (Please print)

-----------------------------------
Date<PAGE>
                                                                EXHIBIT 10.15(d)

                       [DELTA AIR LINES, INC. LETTERHEAD]

I hereby acknowledge that I am not a participant in any Delta Air Lines, Inc.
severance plan or program, and that I am not currently eligible for any
severance benefit under any plan or program at Delta, including any benefits
under any Executive Retention Protection Agreement.

ACKNOWLEDGMENT, RELINQUISHMENT
AND RELEASE:

----------------------------
Signature

----------------------------
Name (Please print)

----------------------------
Date<PAGE>
                                                                    Exhibit 10.4
                           FIRST COMMUNITY CORPORATION
                             STOCK OPTION AGREEMENT

OPTIONS GRANTED:
                ----------------------------

DATE OF GRANT:
              ------------------------------

EXERCISE PRICE:  $            per share
               -----------------------------

                               RECORD OF EXERCISES
                   ALL SHARES VEST ONE YEAR FROM DATE OF GRANT

<Table>
<Caption>
--------------------------------------------------------------------------------------------------------------------
             Date          Number of Options          Amount                 Sale             Amount Gained
          of Exercise         Exercised         Paid to Corporation         Price              by Employee
--------------------------------------------------------------------------------------------------------------------
<S>       <C>              <C>                  <C>                         <C>               <C>
--------------------------------------------------------------------------------------------------------------------
    1
--------------------------------------------------------------------------------------------------------------------
    2
--------------------------------------------------------------------------------------------------------------------
    3
--------------------------------------------------------------------------------------------------------------------
    4
--------------------------------------------------------------------------------------------------------------------
    5
--------------------------------------------------------------------------------------------------------------------
    6
--------------------------------------------------------------------------------------------------------------------
    7
--------------------------------------------------------------------------------------------------------------------
    8
--------------------------------------------------------------------------------------------------------------------
    9
--------------------------------------------------------------------------------------------------------------------
   10
--------------------------------------------------------------------------------------------------------------------
</Table>

     THIS STOCK OPTION AGREEMENT ("Agreement") is made and entered into as of
_________________, by and between FIRST COMMUNITY CORPORATION, a Tennessee
corporation (the "Corporation"), and _________________________ ("Employee").

                                    RECITALS:

     A. Corporation is the holding company of First Community Bank, Rogersville,
Tennessee.

     B. Corporation has adopted its 1994 Stock Option Plan, as amended (the
"Plan"), which governs and controls the terms of this Agreement.

     C. Employee has been granted stock options under this Agreement in
recognition of service to the Corporation.

                                   AGREEMENT:

     NOW, THEREFORE, for and in consideration of the promises and the mutual
covenants and agreements contained herein, and other good and valuable
consideration, the receipt and sufficiency

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

of which are hereby acknowledged, the parties hereby agree as follows:

1.   DEFINITIONS. For purposes of this Agreement, the following terms shall have
     the meanings specified below. Capitalized terms in this Agreement have the
     meaning ascribed to such terms in the Plan unless otherwise defined herein.

               1.1 "BENEFICIAL OWNER" shall have the meaning attributed to that
          term under Rule 13d-3 of the Securities Exchange Act of 1934, as
          amended.

               1.2 "CODE" means the Internal Revenue Code of 1986, as amended
          from time to time.

               1.3 "DISABILITY" means, as defined by and to be construed in
          accordance with Code Section 22(e)(3), any medically determinable
          physical or mental impairment that is expected to result in death or
          that has lasted or can be expected to last for a continuous period of
          not less than twelve (12) months, and that renders Employee unable to
          engage in any substantial gainful activity. An Employee shall not be
          considered to have a Disability unless Employee furnishes proof of the
          existence thereof in such form and manner, and at such time, as the
          Board of Directors or the Compensation Committee of the Board may
          require.

2.   STOCK OPTIONS.

          2.1  The Corporation hereby grants to Employee an option that, except
               as provided in Section 2.2, is intended to be an "Incentive Stock
               Option" pursuant to Code Section 422 to purchase up to
               ____________ shares of the Corporation's Common Stock, no par
               value, at an exercise price of $_____________ per share, expiring
               10 years from the date granted, as referenced above. Such
               Incentive Stock Option is granted pursuant to the Plan, and the
               exercise price of the option has been determined by the Board of
               Employees of the Corporation to be not less than one hundred
               percent (100%) of the fair market value of the stock as of the
               date of this Agreement. Pursuant to this Section, the option
               granted hereunder shall vest one year from the date granted, as
               referenced above.

          2.2  In the event that the number of option shares of Common Stock
               subject to this Agreement exceeds any maximum established under
               the Code for Incentive Stock Options that may be granted to
               Employee, or in the event that the option granted under this
               Agreement becomes first exercisable in any calendar year to
               obtain the Corporation's Common Stock having a fair market value
               in excess of $100,000, the option granted hereunder shall be
               treated as a non-qualified stock option to the extent of such
               excess. If the exercise of the option granted hereunder is
               accelerated by reason of a Change in Control or Potential Change
               in Control, any portion of such option that is not exercisable as
               an Incentive Stock Option by reason of the $100,000 limitation
               contained

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

               in Section 422(d) of the Code shall be treated as a non-qualified
               stock option.

3.   EXERCISE OF OPTIONS. To exercise this option, in whole or in part, the
     Employee shall complete Exhibit A to this Agreement and must submit it with
     the payment for the Exercise Price multiplied by the number of shares being
     exercised. Upon confirmation that [a] such shares are exercisable, [b] the
     payment presented is in good funds, and [c] such exercise is in compliance
     with this Agreement, the Corporation will transfer the shares of Common
     Stock to the Employee or the Employer's stock brokerage account at the
     Employee's direction. The Employee agrees that, to avoid even the
     appearance of any Employee trading the Corporation's Common Stock based on
     "insider" information or for other business reasons, the Corporation may
     determine from time to time that a "quiet period" is in effect during which
     all employees, including the Employee, shall not be permitted to sell the
     Corporation's Common Stock. By entering into this Agreement, the Employee
     agrees not to sell any of the Corporation's Common Stock during such quiet
     periods.

4.   RESERVATION OF SHARES. The Corporation shall at all times reserve and keep
     available a number of its authorized but unissued shares of its Common
     Stock sufficient to permit the exercise in full the option granted under
     this Agreement.

5.   RESTRICTIONS ON SALE OF STOCK. The option granted under this Agreement is
     not transferable or assignable except by will or by the applicable laws of
     descent and distribution, and only the Employee may exercise the option
     granted hereunder during the Employee's lifetime. If the Employee is an
     executive officer of the Corporation, or is deemed to be an "affiliate" of
     the Corporation, within the meaning ascribed to that term under Rule 144 of
     the Securities and Exchange Commission, the number of option shares such
     person may transfer during any three-month period will be restricted under
     the provisions of Rule 144. If the Employee is such a person, each
     certificate evidencing any of the shares of Common Stock acquired by
     Employee pursuant to this Agreement shall include a restrictive legend
     consistent with such limitation on transfers.

     The option granted hereunder shall be registered on the books of the
     Corporation maintained at its principal office, and shall be exercised only
     on said books by the registered owner hereof in person or by duly
     authorized attorney upon surrender of an Exercise Form attached hereto as
     Exhibit A properly endorsed, and only in compliance with the provisions of
     the Plan and this Agreement. The Corporation will record any exercises on
     the Corporation's books indicating the number of option shares having been
     exercised and the number of option shares remaining to be exercised.

6.   CAPITAL ADJUSTMENTS AFFECTING STOCK, MERGERS AND CONSOLIDATIONS.

          A. Capital Adjustments. In the event of a capital adjustment in the
     Common Stock resulting from a stock dividend, stock split, reorganization,
     merger, consolidation, or a combination or exchange of shares, the number
     of shares of Common Stock under option shall be automatically adjusted to
     take into account such capital adjustment. The price of any

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

     share of Common Stock under option shall be adjusted so that there will be
     no change in the aggregate purchase price payable upon exercise of the
     option.

          B. Mergers and Consolidations. In the event the Corporation merges or
     consolidates with another entity, or all or a substantial portion of the
     Corporation's assets or outstanding capital stock are acquired (whether by
     merger, purchase or otherwise) by a successor, the Common Stock subject to
     the Plan and to each outstanding option shall, automatically by virtue of
     such merger, consolidation or acquisition, be converted into and replaced
     by shares of stock of the Corporation's successor having rights and
     preferences no less favorable than the Common Stock, and the number of
     shares subject to the option and the purchase price per share upon exercise
     of the option shall be correspondingly adjusted, so that, by virtue of such
     merger, consolidation or acquisition, each Employee shall have the right to
     purchase [i] that number of shares of stock of the Corporation's successor
     that have a value equal, as of the date of such merger, conversion or
     acquisition, to the value, as of the date of such merger, conversion or
     acquisition, of the shares of Common Stock of the Corporation theretofore
     subject to Employee's option, [ii] for a purchase price per share that,
     when multiplied by the number of shares of stock of the Successor subject
     to the option, equal the aggregate exercise price at which Employee could
     have acquired all of the shares of Common Stock of the Corporation
     theretofore optioned to Employee.

          C. No Effect on Corporation's Rights. The granting of an option
     pursuant to the Plan shall not affect in any way the right and power of the
     Corporation to make adjustments, reorganizations, reclassifications, or
     changes of its capital or business structure or to merge, consolidate,
     dissolve, liquidate, sell or transfer all or any part of its business or
     assets.

7.   NOTIFICATION OF SALE. The Employee agrees that, if the shares obtained
     under this Agreement are sold within two (2) years from the date of grant
     and one (1) year of the date of exercise, the Employee shall notify the
     Corporation, at the address set out in Section 14 below, the sale price and
     the number of shares sold, within ten (10) days from the date of sale on
     the form attached hereto as Exhibit B.

8.   TAXES. The Employee shall be responsible for paying all taxes (both federal
     and state) on any gain from the sale of Common Stock obtained from the
     exercise of the option granted hereunder. The Employee should consult with
     his or her tax adviser concerning any questions about the tax liability
     arising from the sale of stock obtained through the exercise of this option
     to determine, among other things, whether the Employee needs to pay
     quarterly estimated taxes on any gain. Employee acknowledges that the
     Corporation may be required to collect the taxes at the time of the
     exercise. Employee agrees that, if the Corporation must collect the taxes,
     the Employee shall promptly supply the Corporation such information
     necessary to properly calculate the taxes due, and Employee agrees to pay,
     in addition to the amount required to exercise the option granted
     hereunder, all such taxes due at the time of the exercise to the
     Corporation.

9.   LIMITATIONS OF DAMAGES. Employee agrees that, notwithstanding any other
     provision of this Agreement to the contrary, Employee's sole and exclusive
     remedy for breach of this

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

     Agreement shall be for the Corporation to deliver any shares of Common
     Stock that are vested, properly exercisable and are properly exercised
     under the terms of the Plan and this Agreement. THE EMPLOYEE AGREES THAT
     THE CORPORATION SHALL NOT BE LIABLE FOR EMPLOYEE'S CONSEQUENTIAL DAMAGES,
     IF ANY, RESULTING FROM CORPORATION'S BREACH OR ALLEGED BREACH OF THIS
     AGREEMENT, INCLUDING EMPLOYEE'S DAMAGES FOR LOST PROFITS, EVEN THOUGH BOTH
     PARTIES RECOGNIZE THAT SUCH BREACH COULD COST THE EMPLOYEE LOST PROFITS AND
     CONSEQUENTIAL DAMAGES.

10.  INDEMNIFICATION OF CORPORATION BY EMPLOYEE. Employee covenants and agrees
     to indemnify and hold harmless the Corporation from any and all losses,
     damages, liabilities, expenses or claims, including reasonable attorney
     fees and costs of collection, resulting from or arising out of the
     Employee's breach of this Agreement.

11.  WAIVER OF JURY TRIAL. EMPLOYEE WAIVES ANY RIGHT TO A JURY TRIAL IN ANY
     DISPUTE CONCERNING THIS STOCK OPTION AGREEMENT.

12.  ASSIGNMENT. The parties acknowledge that this Agreement has been entered
     into due to, among other things, the special skills of Employee, and agree
     that this Agreement may not be assigned or transferred by Employee. Any
     attempted assignment or transfer of this Agreement by Employee shall be
     null and void ab initio. The options hereunder may be exercised only by the
     Employee during the Employee's lifetime, or by Employee's personal
     representative in the event of death or disability to the extent the
     options were exercisable on the date of death or disability. The
     Corporation may freely assign this Agreement to its successors and assigns
     without notice to the Employee or the Employee's consent.

13.  NOTICES. All notices, requests, demands and other communications required
     or permitted hereunder shall be in writing and shall be deemed to have been
     duly given on the date of receipt if delivered or mailed, first class,
     certified mail, postage prepaid, with a copy by facsimile, if any is
     provided,:

                         If to the Corporation:

                         First Community Corporation
                         Attention: Chief Financial Officer
                         809 West Main Street
                         Rogersville, Tennessee 37857
                         Facsimile: (423) 272-1962

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

                         To Employee:

                         --------------------------------------------

                         --------------------------------------------

                         --------------------------------------------
                         Home Telephone:
                                        -----------------------------

14.  NO RIGHTS AS STOCKHOLDER. This Agreement does not confer any rights of a
     stockholder on the Employee, except as to shares of Common Stock that are
     actually delivered to the Employee.

15.  AMENDMENTS AND MODIFICATIONS. This Agreement may be amended or modified
     only in writing signed by both parties hereto.

16.  GOVERNING LAW AND JURISDICTION. This Agreement will be governed by and
     construed in accordance with the laws of Tennessee, without giving effect
     to its conflict of laws rules. Each party hereto hereby irrevocably
     consents to the jurisdiction of the courts of the State of Tennessee and of
     any federal court located in Tennessee in connection with any action or
     proceeding arising out of or relating to this Agreement, any document or
     instrument delivered pursuant to or in connection with this Agreement, or
     any breach of this Agreement or any such document or instrument. Each party
     hereto agrees not to assert, by way of motion, as a defense, or otherwise,
     in any such action, suit or proceeding, that such party is not subject
     personally to the jurisdiction of the court, that the action, suit or
     proceeding is brought in an inconvenient forum, that the venue of the
     action, suit or proceeding is improper, or that this Agreement or any such
     document or instrument may not be enforced in or by the court.

17.  EXECUTION IN COUNTERPARTS. This Agreement may be executed by each party
     upon a separate copy or separate signature pages, and any combination of
     separate copies executed by all parties or including signature pages so
     executed will constitute a single counterpart of this Agreement. This
     Agreement may be executed in any number of counterparts, each of which will
     be deemed to be an original, but all of which together will constitute one
     and the same agreement. It will not be necessary, in proving this Agreement
     in any proceeding, to produce or account for more than one counterpart of
     this Agreement.

18.  HEADINGS. The headings set out in this Agreement are for convenience of
     reference and shall not be deemed a part of this Agreement and shall not
     affect the meaning or construction of any of the provisions hereof.

                [Remainder of this page is intentionally blank.]

<PAGE>
FIRST COMMUNITY CORPORATION
STOCK OPTION AGREEMENT

         IN WITNESS WHEREOF, the parties have executed this Agreement on the day
and year first above written.

                                     FIRST COMMUNITY CORPORATION

                                     By:
                                         ----------------------------------

                                     Name:
                                          ---------------------------------

                                     Title:
                                           --------------------------------

                                     EMPLOYEE:

                                     --------------------------------------
                                     Signature

                                     Name:
                                          ---------------------------------

<PAGE>

                                    EXHIBIT A

                         EXERCISE FORM FOR STOCK OPTIONS

Name:______________________________________________________

Grant Date:________________________________________________

------------------------------------------------------------------------
Number of Shares Being Exercised

------------------------------------------------------------------------

Multiplied Times Option Price                          X  $_______

------------------------------------------------------------------------
Total Amount Submitted
=
------------------------------------------------------------------------

         Please check the appropriate box and fill out the requested information
         each time shares are being exercised and send form to: _______________.

[ ]  Upon the receipt of good funds from me for the exercise price of the
     options exercised, I request the Corporation to send a certificate
     representing the number of shares exercised to:

     [ ] My address set out in Section 14 of this Agreement; or
     [ ] My broker's address set out below.

===================================================================
Broker's Name:

-------------------------------------------------------------------
Broker's Corporation Name:

-------------------------------------------------------------------
Address:
-------------------------------------------------------------------

-------------------------------------------------------------------

-------------------------------------------------------------------

-------------------------------------------------------------------

-------------------------------------------------------------------
Telephone Number:
-------------------------------------------------------------------
Facsimile Number:
===================================================================

    Submitted this ______ day of _____________________, _____________.
                                 (Month)                   (Year)

                   -----------------------------------
                   Signature
                   Name:
                        ------------------------------

<PAGE>

                                    EXHIBIT B

                         NOTIFICATION OF SALE OF SHARES
                               FROM STOCK OPTIONS

Name:______________________________________________________

Grant Date:________________________________________________

<Table>
<S>                          <C>                                   <C>
-----------------------------------------------------------------------------------------------------------
                                      DATE OF EXERCISE: ___________
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
                                        DATE OF SALE: ___________
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
    Sale Price      (Minus)     Exercise Price    (Equals)     Gain Per Share
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
                          -                                      =
-------------------------    ------------------------------------  ------------------------------
-----------------------------------------------------------------------------------------------------------
        (Sale Price)              (Exercise Price)                               (Gain Per Share)
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
Gain Per Share (Times) Number of Shares Sold (Equals) Total Gain
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
                          x                                      =
-------------------------   -------------------------------------  ----------------------------------------
   (Gain Per Share)          (Number of Shares Exercised)       (Total Gain)
-----------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------
</TABLE>

     Submitted this _____ day of ___________________, __________________.
                                       (Month)              (Year)

                            ----------------------------------------
                            Signature
                            Name:
                                  ----------------------------------

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