Document:

exhibit1016.htm

Exhibit 10.16

 

AMENDMENT NO. 1 TO

LEASE AGREEMENT

THIS AMENDMENT NO. 1 TO LEASE AGREEMENT ( this “Amendment”) is made effective as of the 8th of May, 2012 (“Effective Date”) by and between BOMAX PROPERTIES, LLC (“Bomax”) and TRANSACT TECHNOLOGIES INCORPORATED (“TransAct”).

WITNESSETH:

WHEREAS, Bomax and TransAct entered into a certain Lease Agreement dated July 18, 2001, having a “Commencement Date” of June 4, 2002 (the “Lease”), pursuant to which TransAct leased the “Leased Premises”, as defined therein, from Bomax; and

WHEREAS, TransAct has requested and Bomax has agreed to extend the Lease Term and otherwise amend the Lease upon the terms and conditions contained herein (all defined terms used herein, as evidenced by the first letter thereof being capitalized, not otherwise defined herein, shall be as defined in the Lease).

NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:

1.           Amendment of the Lease.   The Lease is hereby amended as follows:

(a)           Article II is amended to delete the last paragraph (and any reference to an Option Term) and to extend the Lease Term from June 4, 2012 through May 31, 2016.

(b)           Article III, Section A. is amended to refer to rent of $5.82 per gross square foot (i.e. $430,022.34) per annum for the balance of the Lease Term, effective on and after June 1, 2012; provided, however, acknowledging that Bomax has no obligation to do so, if Bomax does not take any action to review or contest any Impositions imposed upon or against the Leased Premises based on the assessed valuation thereof for which TransAct is responsible under the Lease by action taken on or before May 31, 2013, the rent will be adjusted to $5.80 per gross square foot (i.e. $428,544.60) retroactive to June 1, 2012 and any overage paid refunded or credited against the next month’s rental payment.

(c)           Article III, Section C. is deleted in its entirety.

(d)           Article IV, Section D. is deleted in its entirety and replaced with the following:

Provided that Bomax takes any action to review or contest the assessed valuation of the Leased Premises on or before May 31, 2013, TransAct waives its right to review or contest any Impositions imposed upon or against the Leased Premises based on the assessed valuation thereof for which TransAct is responsible under the Lease, such right inuring solely to Bomax, without any obligation to take any action to so review or contest such Impositions.  If and in the event Bomax takes action to review or contest any Impositions imposed upon or against the Leased Premises based on the assessed valuation 

 

  

  

  

thereof for which TransAct is responsible under the Lease and is successful in reducing such Impositions, TransAct will pay to Bomax fifty (50%) percent of such savings plus fifty (50%)  of the cost of prosecuting such including, without limitation reasonable attorney’s fees, provided such cost does not exceed such savings, based on the reduced assessed value of the Leased Premises  as compared to the current assessed value of the Leased Premises. , TransAct will pay the aforementioned amounts out of any refund of the Impositions previously paid by TransAct and/or when and to the extent that the reduced Impositions are payable under the Lease each year during the remainder of the Lease Term.

(e)           Article IX, Sections A and B are amended to reflect the fact that (i) while TransAct shall remain responsible for the maintenance and minor repairs to all air handling units located on the Leased Premises, as of the Effective Date of this Amendment shall not be responsible for any major repairs or the replacement thereof unless due to its failure to provide necessary maintenance and minor repairs (A “minor repair” is defined as a repair or series of related repairs, the cost of which is less than $1,000 for any one given unit, and a “major repair” is defined as a repair or series of related repairs, the cost of which is $1,000 or more for any one given unit) and (ii) while TransAct shall remain responsible for maintaining and keeping the parking area in clean and orderly condition, it shall not be responsible for any required resurfacing other than minor patching, if and when necessary.

(f)           A new Article XXXIV is added reading as follows:

ARTICLE XXXIV

Bomax shall, at its sole cost and expense, undertake and complete such repairs and/or improvements as are referenced on Exhibit “C” annexed hereto within a commercially reasonable time, but in no event later than December 31, 2012.  No diminution of rent shall be claimed or allowed for any inconvenience or discomfort arising from undertaking such repairs and/or improvements.  Notwithstanding the foregoing, Landlord agrees to use commercially reasonable efforts not to interfere with the conduct of Tenant’s ordinary business operations in the Premises during any access of the Premises by Landlord to perform the tenant improvement work. Landlord agrees to provide the Tenant with at least 48 hours prior notice (except in the event of an emergency) prior to entering the Premises to perform its obligations hereunder.

2.           Miscellaneous.

(a)           Except as amended hereby, the Lease remains in full force and effect.

(b)           This Amendment shall be governed by and construed in accordance with the laws of the State of New York applicable to agreements made and to be performed in the State of New

 

 

  

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York and shall be construed without regard to any presumption or other rule requiring the construction of an agreement against the party causing it to be drafted.

(c)           This Amendment may be executed in any number of counterparts, each of which shall be an original, but which together constitute one and the same instrument.   Signatures delivered by facsimile or electronically shall be deemed original signatures for all purposed of this Agreement.

(d)           TransAct hereby confirms that, to its actual knowledge, it has no claim, set-off, counter-claim, defense or other cause of action against Bomax arising out of the Lease Agreement as of the date hereof.  To the extent that TransAct has actual knowledge of any claim, set-off, counterclaim, defense or other cause of action existing as of the date hereof, such claim, set-off, counterclaim, defense or other cause of action is hereby expressly and knowingly waived and released by TransAct.

IN WITNESS WHEREOF, the parties have executed this Amendment No. 1 to Lease Agreement as of the date first above written.

BOMAX PROPERTIES, LLC

By:________________________________

Maxine P. Dean, Manager

TRANSACT TECHNOLOGIES

INCORPORATED

By: ________________________________

Steven A. DeMartino

President and CFO

 

  

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Exhibit “C”

Landlord Work

	
·  

	
Renovating four (4) toilet rooms, including installation of ceramic tile floors, new counter tops, new fixtures (including toilets, urinals, sinks and faucets), new ventilation and paint and two (2) other toilet rooms with counter tops and fixtures.

	
·  

	
Replace kitchen counter top, cabinets and faucet.

	
·  

	
Repair through patching, floor transitions.

	
·  

	
In the manufacturing area, remove loose paint and repaint exposed ceiling structure where the current paint has failed and is flaking off.

	
·  

	
Install new carpet in the office area.*

	
·  

	
Repaint office area.*

*TransAct to move the furniture out of agreed upon areas for work to take place.

 

  

4rdnt_10q-ex1001.htm

Exhibit 10.1

 

RADNET, INC.

2006 EQUITY INCENTIVE PLAN

 

STOCK AWARD AGREEMENT

 

The Company hereby awards a Stock Award (the “Restricted Stock”) to the Awardee named below.  The terms and conditions of the Stock Award are set forth in this cover sheet and the attached Stock Award Agreement and in the Plan.  This cover sheet is incorporated into and a part of the attached Stock Award Agreement (together, the “Agreement”).

Date of Award:

 

Name of Awardee:

 

Number of Shares of Restricted Stock Awarded:

 

	
Amount Paid by Awardee for the Shares of Restricted Stock Awarded:

	
$

	 	 
	
Fair Market Value of a Share on Date of Award:

	
$

 

Vesting Calculation Date:  __________________,

Vesting Schedule:

 

As long as you continuously are a Service Provider, you will become incrementally vested as to [   %] of the total number of Shares of Restricted Stock awarded (rounded down to the nearest whole number), as shown above on the cover sheet, on each of the first [     ] anniversaries of the Vesting Calculation Date.  In the event that you cease to be a Service Provider prior to the [     ] anniversary of the Vesting Calculation Date, you will forfeit to the Company without consideration (except for any amount paid by you to the Company for the unvested Shares as shown above) all of the unvested Shares subject to this Award.  However, the total number of then unvested Shares subject to this Award shall become fully vested if there is a Change in Control and your status as a Service Provider is either terminated without cause (as defined below) by the Company or terminated by you for Good Reason (as defined below) in anticipation of or written 24 months after the Change in Control

 

By signing this cover sheet, you agree to all terms and conditions described in the attached Stock Award Agreement and in the Plan and Plan prospectus.  You specifically acknowledge that you have carefully read the section entitled "Code Section 83(b) Election" and the attachment entitled "Section 83(b) Elections" and you further acknowledge that you are solely responsible for filing any Code Section 83(b) election, and that such election must be filed within thirty (30) days after the Date of Award in order to be effective. You are also acknowledging receipt of this Agreement and copies of the Plan and its prospectus.

 

	
Company:

	  	
Awardee:

	 	 	 
	
By: ________________________

	  	  ________________________
	
Its: ________________________

	  	  

Attachments

 

 

  

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RADNET, INC.

2006 EQUITY INCENTIVE PLAN

 

STOCK AWARD AGREEMENT

 

	
The Plan and Other Agreements

	
The text of the Plan is incorporated in this Agreement by this reference.  You and the Company agree to execute such further instruments and to take such further action as may reasonably be necessary to carry out the intent of this Agreement.  Unless otherwise defined in this Agreement, certain capitalized terms used in this Agreement are defined in the Plan.

This Agreement, the attached Exhibits and the Plan constitute the entire understanding between you and the Company regarding this Award of Restricted Stock.  Any prior agreements, commitments or negotiations are superseded.

	 	 
	
Award of Restricted Stock

	
The Company awards you the number of shares of Restricted Stock shown on the cover sheet of this Agreement.  The Award is subject to the terms and conditions of this Agreement and the Plan.  This Award is not intended to constitute a nonqualified deferred compensation plan within the meaning of section 409A of the Code and will be interpreted accordingly.

	 	 
	
Vesting

	
This Award will vest according to the Vesting Schedule on the attached cover sheet and also the below paragraphs of this section.

The term "Cause" shall mean (1) the Awardee's theft, dishonesty, or falsification of any documents or records of the Company or any affiliate; (2) the Awardee's improper use or disclosure of confidential or proprietary information of the Company or any affiliate; (3) any action by the Awardee which has a detrimental effect on the reputation or business of the Company or any affiliate; (4) the Awardee's failure or inability to perform any reasonable assigned duties after written notice from the Company or an affiliate, and a reasonable opportunity to cure, such failure or inability; (5) any material breach by the Awardee of any employment or service agreement between the Awardee and the Company or an affiliate, which breach is not cured pursuant to the terms of such agreement; (6) the Awardee's conviction (including any plea of guilty or nolo contendere) of any criminal act which impairs the Awardee's ability to perform his or her duties with the Company or an affiliate; or (7) violation of a material Company policy.

 

The term "Good Reason" shall mean, as determined by the Administrator, (A) a material adverse change in the Awardee's title, stature, authority, or responsibilities with the Company (or the affiliate employing him or her); (B) a material reduction in the Awardee's base salary or annual bonus opportunity; or (C) receipt of notice that the Awardee's principal workplace will be relocated by more than 50 miles.  The Awardee must provide written notice to the Company within 60 days of the initial existence of a Good Reason event or else the Awardee will have waived any ability to resign his/her service for Good Reason with respect to such event.

 

Upon the death or permanent disability (as determined by a physician independent of Awardee and Company) of Awardee.

	 	 

 

 

  

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Escrow

	
The certificate(s) for the Restricted Stock shall be deposited in escrow with the Secretary of the Company (or his/her designee) to be held in accordance with the provisions of this paragraph.  Each deposited certificate shall be accompanied by a duly executed Assignment Separate from Certificate in the form attached hereto as Exhibit A.  The deposited certificates shall remain in escrow until such time as the certificates are to be released or otherwise surrendered for cancellation as discussed below.  Upon delivery of the certificates to the Company, you shall be issued an instrument of deposit acknowledging the number of Shares of Restricted Stock delivered in escrow to the Secretary of the Company.

	 	 
	  	
All regular cash or stock dividends, if any, on the Restricted Stock shall be held in escrow and shall be subject to the same vesting conditions provided in this Agreement.

 

The Restricted Stock held in escrow hereunder shall be subject to the following terms and conditions relating to their release from escrow or their surrender to the Company, provided, however, that the minimum number of Shares released to you in any individual release of Share certificates must be at least twenty-five (25) Shares (unless the release represents your final release of Share certificates from escrow):

 

· When your interest in the Restricted Stock vests, the certificates for such vested Restricted Stock (and related dividends) shall be released from escrow and delivered to you, at your request.  Upon your Termination of Service for any reason prior to vesting and in which no vesting is provided upon such termination, any unvested Restricted Stock (and dividends) subject to this Agreement shall be immediately surrendered to the Company.

 

	
No Assignment

	
The Shares subject to this Award shall not be sold, anticipated, assigned, attached, garnished, optioned, transferred or made subject to any creditor’s process, whether voluntarily, involuntarily or by operation of law.  However, this shall not preclude a transfer of vested Shares by will or by the laws of descent and distribution.  In addition, pursuant to Company procedures, you may designate a beneficiary who will receive any outstanding vested Shares in the event of your death.  Regardless of any marital property settlement agreement, the Company is not obligated to recognize your spouse’s interest in your Award in any way.

	 	 
	
Code Section 83(b) Election

	
You represent and warrant that you understand the Federal, state and local income tax consequences of the granting of this Restricted Stock.  Under Section 83 of the Code, the Fair Market Value of the Restricted Stock on the date any forfeiture restrictions applicable to such Restricted Stock lapse will be reportable as ordinary income at that time.  For this purpose, “forfeiture restrictions” include surrender to the Company of unvested Restricted Stock as described above.  You may voluntarily elect to be taxed at the time the Restricted Stock is acquired to the extent that the Fair Market Value of the Restricted Stock exceeds the amount of consideration paid by you (if any) for such Restricted Stock at that time rather than when such Restricted Stock ceases to be subject to such forfeiture restrictions, by filing an election under Section 83(b) of the Code with the Internal Revenue Service within thirty (30) days after the Date of Award.  A form for making this election is attached as Exhibit B hereto.  Failure to make this filing within the thirty (30) day period will result in the recognition of ordinary income by you as the forfeiture restrictions lapse.  YOU ACKNOWLEDGE THAT IT IS YOUR SOLE RESPONSIBILITY, AND NOT THE COMPANY’S, TO FILE A TIMELY ELECTION UNDER CODE SECTION 83(b), EVEN IF YOU REQUEST THE COMPANY OR ITS REPRESENTATIVES TO MAKE THIS FILING ON YOUR BEHALF.  MOREOVER, YOU ARE RELYING SOLELY ON YOUR OWN ADVISORS WITH RESPECT TO THE DECISION AS TO WHETHER OR NOT TO FILE A CODE SECTION 83(b) ELECTION.

	 	 
	
Leaves of Absence

	
For purposes of this Agreement, while you are a common-law employee, your status as a Service Provider does not terminate when you go on a bona fide leave of absence that was approved by the Company (or its parent, subsidiary or affiliate) in writing, if the terms of the leave provide for continued service crediting, or when continued service crediting is required by applicable law.  Your status as a Service Provider terminates in any event when the approved leave ends, unless you immediately return to active work.

The Company determines which leaves count for this purpose (along with determining the effect of a leave of absence on vesting of the Award), and when your status as a Service Provider terminates for all purposes under the Plan.

	 	 
	
Voting and Other Rights

	
Subject to the terms of this Agreement, you shall have all the rights and privileges of a stockholder of the Company while the Restricted Stock is held in escrow, including the right to vote and to receive dividends (if any).

	 	 
	
Adjustments

	
In the event of a stock split, a stock dividend or a similar change in the Company stock, the number of outstanding Shares covered by this Award may be adjusted (and rounded down to the nearest whole number) pursuant to the Plan.  This Award shall be subject to the terms of the agreement of merger, liquidation or reorganization in the event the Company is subject to such corporate activity.

 

 

  

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Taxes and Withholding

	
You will be solely responsible for payment of any and all applicable taxes associated with this Award.

The delivery to you of any Shares will not be permitted unless and until you have satisfied any withholding or other taxes that may be due.  At the discretion of the Administrator, any such tax withholding obligations may be settled by the Company withholding and retaining a portion of the Shares from the Shares that would otherwise be deliverable to you as of the vesting date and/or by Shares which have already been owned by you for more than six (6) months and which are surrendered to the Company.  Such withheld or surrendered Shares will be applied to pay the withholding obligation by using the aggregate fair market value of the withheld or surrendered Shares as of the date of vesting.  If Shares are withheld, then you will be delivered the net amount of vested Shares after the Share withholding has been effected and you will not receive the withheld Shares.

	 	 
	
Restrictions on Issuance and Resale

	
The Company will not issue any Shares if the issuance of such Shares at that time would violate any law or regulation.

 

By signing this Agreement, you agree not to sell, transfer, dispose of, pledge, hypothecate, make any short sale of, or otherwise effect a similar transaction of any Shares acquired under this Award (each a “Sale Prohibition”) at a time when applicable laws, regulations or Company or underwriter trading policies prohibit the exercise or disposition of Shares.  The Company shall have the right to designate one or more periods of time, each of which generally will not exceed one hundred eighty (180) days in length (provided however, that such period may be extended in connection with the Company’s release (or announcement of release) of earnings results or other material news or events), and to impose a Sale Prohibition, if the Company determines (in its sole discretion) that such limitation(s) is needed in connection with a public offering of Shares or to comply with an underwriter’s request or trading policy, or could in any way facilitate a lessening of any restriction on transfer pursuant to the Securities Act of 1933 or any state securities laws with respect to any issuance of securities by the Company, facilitate the registration or qualification of any securities by the Company under the Securities Act of 1933 or any state securities laws, or facilitate the perfection of any exemption from the registration or qualification requirements of the Securities Act of 1933 or any applicable state securities laws for the issuance or transfer of any securities.  The Company may issue stop/transfer instructions and/or appropriately legend any stock certificates issued pursuant to this Award in order to ensure compliance with the foregoing.

 

If the sale of Shares acquired under this Award is not registered under the Securities Act of 1933, but an exemption is available which requires an investment representation or other representation and warranty, you shall represent and agree that the Shares being acquired are being acquired for investment, and not with a view to the sale or distribution thereof, and shall make and warranties as are deemed necessary or appropriate by the Company and its counsel.

	 	 
	
Legends

	
All certificates representing the Shares issued under this Award may, where applicable, have endorsed thereon the following legends and any other legends the Company such other representations determines appropriate:

 

“THE SHARES REPRESENTED BY THIS CERTIFICATE ARE SUBJECT TO CERTAIN RESTRICTIONS ON TRANSFER AND OPTIONS TO PURCHASE SUCH SHARES SET FORTH IN AN AGREEMENT BETWEEN THE COMPANY AND THE REGISTERED HOLDER, OR HIS OR HER PREDECESSOR IN INTEREST.  A COPY OF SUCH AGREEMENT IS ON FILE AT THE PRINCIPAL OFFICE OF THE COMPANY AND WILL BE FURNISHED UPON WRITTEN REQUEST TO THE SECRETARY OF THE COMPANY BY THE HOLDER OF RECORD OF THE SHARES REPRESENTED BY THIS CERTIFICATE.”

 

“THE SHARES REPRESENTED HEREBY HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, AND MAY NOT BE SOLD, PLEDGED, OR OTHERWISE TRANSFERRED WITHOUT AN EFFECTIVE REGISTRATION THEREOF UNDER SUCH ACT OR AN OPINION OF COUNSEL, SATISFACTORY TO THE COMPANY AND ITS COUNSEL, THAT SUCH REGISTRATION IS NOT REQUIRED.”

	 	 
	
No Retention Rights

	
Your Award or this Agreement does not give you the right to be retained by the Company (or any parent or any subsidiaries or affiliates) in any capacity.  The Company (or any parent and any subsidiaries or affiliates) reserves the right to terminate your status as a Service Provider at any time and for any reason.

 

This Award and the Shares subject to the Award are not intended to constitute or replace any pension rights or compensation and are not to be considered compensation of a continuing or recurring nature, or part of your normal or expected compensation, and in no way represent any portion of your salary, compensation or other remuneration for any purpose, including but not limited to, calculating any severance, resignation, termination, redundancy, dismissal, end of service payments, bonuses, long-service awards, pension or retirement benefits or similar payments.

 

 

  

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Notice

	
Any notice to be given or delivered to the Company relating to this Agreement shall be in writing and addressed to the Company at its principal corporate offices.  Any notice to be given or delivered to you relating to this Agreement shall be in writing and addressed to you at such address of which you advise the Company in writing.  All notices shall be deemed effective upon personal delivery or upon deposit in the U.S. mail, postage prepaid and properly addressed to the party to be notified.

	 	 
	
Applicable Law

	
This Agreement will be interpreted and enforced under the laws of the State of California without reference to the conflicts of law provisions thereof.

	 	 
	
Voluntary Awardee

	
You acknowledge that you are voluntarily participating in the Plan.

	 	 
	
No Rights to Future Awards

	
Your rights, if any, in respect of or in connection with this Award or any other Awards are derived solely from the discretionary decision of the Company to permit you to participate in the Plan and to benefit from a discretionary future Award.  By accepting this Award, you expressly acknowledge that there is no obligation on the part of the Company to continue the Plan and/or grant any additional Awards to you or benefits in lieu of other Awards even if Awards have been granted repeatedly in the past.  All decisions with respect to future Awards, if any, will be at the sole discretion of the Administrator.

	 	 
	
Future Value

	
The future value of the underlying Shares is unknown and cannot be predicted with certainty.  If the underlying Shares do not increase in value (or decrease in value) after the Date of Award, the Award could have little or no value.

	 	 
	
No Advice Regarding Award

	
The Company has not provided any tax, legal or financial advice, nor has the Company made any recommendations regarding your participation in the Plan, or your acquisition or sale of the underlying Shares.  You are hereby advised to consult with your own personal tax, legal and financial advisors regarding your participation in the Plan before taking any action related to the Plan or this Award.

	 	 
	
No Right to Damages

	
You will have no right to bring a claim or to receive damages if any portion of the Award is cancelled or expires.  The loss of existing or potential profit in the Award will not constitute an element of damages in the event of your Termination of Service for any reason, even if the termination is in violation of an obligation of the Company or a parent or a subsidiary or an affiliate to you.

	 	 
	
Data Privacy

	
You hereby explicitly and unambiguously consent to the collection, use and transfer, in electronic or other form, of your personal data as described in this document by the Company for the exclusive purpose of implementing, administering and managing your participation in the Plan.  You understand that the Company holds certain personal information about you, including, but not limited to, name, home address and telephone number, date of birth, social security or insurance number or other identification number, salary, nationality, job title, any shares of stock or directorships held in the Company, details of all Awards or any other entitlement to Shares awarded, cancelled, purchased, exercised, vested, unvested or outstanding in your favor for the purpose of implementing, managing and administering the Plan (“Data”).  You understand that the Data may be transferred to any third parties assisting in the implementation, administration and management of the Plan, that these recipients may be located in your country or elsewhere and that the recipient country may have different data privacy laws and protections than your country.  You authorize the recipients to receive, possess, use, retain and transfer the Data, in electronic or other form, for the purposes of implementing, administering and managing your participation in the Plan, including any requisite transfer of such Data, as may be required to a broker or other third party with whom you may elect to deposit any Shares acquired under the Plan.

 

By signing the cover sheet of this Agreement, you agree to all of the terms and conditions described above and in the Plan and its prospectus.  Any inconsistency between this Agreement and the Plan shall be resolved by reference to the Plan.

 

  

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EXHIBIT A

 

ASSIGNMENT SEPARATE FROM CERTIFICATE

 

FOR VALUE RECEIVED and pursuant to that certain Stock Award Agreement dated as of ________________, 20_____ the undersigned hereby sells, assigns and transfers unto _________ shares of the Common Stock of Radnet, Inc., a Delaware corporation, standing in the undersigned’s name on the books of said corporation represented by certificate No. ____________, herewith, and does hereby irrevocably constitute and appoint ______________________________ attorney-in-fact to transfer the said stock on the books of the said corporation with full power of substitution in the premises.

 

Dated:                      __________________, 20____

 

_______________________________________

 

  

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EXHIBIT B

 

ELECTION UNDER SECTION 83(b) OF

THE INTERNAL REVENUE CODE

 

The undersigned hereby makes an election pursuant to Section 83(b) of the Internal Revenue Code with respect to the property described below and supplies the following information in accordance with the regulations promulgated thereunder:

 

1.           The name, address and social security number of the undersigned:

 

___________________________________________________________________________________

 

___________________________________________________________________________________

___________________________________________________________________________________

Social Security No. :

 

	
2.

	
Description of property with respect to which the election is being made:

 

____________________ shares of common stock of Radnet, Inc. (the “Company”).

 

	
3.

	
The date on which the property was transferred is _____________, 20_______

 

	
4.

	
The taxable year to which this election relates is calendar year 20___________.

 

	
5.

	
Nature of restrictions to which the property is subject:

 

The shares of stock are subject to the provisions of a Stock Award Agreement (the “Agreement”) between the undersigned and the Company.  The shares of stock are subject to forfeiture under the terms of the Agreement.

 

	
6.

	
The Fair Market Value of the property at the time of transfer (determined without regard to any lapse restriction) was $__________ per share, [for a total of $__________.]

 

	
7.

	
The amount paid by taxpayer for the property was $__________.

 

	
8.

	
A copy of this statement has been furnished to the Company.

 

Dated:  _____________ __, 20________.

 

_______________________________________

[Taxpayer’s Name]

 

 

 

7

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