Document:

Exhibit 4.03

 

CUSIP NO. 5252M0CE5

ISIN NO. US5252M0CE53

 

	
  REGISTERED

  	
   

  	
  PRINCIPAL AMOUNT: $3,975,000

  
	
  No. R-1

  	
   

  	
   

  

 

LEHMAN BROTHERS
HOLDINGS INC.

 

MEDIUM-TERM NOTE,
SERIES I

 

FX
BASKET-LINKED NOTE
 DUE FEBRUARY 19, 2010

 

THIS NOTE IS A GLOBAL SECURITY WITHIN THE MEANING OF
THE INDENTURE HEREINAFTER REFERRED TO AND IS REGISTERED IN THE NAME OF THE
DEPOSITORY OR A NOMINEE OF THE DEPOSITORY. 
UNLESS THIS CERTIFICATE IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF
THE DEPOSITORY TRUST COMPANY (55 WATER STREET, NEW YORK, NEW YORK) TO THE
COMPANY (AS DEFINED BELOW) OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE
OR PAYMENT AND ANY CERTIFICATE ISSUED IS REGISTERED IN THE NAME OF CEDE &
CO. OR SUCH OTHER NAME AS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF THE
DEPOSITORY TRUST COMPANY AND ANY PAYMENT IS MADE TO CEDE & CO., ANY
TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON
IS WRONGFUL SINCE THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN
INTEREST HEREIN.

 

UNLESS AND UNTIL IT IS EXCHANGED IN WHOLE OR IN
PART FOR NOTES IN CERTIFICATED FORM (A “CERTIFICATED NOTE”), THIS
GLOBAL SECURITY MAY NOT BE TRANSFERRED EXCEPT AS A WHOLE BY THE DEPOSITORY
TO A NOMINEE OF THE DEPOSITORY OR BY A NOMINEE OF THE DEPOSITORY TO THE
DEPOSITORY OR ANOTHER NOMINEE OF THE DEPOSITORY OR BY THE DEPOSITORY OR ANY
SUCH NOMINEE TO A SUCCESSOR DEPOSITORY OR A NOMINEE OF SUCH SUCCESSOR
DEPOSITORY.

 

 

LEHMAN BROTHERS HOLDINGS INC., a corporation duly
organized and existing under the laws of the State of Delaware (herein called
the “Company,” which term includes any successor corporation under the
Indenture referred to on the reverse hereof), for value received, hereby
promises to pay to CEDE & Co., or registered assigns, on the Maturity
Date, an amount equal to
the Redemption Amount.

 

The “Maturity Date” is February 19,
2010, or if such day is not a Business Day, on the next following Business Day.

 

The “Redemption Amount” is the
amount equal to the sum of the principal amount of the Notes plus the
Additional Amount, if any.

 

The “Additional Amount” is a
single U.S. dollar amount equal the principal amount of the Notes multiplied by
the product of the Leverage times the Basket Return; provided
that the minimum Additional Amount payable on the notes shall be zero.

 

The “Leverage” is 260%.

 

The “Reference Currencies” are
the South Korean Won (KRW), Indonesian Rupiah (IDR), Indian Rupee (INR),
Malaysian Ringgit (MYR) and Singapore Dollar (SGD.

 

The “Basket Return” equals the sum of the Weighted
Currency Returns for the Reference Currencies.

 

The “Weighted
Currency Return” for each Reference Currency is the product of the Weighting
for such Reference Currency times a quotient, the numerator of which is the
difference of the Initial Reference Currency Rate for such Reference Currency
minus the Settlement Rate for such Reference Currency and the denominator of
which is the Initial Reference Currency Rate for such Reference Currency.

 

The “Weighting”
and “Initial Reference Currency Rate” for each Reference Currency are as
follows:

 

	
  Reference 

  Currency

  	
   

  	
  Weighting

  	
   

  	
  Initial

  Reference 

  Currency Rate

  	
   

  
	
  KRW

  	
   

  	
  20

  	
  %

  	
  945.4

  	
   

  
	
  IDR

  	
   

  	
  20

  	
  %

  	
  9268

  	
   

  
	
  INR

  	
   

  	
  20

  	
  %

  	
  39.68

  	
   

  
	
  MYR

  	
   

  	
  20

  	
  %

  	
  3.2340

  	
   

  
	
  SGD

  	
   

  	
  20

  	
  %

  	
  1.4163

  	
   

  

 

The “Settlement Rate” for each Reference Currency is the
Reference Exchange Rate on the Valuation Date, determined in accordance with
the applicable Settlement Rate Option (subject to the occurrence of a
Disruption Event).

 

The “Reference Exchange Rates” are the spot exchange rates
for each of the Reference Currencies quoted against the U.S. dollar expressed
as number of currency units per one USD.

 

2

 

The “Valuation Date” is February 12,
2010; provided that, upon the occurrence of a
Disruption Event with respect to a Reference Currency, the Valuation Date for
the affected Reference Currency may be postponed (as described in “Disruption
Events” below).

 

The “Issue Date” is February 20,
2008.

 

If the Calculation Agent determines that a Disruption Event
relating to one or more of the Reference Currencies is in effect on the
scheduled Valuation Date, the Calculation Agent will determine the Basket
Return using:

 

·                                          for each Reference
Currency that did not suffer a Disruption Event on the scheduled Valuation
Date, the Settlement Rate on the scheduled Valuation Date, and

 

·                                          for each Reference
Currency that did suffer a Disruption Event on the scheduled Valuation Date,
the Settlement Rate on the immediately succeeding scheduled Valuation Business
Day for such Reference Currency on which no Disruption Event occurs or is
continuing with respect to such Reference Currency;

 

provided, however, that if a
Disruption Event has occurred or is continuing with respect to a Reference
Currency on each of the three scheduled Valuation Business Days following the
scheduled Valuation Date, then (a) such third scheduled Valuation Business
Day shall be deemed the Valuation Date for the affected Reference Currency; and
(b) the Calculation Agent will determine the Settlement Rate for the
affected Reference Currency on such day in accordance with Fallback Rate
Observation Methodology.

 

For purposes of the above, “scheduled Valuation Business
Day” means a day that is or, in the judgment of the Calculation Agent, should
have been, a Valuation Business Day for the affected Reference Currency.

 

A “Disruption Event” means any of the following events as determined in
good faith by the Calculation Agent:

 

(A)                              the occurrence and/or existence of an event on any
day that has the effect of preventing or making impossible (x) the
delivery of USD from accounts inside the country for which a Reference Currency
is the lawful currency (such jurisdiction with respect to such Reference
Currency, the “Reference Currency Jurisdiction”) for that Reference Currency to
accounts outside that Reference Currency Jurisdiction, or (y) the
conversion of SGD into USD through customary legal channels;

 

(B)                                the occurrence of any
event causing the Reference Exchange Rate for the Reference Currency to be
split into dual or multiple currency exchange rates; or

 

(C)                                the Settlement Rate being unavailable for the
Reference Currency, or the occurrence of an event (i) in the Reference
Currency Jurisdiction for that Reference Currency that materially disrupts the
market for the Reference 

 

3

 

Currency
or (ii) that generally makes it impossible to obtain the Settlement Rate
for the Reference Currency, on the Valuation Date.

 

A “Valuation
Business Day” means, with respect to each Reference Currency, any day, other
than a Saturday or Sunday, that is neither a legal holiday nor a day on which
commercial banks are authorized or required by law, regulation or executive
order to close (including for dealings in foreign exchange in accordance with
the practice of the foreign exchange market) in the city or jurisdiction
indicated in the table below:

 

	
  Reference
  

  Currency

  	
   

  	
  Screen
  Reference

  	
   

  	
  Valuation
  Business 

  Day

  
	
  KRW

  	
   

  	
  KFTC18

  	
   

  	
  Seoul

  
	
  IDR

  	
   

  	
  ABSIRFIX01

  	
   

  	
  Singapore

  
	
  INR

  	
   

  	
  RBIB

  	
   

  	
  Mumbai

  
	
  MYR

  	
   

  	
  ABSIRFIX01

  	
   

  	
  Singapore

  
	
  SGD

  	
   

  	
  ABSIRFIX01

  	
   

  	
  Singapore

  

 

The “Settlement Rate Option” for the KRW is the South
Korean Won/U.S. dollar market average rate, expressed as the amount of South
Korean Won per one U.S. dollar, for settlement in two Business Days reported by
the Korea Financial Telecommunications and Clearing Corporation which appears
on the Reuters Screen KFTC18 Page to the right of the caption “USD Today”
that is available at approximately 5:30 p.m., Seoul time, on the Valuation
Date or as soon thereafter as practicable, but in no event later than 9:00 a.m.,
Seoul time, on the first Business Day following the relevant Valuation
Date.  The Settlement Rate Option for the
IDR is the Indonesian Rupiah/U.S. dollar spot rate at 11:00 a.m.,
Singapore time, expressed as the amount of Indonesian Rupiah per one U.S.
dollar, for settlement in two Business Days, reported by the Association of
Banks in Singapore which appears on the Reuters Page ABSIRFIX01 to the
right of the caption “Spot” under the column “IDR” at approximately 11:30 a.m.,
Singapore time, on the relevant Valuation Date. 
The Settlement
Rate Option for the INR is the Indian Rupee/U.S. dollar reference rate,
expressed as the amount of Indian Rupee per one U.S. dollar, for settlement in
two Business Days reported by the Reserve Bank of India which appears on the
Reuters Screen RBIB Page at approximately 2:30 p.m., Mumbai time, or
as soon thereafter as practicable on the on the Valuation Date or such
other relevant date.  The Settlement Rate Option for the MYR is the
Malaysian Ringgit/U.S. dollar spot rate at 11:00 a.m., Singapore time,
expressed as the amount of Malaysian Ringgit per one U.S. dollar, for
settlement in two Business Days, reported by the Association of Banks in
Singapore, which appears on the Reuters Page ABSIRFIX01 to the right of
the caption “Spot” under the column “MYR” at approximately 11:30 a.m.,
Singapore time, on the relevant Valuation Date. 
The Settlement Rate Option for the SGD is the Singapore Dollar/U.S.
dollar spot rate at 11:00 a.m., Singapore time, expressed as the amount of
Singapore Dollar per one U.S. dollar, for settlement in two Business Days,
reported by the Association of Banks in Singapore which appears on the Reuters Page ABSIRFIX01
to the right of the caption “Spot” under the column “SGD” at approximately
11:30 a.m., Singapore time, on the relevant Valuation Date.

 

The
screen or time of observation indicated in relation to any Settlement Rate
Option above shall be deemed to refer to such screen or time of observation as
modified or amended from time to time, or to any substitute screen thereto.

 

4

 

The “Fallback Rate Observation Methodology” means that the reference exchange rate, Settlement
Rate or other rate, as specified in the applicable pricing supplement, in respect
of a reference currency will equal the noon buying rate in New York for cable
transfers in foreign currencies as announced by the Federal Reserve Bank of New
York for customs purposes (the “Noon Buying Rate”) on the relevant Valuation
Date or such other date specified in the applicable pricing supplement. If the
Noon Buying Rate is not announced on that date, the Reference Exchange Rate,
Settlement Rate or other rate for such Reference Currency will be calculated on
the basis of the arithmetic mean of the applicable spot quotations received by
the Calculation Agent at approximately 10:00 a.m., New York City time, on
the Valuation Business Day next succeeding the Valuation Date or such other
date specified in the applicable pricing supplement, for the purchase or sale
for deposits in the reference currency by the New York offices of three leading
banks engaged in the interbank market (selected in the sole discretion of the
Calculation Agent) (the “Reference Banks”). If fewer than three Reference Banks
provide spot quotations, then the Reference Exchange Rate, Settlement Rate or
other rate, as applicable, will be calculated on the basis of the arithmetic
mean of the applicable spot quotations received by the Calculation Agent at
approximately 10:00 a.m., New York City time, on the relevant date from
two Reference Banks (selected in the sole discretion of the Calculation Agent),
for the purchase or sale for deposits in the Reference Currency. If these spot
quotations are available from only one Reference Bank, then the Calculation
Agent, in its sole discretion, will determine whether that quotation is
reasonable to be used. If no spot quotation is available, then the Reference
Exchange Rate, Settlement Rate or other rate, as applicable, for such Reference
Currency will be determined by the Calculation Agent in good faith and in a
commercially reasonable manner.

 

A “Business Day”, notwithstanding any provision in the Indenture, is
any day that is not is not a Saturday or Sunday and that is not a day on which
banking institutions in New York City generally are authorized or obligated by
law or executive order to be closed.

 

The “Calculation Agent” means Lehman Brothers Inc.

 

Except
as provided below, the Redemption Amount may, at the option of the Company, be
made by check mailed to the person entitled thereto at such person’s address as
it appears on the registry books of the Company.

 

Payment
of the Redemption Amount will be made in immediately available funds in
accordance with the normal procedures of the Trustee (or any duly appointed
Paying Agent).

 

The
Company will pay any administrative costs imposed by banks in making
payments in immediately available funds, but any tax, assessment or
governmental charge imposed upon payments hereunder, including, without limitation,
any withholding tax, will be borne by the Holder hereof.

 

References herein to “U.S.
dollars” or “U.S.$” or “$” or “USD” are to the coin or currency of the United
States as at the time of payment is legal tender for the payment of public and
private debts.

 

REFERENCE IS HEREBY MADE
TO THE FURTHER PROVISIONS OF THIS NOTE SET FORTH ON THE REVERSE HEREOF.  SUCH FURTHER PROVISIONS SHALL FOR ALL
PURPOSES HAVE THE SAME EFFECT AS IF SET FORTH AT THIS PLACE.

 

5

 

This Note shall not be
valid or become obligatory for any purpose until the certificate of
authentication hereon shall have been signed by the Trustee under the
Indenture.

 

6

 

IN WITNESS WHEREOF,
Lehman Brothers Holdings Inc. has caused this instrument to be signed by its
Chairman of the Board, its President, its Vice Chairman, its Chief Financial
Officer, one of its Vice Presidents or its Treasurer, by manual or facsimile
signature under its corporate seal, attested by its Secretary or one of its
Assistant Secretaries by manual or facsimile signature.

 

Dated:  February 20, 2008

 

	
  [SEAL]

  	
   

  	
  LEHMAN BROTHERS HOLDINGS INC.

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
             

  	
  By:

  	
   

  
	
   

  	
   

  	
   

  	
  Name: Andrew Yeung

  	
   

  
	
   

  	
   

  	
   

  	
  Title:   Vice
  President

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Attest:

  	
   

  
	
   

  	
   

  	
   

  	
  Name: Cindy Buckholz

  	
   

  
	
   

  	
   

  	
   

  	
  Title:   Assistant
  Secretary

  	
   

  

 

TRUSTEE’S
CERTIFICATE OF AUTHENTICATION

 

This is one of the
Securities of the series designated herein referred to in the within-mentioned
Indenture.

 

CITIBANK, N.A.

  as Trustee

 

 

	
  By: 

  	
   

  	
   

  
	
   

  	
  Authorized Officer

  	
   

  

 

7

 

[REVERSE
OF NOTE]

 

LEHMAN BROTHERS
HOLDINGS INC.

MEDIUM-TERM NOTES,
SERIES I

FX BASKET-LINKED NOTE
 DUE FEBRUARY 19, 2010

 

Section 1.  General.  This Note is one of a duly authorized series
of Notes of the Company designated as the Medium-Term Notes, Series I, FX Basket-Linked Note (herein called
the “Notes”).  The Notes are one of an indefinite
number of series of debt securities of the Company (collectively, the “Securities”)
issued or issuable under and pursuant to an indenture dated as of September 1,
1987, as amended and supplemented (the “Indenture”), duly executed and
delivered by the Company and Citibank, N.A., as Trustee (herein called the “Trustee”),
to which Indenture and all indentures supplemental thereto reference is hereby
made for a description of the rights, limitations of rights, obligations,
duties and immunities thereunder of the Trustee, the Company and the holders of
the Securities.  The separate series of
Securities may be issued in various aggregate principal amounts, may mature at
different times, may bear interest (if any) at different rates, may be subject
to different redemption provisions or repurchase rights (if any), may be
subject to different sinking, purchase or analogous funds (if any), may be
subject to different covenants and Events of Default and may otherwise vary as
in the Indenture provided.

 

Section 2.  Principal Amount for Indenture Purposes.  For the purpose of determining whether
Holders of the requisite amount of Notes of this series outstanding under the
Indenture have made a demand, given a notice or waiver or taken any other
action, the principal amount of this Note will be deemed to be the principal
amount of this Note then outstanding.

 

Section 3.  Modification and Waivers.  The Indenture contains provisions permitting
the Company and the Trustee, with the consent of the Holders of not less than
66-2/3% in aggregate principal amount of each series of the Securities at the
time Outstanding to be affected, evidenced as in the Indenture provided, to
execute supplemental indentures adding any provisions to or changing in any
manner or eliminating any of the provisions of the Indenture or of any
supplemental indenture or modifying in any manner the rights of the holders of
the Securities of all such series; provided, however, that no such supplemental
indenture shall, among other things, (i) change the fixed maturity of any
Security, or reduce the Additional Amount or the principal amount thereof, or
reduce the rate or extend the time of payment of interest thereon or reduce any
premium or other amount payable on redemption, or make the Additional Amount or
the principal amount thereof, premium or other amount payable, if any, or
interest thereon payable in any coin or currency other than that herein above
provided, without the consent of the Holder of each Security so affected, or (ii) change
the place of payment on any Security, or impair the right to institute suit for
payment on any Security, or reduce the aforesaid percentage of Securities, the
holders of which are required to consent to any such supplemental indenture,
without the consent of the holders of each Security so affected.  It is also provided in the Indenture that,
prior to any declaration accelerating the maturity of any series of Securities,
the holders of a majority in aggregate principal amount of the Securities of
such series 

 

 

Outstanding may on behalf
of the holders of all the Securities of such series waive any past default or
Event of Default under the Indenture with respect to such series and its
consequences, except a default in the payment of interest, if any, on the
Additional Amount or the principal amount, or premium, if any, on any of the
Securities of such series, or in the payment of any sinking fund installment or
analogous obligation with respect to Securities of such series.  Any such consent or waiver by the Holder of
this Note shall be conclusive and binding upon such Holder and upon all future
holders and owners of this Note and any Notes of this series which may be
issued in exchange or substitution herefor, irrespective of whether or not any
notation thereof is made upon this Note or such other Notes of this series.

 

Section 4.  Obligations Unconditional.  No reference herein to the Indenture and no
provisions of this Note or of the Indenture shall alter or impair the
obligation of the Company, which is absolute and unconditional, to pay the
Additional Amount or the principal amount on this Note at the place, at the
respective times, at the rate, and in the coin or currency herein prescribed.

 

Section 5.  Defeasance.  The Indenture contains provisions for the
discharge of the Indenture and defeasance at any time of the indebtedness on
this Note upon compliance by the Company with certain conditions set forth
therein, which provisions apply to this Note.

 

Section 6.  Authorized Form and Denominations.  The Notes of this series are issuable in
registered form, without coupons.  Each
Note will be issued initially as either a Global Security or a Certificated
Note, at the option of the Company, in denominations of $1,000 or integral
multiples of $1,000, either at the office or agency to be designated and
maintained by the Company for such purpose in the Borough of Manhattan, New
York City, pursuant to the provisions of the Indenture or at any of such other
offices or agencies as may be designated and maintained by the Company for such
purpose pursuant to the provisions of the Indenture, and in the manner and
subject to the limitations provided in the Indenture, but without the payment
of any service charge, except for any tax or other governmental charges imposed
in connection therewith.  Notes of this
series are exchangeable for a like aggregate principal amount of Notes of this
series of a different authorized denomination, except that Global Securities
will not be exchangeable for Certificated Notes of this series.

 

Section 7.  Registration of Transfer.  As provided in the Indenture and subject to
certain limitations as therein set forth, the transfer of this Note is
registrable in the Security Register, upon surrender of this Note for
registration of transfer, at the Corporate Trust Office or agency in a Place of
Payment for this Note, duly endorsed by, or accompanied by a written instrument
of transfer in form satisfactory to the Company and the Security Registrar
requiring such written instrument of transfer duly executed by, the Holder
hereof or his attorney duly authorized in writing, and thereupon one or more
new Notes of this series, of authorized denominations and for the same aggregate
principal amount, will be issued to the designated transferee or transferees.

 

If at any time the
Depository notifies the Company that it is unwilling or unable to continue as
Depository or if at any time the Depository shall no longer be eligible under
the Indenture, the Company shall appoint a successor Depository.  If a successor Depository for the Notes of
this series is not appointed by the Company within 90 days after the Company
receives such notice or becomes aware of such ineligibility, the Company will
issue, and the Trustee will 

 

 

authenticate and deliver,
Notes of this series in definitive form in an aggregate principal amount equal
to the principal amount of this Note.

 

No service charge shall be made for any such
registration of transfer or exchange, but the Company may require payment of a
sum sufficient to cover any tax or other governmental charge that may be
imposed in connection therewith.

 

Prior to due
presentment of this Note for registration of transfer, the Company, the Trustee
and any agent of the Company or the Trustee may treat the person in whose name
this Note is registered as the owner hereof for all purposes, and neither the
Company nor the Trustee nor any agent of the Company or of the Trustee shall be
affected by any notice to the contrary.

 

Section 8.  Events of Default.  If an Event of Default with respect to Notes
of this series shall occur and be continuing, the amount that may be declared
due and payable upon any acceleration of the notes will be determined by the
Calculation Agent for the period from and including the Issue Date to but
excluding the date of early repayment and will equal, for each note, the
Redemption Amount, calculated as the date of early repayment were the Maturity
Date. If a bankruptcy proceeding is commenced in respect of Lehman Brothers
Holdings, the claim of the beneficial owner of a note for the period from and
including the Issue Date to but excluding the date of early repayment will be
capped at the Redemption Amount, calculated as though the date of the
commencement of the proceeding were the Maturity Date.

 

Section 9.  No Recourse Against Certain Persons.  No recourse for the payment of the Additional
Amount or for any claim based hereon or otherwise in respect hereof, and no
recourse under or upon any obligation, covenant or agreement of the Company in
the Indenture or any Indenture supplemental thereto or in any Note, or because
of the creation of any indebtedness represented thereby, shall be had against
any incorporator, stockholder, officer or director, as such, past, present or
future, of the Company or of any successor corporation, either directly or
through the Company or any successor corporation, whether by virtue of any
constitution, statute or rule of law or by the enforcement of any
assessment or penalty or otherwise, all such liability being, by the acceptance
hereof and as part of the consideration for the issue hereof, expressly waived
and released.

 

Section 10.  Defined
Terms.  All terms used but not
defined in this Note are used herein as defined in the Indenture.

 

Section 11.  GOVERNING LAW.  THIS NOTE SHALL BE GOVERNED BY AND CONSTRUED
IN ACCORDANCE WITH THE LAWS OF THE STATE OF NEW YORK.Exhibit 10.1

 

FARMER BROS. CO.

 

FORM OF

2007 OMNIBUS PLAN

STOCK OPTION GRANT NOTICE AND

STOCK OPTION AGREEMENT

 

                Farmer Bros. Co., a Delaware
corporation (the “Company”),
pursuant to its 2007 Omnibus Plan (the “Plan”), hereby grants to the holder listed below
(“Participant”),
an option to purchase the number of shares of the Company’s Stock set forth
below (the “Option”).
This Option is subject to all of the terms and conditions as set forth herein
and in the Stock Option Agreement attached hereto as Exhibit A (the
“Stock Option Agreement”)
and the Plan, which are incorporated herein by reference. Unless otherwise
defined herein, the terms defined in the Plan shall have the same defined
meanings in this Grant Notice and the Stock Option Agreement.

 

	
  Participant:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Grant Date:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Exercise Price per Share:

  	
   

  	
  $

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Total Exercise Price:

  	
   

  	
  $

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Total Number of Shares Subject
  to the Option:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Expiration Date:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Type of
  Option:

  	
  o  Incentive
  Stock Option

  	
   

  	
  o  Non-Qualified
  Stock Option

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Vesting
  Schedule:

  	
  One-third (1/3) of the
  Total Number of Shares Subject to the Option, rounded down to the nearest
  whole number of shares, vest on each of the first two anniversaries of the
  Grant Date, and the remainder vest on the third anniversary of the Grant
  Date, subject to the acceleration provision of the Stock Option Agreement.

  

 

                By his or her signature,
Participant agrees to be bound by the terms and conditions of the Plan, the
Stock Option Agreement and this Grant Notice. Participant has reviewed the
Stock Option Agreement, the Plan and this Grant Notice in their entirety, has
had an opportunity to obtain the advice of counsel prior to executing this
Grant Notice and fully understands all provisions of this Grant Notice, the
Stock Option Agreement and the Plan. Participant hereby agrees to accept as
binding, conclusive and final all decisions or interpretations of the
Administrator of the Plan upon any questions arising under the Plan, this Grant
Notice or the Stock Option Agreement. Participant further agrees to notify the
Company upon any change in the residence address indicated below.

 

	
  FARMER BROS. CO.

  	
   

  	
  PARTICIPANT

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  By:

  	
   

  	
   

  	
   

  	
  By:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Print
  Name:

  	
   

  	
   

  	
   

  	
  Print
  Name:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Address:

  	
   

  	
  20333
  South Normandie Avenue

  Torrance, California 90502

  	
   

  	
  Address:

  	
   

  	
   

  	
   

  

 

 

 

EXHIBIT A

TO STOCK OPTION GRANT NOTICE

 

STOCK OPTION AGREEMENT

 

                Pursuant to the Stock Option Grant Notice (“Grant Notice”) to
which this Stock Option Agreement (this “Agreement”) is attached, Farmer Bros. Co., a
Delaware corporation (the “Company”),
has granted to Participant an option under the Company’s 2007 Omnibus Plan (the
“Plan”)
to purchase the number of shares of Stock indicated in the Grant Notice.

 

ARTICLE I

GENERAL

 

                1.1           Defined Terms. Capitalized terms not specifically
defined herein shall have the meanings specified in the Plan and the Grant
Notice.

 

                1.2           Incorporation of Terms of Plan. The Option is
subject to the terms and conditions of the Plan which are incorporated herein
by reference.

 

ARTICLE II

GRANT OF OPTION

 

                2.1           Grant of Option. In consideration of Participant’s
past and/or continued employment with or service to the Company or a Parent or
Subsidiary and for other good and valuable consideration, effective as of the
Grant Date set forth in the Grant Notice (the “Grant Date”), the Company irrevocably
grants to Participant the Option to purchase any part or all of an aggregate of
the number of shares of Stock set forth in the Grant Notice, upon the terms and
conditions set forth in the Plan and this Agreement. Unless designated as a Non-Qualified
Stock Option in the Grant Notice, the Option shall be an Incentive Stock Option
to the maximum extent permitted by law.

 

                2.2           Exercise Price. The exercise price of the shares of
Stock subject to the Option shall be as set forth in the Grant Notice, without
commission or other charge; provided,
however, that if this Option is
designated as an Incentive Stock Option, the price per share of the shares
subject to the Option shall not be less than the greater of (i) 100% of
the Fair Market Value of a share of Stock on the Grant Date, or (ii) 110%
of the Fair Market Value of a share of Stock on the Grant Date in the case of a
Participant then owning (within the meaning of Section 424(d) of the
Code) more than 10% of the total combined voting power of all classes of stock
of the Company or any “subsidiary corporation” of the Company or any “parent
corporation” of the Company (each within the meaning of Section 424 of the
Code).

 

                2.3           Consideration to the Company. In consideration of
the grant of the Option by the Company, Participant agrees to render faithful
and efficient services to the Company or any Parent or Subsidiary. Nothing in
the Plan or this Agreement shall confer upon Participant any right to (a) continue
in the employ of the Company or any Parent or Subsidiary or shall interfere
with or restrict in any way the rights of the Company and its Parents and  Subsidiaries, which are hereby expressly
reserved, to discharge Participant, if Participant is an Employee, or (b) continue
to provide services to the Company or any Parent or Subsidiary or shall
interfere with or restrict in any way the rights of the Company or its Parents
and Subsidiaries, which are hereby expressly reserved, to terminate the
services of Participant, if Participant is a Consultant, at any time for any
reason whatsoever, with or without Cause, except to the extent expressly
provided otherwise in a written agreement between the Company, a Parent or a
Subsidiary and Participant, or (c) continue to serve as a member of the
Board or shall interfere with or 

 

 

A-1

 

restrict
in any way the rights of the Company, which are hereby expressly reserved, to
discharge Participant in accordance with the Company’s Bylaws.

 

ARTICLE III

PERIOD OF EXERCISABILITY

 

                3.1           Commencement of Exercisability

 

                                (a)           Subject to Sections 3.3 and 5.8, the
Option shall become vested and exercisable in such amounts and at such times as
are set forth in the Grant Notice.

 

                                (b)           No portion of the Option which has
not become vested and exercisable at the date of Participant’s Termination of
Employment, Termination of Directorship or Termination of Consultancy shall
thereafter become vested and exercisable, except as may be otherwise provided
in the Grant Notice, this Agreement, by the Administrator or as set forth in a
written agreement between the Company and Participant.

 

                3.2           Duration of Exercisability. The installments
provided for in the vesting schedule set forth in the Grant Notice are
cumulative. Each such installment which becomes vested and exercisable pursuant
to the vesting schedule set forth in the Grant Notice shall remain vested and
exercisable until it becomes unexercisable under Section 3.3.

 

                3.3           Expiration of Option. The Option may not be
exercised to any extent by anyone after the first to occur of the following
events:

 

                                (a)           The expiration of seven years from
the Grant Date;

 

                                (b)           If this Option is designated as an
Incentive Stock Option and Participant owned (within the meaning of Section 424(d) of
the Code), at the time the Option was granted, more than 10% of the total
combined voting power of all classes of stock of the Company or any “subsidiary
corporation” of the Company or “parent corporation” of the Company (each within
the meaning of Section 424 of the Code), the expiration of five years from
the Grant Date; or

 

                                (c)           Except as set forth in a written
agreement with the Company, the expiration of three months following the date
of Participant’s Termination of Employment, Termination of Directorship or
Termination of Consultancy, unless such termination occurs by reason of
Participant’s retirement, death or Disability; or

 

                                (d)           The expiration of one year following
the date of Participant’s Termination of Employment, Termination of
Directorship or Termination of Consultancy by reason of Participant’s
retirement, death or Disability.

 

                Participant acknowledges that an
Incentive Stock Option exercised more than three months after Participant’s
Termination of Employment, other than by reason of death or Disability, will be
taxed as a Non-Qualified Stock Option.

 

                3.4           Special Tax Consequences. Participant acknowledges
that, to the extent that the aggregate Fair Market Value (determined as of the
time the Option is granted) of all shares of Stock with respect to which
Incentive Stock Options, including the Option, are exercisable for the first
time by Participant in any calendar year exceeds $100,000 (or such other
limitation as imposed by Section 422(d) of the Code), the Option and
such other options shall be treated as not qualifying under Section 422 of
the 

 

 

A-2

 

Code
but rather shall be considered Non-Qualified Stock Options. Participant further
acknowledges that the rule set forth in the preceding sentence shall be
applied by taking Options and other “incentive stock options” into account in
the order in which they were granted, as determined under Section 422(d) of
the Code and the Treasury Regulations thereunder.

 

                3.5           Acceleration of Vesting

 

                                (a)           Acceleration of Vesting Upon Death
or Disability. In the event of Participant’s Termination of Employment,
Termination of Directorship or Termination of Consultancy by reason of
Participant’s death or Disability, 
Participant or Participant’s estate will have the right to exercise the
Option during the applicable time period set forth in Section 3.3 with
respect to the then vested shares plus a pro rata portion of the unvested
shares as of the date of such termination determined as follows:

 

(Actual
Number of Service Days During Remaining Vesting Period)

(Total
Number of Days During Remaining Vesting Period)                          X             (No. of Unvested Shares) =
(Accelerated Shares)

 

                                (b)           Other Events.  The Administrator retains the discretion to
determine whether an acceleration of vesting will occur upon the occurrence of
certain other events, including Termination of Consultancy, Termination of
Directorship, and Termination of Employment other than by reason of death or
Disability, and an impending Change in Control.

 

ARTICLE IV

EXERCISE OF OPTION

 

                4.1           Person Eligible to Exercise. Except as provided in
Sections 5.2(b) and 5.2(c), during the lifetime of Participant, only
Participant may exercise the Option or any portion thereof. After the death of
Participant, any exercisable portion of the Option may, prior to the time when
the Option becomes unexercisable under Section 3.3, be exercised by
Participant’s personal representative or by any person empowered to do so under
the deceased Participant’s will or under the then applicable laws of descent
and distribution.

 

                4.2           Partial Exercise. Any exercisable portion of the
Option or the entire Option, if then wholly exercisable, may be exercised in
whole or in part at any time prior to the time when the Option or portion
thereof becomes unexercisable under Section 3.3.

 

                4.3           Manner of Exercise. The Option, or any exercisable
portion thereof, may be exercised solely by delivery to the Secretary of the
Company or the Secretary’s office of all of the following prior to the time
when the Option or such portion thereof becomes unexercisable under Section 3.3:

 

                                (a)           An Exercise Notice in writing signed
by Participant or any other person then entitled to exercise the Option or
portion thereof, stating that the Option or portion thereof is thereby
exercised, such notice complying with all applicable rules established by
the Administrator. Such notice shall be substantially in the form attached as Exhibit B
to the Grant Notice (or such other form as is prescribed by the Administrator);
and

 

                                (b)           Subject to Section 5.1(c) of
the Plan:

 

 

A-3

 

 

                                                (i)            Full payment (in cash or by check)
for the shares with respect to which the Option or portion thereof is
exercised; or

 

                                                (ii)           Such payment may be made, in whole or
in part, through the delivery of shares of Stock which have been owned by
Participant for at least six months, duly endorsed for transfer to the Company
with a Fair Market Value on the date of delivery equal to the aggregate
exercise price of the Option or exercised portion thereof; or

 

                                                (iii)          Through the delivery of a notice that
Participant has placed a market sell order with a broker with respect to shares
of Stock then issuable upon exercise of the Option, and that the broker has
been directed to pay a sufficient portion of the net proceeds of the sale to
the Company in satisfaction of the Option exercise price; provided, that payment of such proceeds is
made to the Company upon settlement of such sale; or

 

                                                (iv)          Subject to any applicable laws, any
combination of the consideration provided in the foregoing paragraphs (i), (ii) and
(iii); and

 

                                (c)           A bona fide written representation
and agreement, in such form as is prescribed by the Administrator, signed by
Participant or the other person then entitled to exercise such Option or
portion thereof, stating that the shares of Stock are being acquired for
Participant’s own account, for investment and without any present intention of
distributing or reselling said shares or any of them except as may be permitted
under the Securities Act and then applicable rules and regulations
thereunder and any other applicable law, and that Participant or other person
then entitled to exercise such Option or portion thereof will indemnify the
Company against and hold it free and harmless from any loss, damage, expense or
liability resulting to the Company if any sale or distribution of the shares by
such person is contrary to the representation and agreement referred to above.
The Administrator may, in its absolute discretion, take whatever additional
actions it deems appropriate to ensure the observance and performance of such
representation and agreement and to effect compliance with the Securities Act
and any other federal or state securities laws or regulations and any other
applicable law. Without limiting the generality of the foregoing, the
Administrator may require an opinion of counsel acceptable to it to the effect
that any subsequent transfer of shares acquired on an Option exercise does not
violate the Securities Act, and may issue stop-transfer orders covering such
shares. Share certificates evidencing Stock issued on exercise of the Option
shall bear an appropriate legend referring to the provisions of this subsection
(c) and the agreements herein. The written representation and agreement
referred to in the first sentence of this subsection (c) shall, however,
not be required if the shares to be issued pursuant to such exercise have been
registered under the Securities Act, and such registration is then effective in
respect of such shares; and

 

                                (d)           The receipt by the Company of full
payment for such shares, including payment of any applicable withholding tax,
which may be in the form of consideration used by Participant to pay for such
shares under Section 4.3(b), subject to Section 16.3 of the Plan; and

 

                                (e)           In the event the Option or portion
thereof shall be exercised pursuant to Section 4.1 by any person or
persons other than Participant, appropriate proof of the right of such person
or persons to exercise the Option.

 

                4.4           Conditions to Issuance of Stock Certificates. The
shares of Stock deliverable upon the exercise of the Option, or any portion
thereof, may be either previously authorized but unissued shares or issued
shares which have then been reacquired by the Company. Such shares shall be
fully paid and nonassessable. The Company shall not be required to issue or
deliver any shares of Stock purchased upon the exercise of the Option or
portion thereof prior to fulfillment of all of the following conditions:

 

 

A-4

 

 

                                (a)           The admission of such shares to
listing on all stock exchanges on which such Stock is then listed; and

 

                                (b)           The completion of any registration or
other qualification of such shares under any state or federal law or under
rulings or regulations of the Securities and Exchange Commission or of any
other governmental regulatory body, which the Administrator shall, in its
absolute discretion, deem necessary or advisable; and

 

                                (c)           The obtaining of any approval or
other clearance from any state or federal governmental agency which the
Administrator shall, in its absolute discretion, determine to be necessary or
advisable; and

 

                                (d)           The receipt by the Company of full
payment for such shares, including payment of any applicable withholding tax,
which may be in the form of consideration used by Participant to pay for such
shares under Section 4.3(b); and

 

                                (e)           The lapse of such reasonable period
of time following the exercise of the Option as the Administrator may from time
to time establish for reasons of administrative convenience.

 

                4.5           Rights as Stockholder. The holder of the Option
shall not be, nor have any of the rights or privileges of, a stockholder of the
Company in respect of any shares purchasable upon the exercise of any part of
the Option unless and until such shares shall have been issued by the Company
to such holder (as evidenced by the appropriate entry on the books of the
Company or of a duly authorized transfer agent of the Company). No adjustment
will be made for a dividend or other right for which the record date is prior
to the date the shares are issued, except as provided in Article 12 of the
Plan.

 

ARTICLE V

OTHER PROVISIONS

 

                5.1           Administration.
The Administrator shall have the power to interpret the Plan and this Agreement
and to adopt such rules for the administration, interpretation and
application of the Plan as are consistent therewith and to interpret, amend or
revoke any such rules. All actions taken and all interpretations and
determinations made by the Administrator in good faith shall be final and
binding upon Participant, the Company and all other interested persons. No
member of the Administrator shall be personally liable for any action, determination
or interpretation made in good faith with respect to the Plan, this Agreement
or the Option. In its absolute discretion, the Board may at any time and from
time to time exercise any and all rights and duties of the Administrator under
the Plan and this Agreement.

 

                5.2           Option Not Transferable.

 

                                (a)           Subject to Section 5.2(b), the
Option may not be sold, pledged, assigned or transferred in any manner other
than by will or the laws of descent and distribution, unless and until the
shares underlying the Option have been issued, and all restrictions applicable
to such shares have lapsed. Neither the Option nor any interest or right
therein shall be liable for the debts, contracts or engagements of Participant
or his or her successors in interest or shall be subject to disposition by
transfer, alienation, anticipation, pledge, encumbrance, assignment or any
other means whether such disposition be voluntary or involuntary or by
operation of law by judgment, levy, attachment, garnishment or any other legal
or equitable proceedings (including bankruptcy), and any attempted disposition
thereof shall be null and void and of no effect, except to the extent that such
disposition is permitted by the preceding sentence.

 

 

A-5

 

                                (b)           Notwithstanding any other provision
in this Agreement, with the consent of the Administrator and to the extent the
Option is not intended to qualify as an Incentive Stock Option, the Option may
be transferred to one or more Permitted Transferees, subject to the terms and
conditions set forth in Section 11.3(b) of the Plan.

 

                                (c)           Unless transferred to a Permitted
Transferee in accordance with Section 5.2(b), during the lifetime of
Participant, only Participant may exercise the Option or any portion
thereof.  Subject to such conditions and
procedures as the Administrator may require, a Permitted Transferee may
exercise the Option or any portion thereof during Participant’s lifetime. After
the death of Participant, any exercisable portion of the Option may, prior to
the time when the Option becomes unexercisable under Section 3.3, be
exercised by Participant’s personal representative or by any person empowered
to do so under the deceased Participant’s will or under the then applicable
laws of descent and distribution.

 

                5.3           Restrictive Legends and Stop-Transfer Orders.

 

                                (a)           The share certificate or certificates
evidencing the shares of Stock purchased hereunder shall be endorsed with any
legends that may be required by state or federal securities laws.

 

                                (b)           Participant agrees that, in order to
ensure compliance with the restrictions referred to herein, the Company may
issue appropriate “stop transfer” instructions to its transfer agent, if any,
and that, if the Company transfers its own securities, it may make appropriate
notations to the same effect in its own records.

 

                                (c)           The Company shall not be required: (i) to
transfer on its books any shares of Stock that have been sold or otherwise
transferred in violation of any of the provisions of this Agreement, or (ii) to
treat as owner of such shares of Stock or to accord the right to vote or pay
dividends to any purchaser or other transferee to whom such shares shall have
been so transferred.

 

                5.4           Shares to Be Reserved. The Company shall at all times
during the term of the Option reserve and keep available such number of shares
of Stock as will be sufficient to satisfy the requirements of this Agreement.

 

                5.5           Notices. Any notice to be given under the terms of
this Agreement to the Company shall be addressed to the Company in care of the
Secretary of the Company at the address given beneath the signature of the
Company’s authorized officer on the Grant Notice, and any notice to be given to
Participant shall be addressed to Participant at the address given beneath
Participant’s signature on the Grant Notice. By a notice given pursuant to this
Section 5.5, either party may hereafter designate a different address for
notices to be given to that party. Any notice which is required to be given to
Participant shall, if Participant is then deceased, be given to the person
entitled to exercise his or her Option pursuant to Section 4.1 by written
notice under this Section 5.5. Any notice shall be deemed duly given when
sent via email or when sent by certified mail (return receipt requested) and
deposited (with postage prepaid) in a post office or branch post office
regularly maintained by the United States Postal Service.

 

                5.6           Titles. Titles are provided herein for convenience
only and are not to serve as a basis for interpretation or construction of this
Agreement.

 

                5.7           Governing Law; Severability. This Agreement shall
be administered, interpreted and enforced under the laws of the State of
Delaware, without regard to the conflicts of law principles thereof. Should any
provision of this Agreement be determined by a court of law to be illegal or
unenforceable, the other provisions shall nevertheless remain effective and
shall remain enforceable.

 

 

A-6

 

                5.8           Conformity to Securities Laws. Participant
acknowledges that the Plan and this Agreement are intended to conform to the
extent necessary with all provisions of the Securities Act and the Exchange
Act, and any and all regulations and rules promulgated thereunder by the
Securities and Exchange Commission, and state securities laws and regulations.
Notwithstanding anything herein to the contrary, the Plan shall be
administered, and the Option is granted and may be exercised, only in such a
manner as to conform to such laws, rules and regulations. To the extent
permitted by applicable law, the Plan and this Agreement shall be deemed
amended to the extent necessary to conform to such laws, rules and
regulations.

 

                5.9           Amendment, Suspension and Termination. To the
extent permitted by the Plan, this Agreement may be wholly or partially amended
or otherwise modified, suspended or terminated at any time or from time to time
by the Administrator, provided, that, except as may otherwise be provided by
the Plan, no amendment, modification, suspension or termination of this
Agreement shall adversely effect the Award in any material way without the
prior written consent of Participant.

 

                5.10         Successors and Assigns. The Company may assign any of
its rights under this Agreement to single or multiple assignees, and this
Agreement shall inure to the benefit of the successors and assigns of the
Company. Subject to the restrictions on transfer herein set forth, this
Agreement shall be binding upon Participant and his or her heirs, executors,
administrators, successors and assigns.

 

                5.11         Notification of Disposition. If this Option is
designated as an Incentive Stock Option, Participant shall give prompt notice
to the Company of any disposition or other transfer of any shares of Stock acquired
under this Agreement if such disposition or transfer is made (a) within
two years from the Grant Date with respect to such shares or (b) within
one year after the transfer of such shares to him. Such notice shall specify
the date of such disposition or other transfer and the amount realized, in
cash, other property, assumption of indebtedness or other consideration, by
Participant in such disposition or other transfer.

 

                5.12         Limitations Applicable to Section 16 Persons.
Notwithstanding any other provision of the Plan or this Agreement, if
Participant is subject to Section 16 of the Exchange Act, the Plan, the
Option and this Agreement shall be subject to any additional limitations set
forth in any applicable exemptive rule under Section 16 of the Exchange
Act (including any amendment to Rule 16b-3 of the Exchange Act) that are
requirements for the application of such exemptive rule. To the extent
permitted by applicable law, this Agreement shall be deemed amended to the
extent necessary to conform to such applicable exemptive rule.

 

                5.13         Entire Agreement. The Plan and this Agreement
(including all Exhibits hereto) constitute the entire agreement of the parties
and supersede in their entirety all prior undertakings and agreements of the
Company and Participant with respect to the subject matter hereof.

 

 

A-7

 

EXHIBIT B

TO STOCK OPTION GRANT NOTICE

 

FORM OF EXERCISE NOTICE

 

                Effective as of today,
                              ,
                        the
undersigned (“Participant”) hereby
elects to exercise Participant’s option to purchase
                              shares
of the Stock (the “Shares”)
of Farmer Bros. Co., a Delaware corporation (the “Company”), under and pursuant to the
Farmer Bros. Co. 2007 Omnibus Plan (the “Plan”) and the Stock Option Grant Notice and
Stock Option Agreement dated                               (the
“Option Agreement”).
Capitalized terms used herein without definition shall have the meanings given
in the Option Agreement.

 

	
  Grant Date:

  	
   

  	
   

  	
   

  
	
  Number of
  Shares as to which Option is Exercised:

  	
   

  	
   

  	
   

  
	
  Exercise Price per Share:

  	
   

  	
  $

  	
   

  	
   

  
	
  Total Exercise Price:

  	
   

  	
  $

  	
   

  	
   

  
	
  Certificate
  to be issued in name of:

  	
   

  	
   

  	
   

  
	
  Payment
  delivered herewith:

  	
   

  	
  $

  	
   

  	
   

  
	
   

  	
   

  	
  (Representing the full
  Exercise Price

  for the Shares, as well as any

  applicable withholding tax)

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Form of Payment:

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  (Please
  specify)

  	
   

  
	
  Type of
  Option:

  	
  o  Incentive
  Stock Option

  	
   

  	
  o  Non-Qualified
  Stock Option

  	
   

  
						

 

                Participant acknowledges that
Participant has received, read and understood the Plan and the Option
Agreement. Participant agrees to abide by and be bound by their terms and
conditions. Participant understands that Participant may suffer adverse tax
consequences as a result of Participant’s purchase or disposition of the
Shares. Participant represents that Participant has consulted with any tax
consultants Participant deems advisable in connection with the purchase or
disposition of the Shares and that Participant is not relying on the Company
for any tax advice. The Plan and Option Agreement are incorporated herein by
reference. This Agreement, the Plan and the Option Agreement constitute the
entire agreement of the parties and supersede in their entirety all prior
undertakings and agreements of the Company and Participant with respect to the
subject matter hereof.

 

	
  ACCEPTED BY:

  	
   

  	
   

  	
   

  
	
  FARMER BROS. CO.

  	
   

  	
  SUBMITTED BY:

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  By:

  	
   

  	
   

  	
   

  	
  By:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Print
  Name:

  	
   

  	
   

  	
   

  	
  Print
  Name:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
   

  	
   

  	
   

  	
  Address:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  

 

 

B-1

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