Document:

KRFT 10-K 2014 EX-10.22

EXHIBIT 10.22
RETIREMENT AGREEMENT AND GENERAL RELEASE
William A. Vernon (“Executive”) has served as Director and Chief Executive Officer of Kraft Foods Group, Inc. (“Kraft”) in Northfield, Illinois.  Reference hereby is made to that certain letter, dated December 3, 2011 (the “Letter Agreement”), clarifying the separation benefits to be received by Executive in the event of a termination of Executive’s employment.  Since the Executive is retiring by mutual agreement with Kraft, Kraft and Executive desire to enter into this Retirement Agreement and General Release (the “Agreement”) to set forth the terms of Executive’s retirement, separation benefits, and other matters related thereto.  Therefore, the Executive and Kraft both agree and promise as follows:
1.Effective December 27, 2014, Executive shall cease to serve as Chief Executive Officer and shall continue to serve as an employee of Kraft with the title of Senior Advisor at his current base salary until March 31, 2015 (“Retirement Date”), with such duties and responsibilities as mutually agreed between Executive by the Chairman of Kraft’s Board of Directors. In addition, Executive agrees to serve as a director of Kraft until Kraft’s 2015 Annual Meeting of Shareholders and that his service as a director shall terminate on the date of such Annual Meeting.  Executive and Kraft agree that the anticipated level of services that Executive will perform prior to the Retirement Date shall be in excess of 20% of the average level of services that Executive performed for Kraft during the three-year period prior to the Retirement Date. 

2.The Executive will receive no additional compensation for his service as a director in the period between the date of this Agreement and the Retirement Date.  The sole compensation that the Executive will receive for his service as a director in the period between the Retirement Date and the date of Kraft’s 2015 Annual Meeting of Shareholders will be a pro-rated portion of the annual cash compensation provided to Kraft’s non-employee directors.

3.In accordance with the Letter Agreement and subject to (i) Paragraph 10 hereof, (ii) Executive’s execution and non-revocation of this Agreement, (iii) Executive’s execution and non-revocation of a commercially reasonable supplemental release agreement to be entered into within 30 days following the Retirement Date, such supplemental release to be substantively consistent with Paragraph 11 hereto, and (iv) Executive’s continued compliance with this Agreement, Executive shall receive the following Separation Benefits: 

		
	a.
	Twenty-four (24) months of base salary, paid in substantially equal installments in accordance with the Company’s normal payroll practices and schedule over the twenty-four (24) month period following the Retirement Date (the “Separation Benefits Period”).  Pursuant to Internal Revenue Code (the “Code”) Section 409A, Executive will be a “Key Employee”; accordingly, the first installment is required to be delayed six (6) months following the Retirement Date.  Therefore, Executive’s first installment (which shall include base salary for the period from April 1, 2015 through September 30, 2015) shall be paid on the first regularly scheduled payroll date following September 30, 2015.   

		
	b.
	During the Separation Benefits Period, Executive will be eligible to receive medical, dental, and life insurance coverage pursuant to the terms of Kraft’s benefit plans.  Executive will not be eligible to make contributions to or receive contributions under the Kraft Thrift 401(k) Plan or to receive Kraft short-term disability insurance coverage or business travel accident coverage after the Retirement Date. 

		
	c.
	The period during which Executive is being provided with health insurance under this Agreement shall be credited against Executive’s period of continued coverage under the Company’s group medical and dental plans pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986, as amended, if any.  If the Executive is entitled to any benefit under the current terms and conditions of any employee benefit plan or arrangement of the Company that is accrued and vested on the Retirement Date and that is not expressly referred to in this Agreement, such benefit shall be provided to the Executive in accordance with the terms and conditions of such employee benefit plan or arrangement.   As a “Key Employee” for purposes of Code Section 409A, the non-grandfathered portion of Executive’s Supplemental Thrift Plan benefits are required to be delayed six months following the Retirement Date.  Therefore, Executive’s Supplemental Thrift Plan benefits shall be paid no earlier than September 30, 2015, with the specific date determined in accordance with the terms of the Supplemental Thrift Plan.  

		
	d.
	Executive shall receive a 2014 Management Incentive Plan (MIP) payment, payable based on Executive’s individual 2014 target percentage and actual business results for the 2014 performance year.  The MIP payment, less any required deductions, shall be paid in accordance with Executive’s previously elected deferrals under the MIP and the cash portion of the MIP shall be paid at the same time MIP payments are paid to other MIP participants, but in any event no later than March 15, 2015. 

		
	e.
	The Executive’s restricted stock and restricted stock units in Kraft (

		
	f.
	“RSUs”), including RSUs received as matching RSUs under the Management Stock Purchase Plan, that remain unvested as of the Retirement Date shall vest on a prorated basis, based on the number of full years of service completed (i.e., grants made over 2 years but less than 3 years prior to the Retirement Date will vest two-thirds, grants made over 1 year but less than 2 years prior to the Retirement Date will vest one-third) during the applicable restriction period and shall be settled in accordance with the original vesting dates set forth in the underlying award agreements.  Any RSUs that do not vest in accordance with this Paragraph 3(e) shall be immediately forfeited by Executive and cancelled by the Company as of the Retirement Date.

  
		
	g.
	The Executive’s stock options in Kraft (the “Stock Options”) that remain unvested as of the Retirement Date shall continue to vest in accordance with the previously scheduled vesting dates set forth in the underlying award agreements. Following the Retirement Date, the Executive may exercise such Stock Options and outstanding stock options in Mondelçz International, Inc. (the “Mondelez Options”) until the original expiration dates of such stock options, as set forth in the underlying award agreements and in accordance with the Employee Matters Agreement between Mondelçz International, Inc. and Kraft Foods Group, Inc., dated as of September 27, 2012.  Stock Options and Mondelez Options that are vested as of the Retirement Date may be exercised following the Retirement Date until the original expiration dates of such Stock Options and Mondelez Options, as set forth in the underlying award agreements.  

		
	h.
	The Executive’s performance shares in Kraft (the “Performance Shares”) that remain unvested as of the Retirement Date shall vest on a prorated basis, based on actual 

performance through the end of the applicable performance cycle and the number of full years of service completed during the applicable performance cycle (i.e., grants made over 2 years but less than 3 years prior to the Retirement Date will vest two-thirds, grants made over 1 year but less than 2 years prior to the Retirement Date will vest one-third).  Any Performance Shares that vest in accordance with this Paragraph 3(g) based on actual performance shall be settled in accordance with the original award agreements (but in any event no later than the March 15th immediately following the end of the performance cycle).  Any Performance Shares that do not vest in accordance with this Paragraph 3(g) shall be immediately forfeited by Executive and cancelled by the Company.

		
	i.
	Executive shall not be entitled to a MIP payment or any equity awards with respect to the 2015 performance year. 

		
	j.
	Kraft will provide reasonable executive outplacement services to the Executive  by a firm selected by Executive and paid for by Kraft.

		
	k.
	Kraft will continue for two years to provide the Executive with a financial counseling allowance consistent with the allowance that has been provided to the Executive in the period immediately prior to the date of this Agreement.

		
	l.
	No later than March 15, 2015, the Company shall reimburse the Executive for his reasonable legal costs incurred in connection with reviewing this Agreement up to a maximum of $20,000, provided that such fees are properly documented and such documentation is submitted to Kraft.                                                                  

		
	m.
	

		
	n.
	Kraft acknowledges that neither the death nor disability of the Executive after the date hereof will reduce or eliminate its obligations to Executive hereunder.

		
	o.
	The Executive agrees that the Company may deduct all required tax withholdings in accordance with the Company’s administrative procedures as in effect from time to time.  

    
4.The Executive agrees to return all company property in his possession, including documents, manuals, handbooks, notes, keys and any other articles he has used in the course of his employment, no later than Retirement Date; provided, however, that Executive may retain only such company property relating to his service as a director through the date of Kraft’s 2015 Annual Meeting of Shareholders.

5.As consideration for Kraft’s payment to the Executive of the Separation Benefits set forth in Paragraph 3, the Executive agrees that he will not engage in Prohibited Conduct from the date of this Agreement through March 31, 2017 (the “Restriction Termination Date”).  Prohibited Conduct will be: (1) working for or providing services to, directly or indirectly (whether as an employee, consultant, officer, director, partner, joint venturer, manager, member, principal, agent, or independent contractor, individually, in concert with others, or in any other manner), any person or entity that competes with Kraft in the consumer packaged food and beverage industry (or of an entity that has a controlling equity interest or management control of any such company) (“Competitive Business”) anywhere within North America, without the written consent of the Chairman of the Board of Directors of Kraft,  such consent to be provided by Kraft in its sole and absolute discretion except that such consent shall not unreasonably be withheld; or (2) soliciting, directly or indirectly, any 

employee of Kraft to leave Kraft and to work for any other entity, whether as an employee, independent contractor or in any other capacity.  

Nothing contained in this Paragraph 5 shall preclude the Executive from accepting employment with a company that provides consulting services whose existing clients include a Competitive Business prior to the Restriction Termination Date, so long as, in addition to honoring all other obligations under this Agreement, the Executive does not provide specific advice or services directly to a Competitive Business.  It will not be a violation of this Agreement for the Executive to have people reporting to him who have responsibility for a Competitive Business so long as the Executive does not provide advice to said companies directly or in any way assist his direct reports, or anyone else, in performing services for a Competitive Business prior to the Restriction Termination Date.
Should the Executive engage in Prohibited Conduct at any time through the Restriction Termination Date, he will be obligated to pay back to Kraft all payments received pursuant to this Agreement, and Kraft will have no obligation to pay the Executive any payments that may be remaining due under this Agreement.  This will be in addition to any other remedy that Kraft may have in respect of such Prohibited Conduct.  Kraft and the Executive acknowledge and agree that Kraft will or would suffer irreparable injury in the event of a breach or violation or threatened breach or violation of the provisions set forth in Paragraphs 5, 6 and 7 and agree that in the event such provisions are violated or breached, Kraft will be entitled to injunctive relief prohibiting any such violation or breach, and that such right to injunctive relief will be in addition to any other remedy to which Kraft may be entitled.
6.The Executive acknowledges that during the course of his employment with Kraft, he received “Confidential Information”, with Confidential Information meaning information that was:  (i) disclosed to or known by the Executive as a consequence of or through his employment with Kraft; (ii) not publicly available and/or not generally known outside of Kraft; and (iii) that relates to the business and development of Kraft.  Without in any way limiting the foregoing and by way of example, Confidential Information includes:  all non-public information or trade secrets of Kraft or its affiliates that gives Kraft or its affiliates a competitive business advantage, the opportunity of obtaining such advantage or disclosure of which might be detrimental to the interests of Kraft or its affiliates; information regarding Kraft’s or its affiliates’ business operations, such as financial and sales data (including budgets, forecasts and historical financial data), operational information, plans and strategies; business and marketing strategies and plans for various products and services; information regarding suppliers, consultants,  employees, and contractors; technical information concerning products, equipment, services, and processes; procurement procedures; pricing and pricing techniques; information concerning past, current and prospective customers, investors and business affiliates; plans or strategies for expansion or acquisitions; budgets; research; trading methodologies and terms; communications information; evaluations, opinions, and interpretations of information and data; marketing and merchandising techniques; electronic databases; models; specifications; computer programs; contracts; bids or proposals; technologies and methods; training methods and processes; organizational structure; personnel information; payments or rates paid to consultants or other service providers; and Kraft files, physical or electronic documents, equipment, and proprietary data or material in whatever form including all copies of all such materials. Confidential Information does not include any of the Executive’s expertise, experience, and knowledge gained throughout his career that falls outside of the three-pronged definition in the first sentence above.  The Executive agrees that he will not communicate or disclose any Confidential Information to any third party, or use it for his own account, without the written consent of Kraft. 

7.Executive agrees not to knowingly make any public statement that would disparage Kraft and its affiliates or persons who are officers and directors of Kraft and its affiliates as of the 

date of this Agreement.  Kraft agrees that neither Kraft nor any of the individuals who are members of the Kraft Leadership Team or members of the Kraft Board of Directors as of the date hereof (the “Kraft Covered Persons”) will knowingly make any public statement that would disparage Executive; provided however that statements by Kraft and the Kraft Covered Persons that are made in the ordinary course of communications for a public company, including but not limited to statements made to the SEC, investors and potential investors, bankers, financial analysts and the press shall not be deemed to violate this covenant.  Notwithstanding the foregoing, nothing in this Paragraph 7 will prevent any person from (a) responding publicly to incorrect, disparaging or derogatory public statements to the extent reasonably necessary to correct or refute such public statement or (b) making any truthful statement to the extent (i) necessary with respect to any litigation, arbitration or mediation involving this Agreement, including, but not limited to, the enforcement of this Agreement or (ii) required by law or by any court, arbitrator, mediator or administrative or legislative body (including any committee thereof) with apparent jurisdiction to order such person to disclose or make accessible such information.  Each of the parties agrees to notify the other of any statement that is required to be made as provided in clause (b)(ii) of the preceding sentence.  Such notice will be given as much in advance of the making of such statement as is reasonably possible.

8.The Executive agrees to fully cooperate with Kraft and its affiliated and parent companies in litigation or potential litigation arising out of any matter in which he was involved during his employment and to make himself reasonably available as required by Kraft or its affiliated and parent companies or their counsel, subject to the Executive’s other commitments.  Kraft will reimburse the Executive for reasonable and appropriate business expenses incurred by the Executive in connection with such cooperation, including a reasonable hourly rate for his services.  

9.In the event either the Executive or Kraft contests the interpretation or application of any of the terms of this Agreement or any asserted breach of this Agreement, the complaining party shall notify the other in writing of the provision that is being contested.  If the parties cannot satisfactorily resolve the dispute within thirty (30) days, the matter will be submitted to arbitration.  An arbitrator will be chosen pursuant to the American Arbitration Association’s (“AAA”) Employment Arbitration Rules and Mediation Procedures from a panel submitted by the AAA and the hearing shall be held in Chicago, Illinois.  The arbitrator’s fees, expenses, and filing fees shall be borne equally by the Executive and Kraft.  The arbitrator shall issue a written award which shall be final and binding upon the parties.

10.It is the intention of the Executive and Kraft that this Agreement and the benefits paid pursuant to its terms be compliant with the provisions of Code Section 409A to the extent that the payments and benefits due under this Agreement are subject to Code Section 409A, and the terms of this Agreement shall be interpreted to comply with Code Section 409A.  In the event that any compensation or benefits provided for by this Agreement or any related plans may result in penalties or accelerated recognition of taxable income under Code Section 409A, Kraft will, in agreement with the Executive, modify the Agreement or such plans in the least restrictive manner necessary in order, where applicable, (i) to exclude such compensation from the definition of “deferred compensation” within the meaning of Code Section 409A, or (ii) to comply with the provisions of Code Section 409A, other applicable provision(s) of the Code, and/or any rules, regulations or other regulatory guidance issued under such statutory provisions and to make such modifications, in each case, without any diminution in the value of the payments to be paid or benefits to be provided to the Executive pursuant to Paragraph 3 of this Agreement or plans to which this Agreement refers.  Notwithstanding any other provision in this Agreement, to the extent any payments hereunder constitute nonqualified deferred compensation, within the meaning of Section 409A, then (A) each such payment which is 

conditioned upon Executive’s execution of this Agreement and which is to be paid or provided during a designated period that begins in one taxable year and ends in a second taxable year, shall be paid or provided in the later of the two taxable years and (B) each such payment that is payable upon the Executive’s separation from service and would have been paid prior to the six-month anniversary of  Executive’s separation from service, shall be delayed until the earlier to occur of (i) the six-month anniversary of the Executive’s separation from service or (ii) the date of Executive’s death.  

11.The Executive is aware of his legal rights concerning his employment with and retirement from Kraft.  The Executive represents that he has not filed any complaints of any kind whatsoever with any local, state, federal, or governmental agency or court against Kraft based upon, or in any way related to, his employment with or retirement from Kraft.   The Executive further represents that he understands that the amounts paid under this Agreement constitute a full and complete satisfaction of any claims, asserted or unasserted, known or unknown, that he has or may have against Kraft or an affiliate.  Accordingly, in exchange for the amounts paid under this Agreement, the Executive individually and on behalf of his spouse, heirs, successors, legal representatives and assigns hereby agrees not to sue or instigate any grievance, charge, action, or suit at law or in equity and unconditionally releases, dismisses, and forever discharges Kraft, including its predecessors, successors, parents, subsidiaries, affiliated corporations, limited liability companies and partnerships, and all of their employee benefit plans, officers, directors, fiduciaries, employees, assigns, representatives, agents, and counsel (collectively the “Released Parties”) from any and all claims, demands, liabilities, obligations, agreements, damages, debts, and causes of action arising out of, or in any way connected with, the Executive’s employment with or retirement from Kraft or any of the Released Parties.  This waiver and release includes, but is not limited to, all claims and causes of action arising under or related to Title VII of the Civil Rights Act of 1964, as amended; the Civil Rights Act of 1991; the Civil Rights Act of 1866; the Age Discrimination in Employment Act of 1967, as amended; the Americans with Disabilities Act; the Employee Retirement Income Security Act of 1974, as amended; the Sarbanes-Oxley Act of 2002; the Older Workers Benefit Protection Act of 1990; the Worker Adjustment and Retraining Notification Act; the Family and Medical Leave Act; all state and federal statutes and regulations; any other federal, state or local law; the Letter Agreement, all oral or written contract rights, including any rights under any Kraft incentive plan, program, or labor agreement; and all claims arising under common law including breach of contract, tort, or for personal injury of any sort, or any other legal theory, whether legal or equitable; provided, however, nothing herein will release Kraft from any claims or damages based on (i) any right Executive may have to enforce this Agreement, (ii) any right or claim that arises after the date of this Agreement, (iii) Executive’s eligibility for indemnification in accordance with applicable laws or the certificate of incorporation and by-laws of Kraft or its affiliates, or any applicable insurance policy, with respect to any liability Executive incurs or incurred as an employee or officer of Kraft or its affiliates or (iv) any right Executive may have to obtain contribution as permitted by law in the event of entry of judgment against Executive as a result of any act or failure to act for which Executive and Kraft are jointly liable.  In consideration for the above release, Kraft, on behalf of itself and its affiliated companies, and their officers, directors, agents and employees, hereby waives, and generally releases Executive and his heirs and representatives from, and agrees not to sue him, for any claims or causes of action existing on the date of this Agreement based on facts known as of the date of this Agreement to any executive officer of Kraft arising out of his employment relationship with Kraft or his retirement from Kraft.      
  
12.By signing below, the Executive acknowledges that he has thoroughly read this Agreement and that he has full understanding and knowledge of its terms and conditions.  He also acknowledges that he has been advised to consult an attorney prior to executing this Agreement and 

that he has up to 21 days to review this Agreement before signing it. The Executive understands that he may revoke this Agreement within 7 days after he signs it, in which case this Agreement will not go into effect and the Executive will not receive the payments or benefits that are being provided by this Agreement.  The Executive also understands that if he does not revoke this Agreement within 7 days after he signs it, this Agreement shall become effective as of such date and will be complete, final and binding on the Executive and Kraft.  

13.If any part of this Agreement is held to be invalid or unenforceable, the remaining parts will remain fully enforceable.  This Agreement will be governed by the laws of Illinois.

	
		
	/s/ William A. Vernon
William A. Vernon
	Date:             12/18/2014               

	
	
	ACCEPTED FOR KRAFT FOODS GROUP, INC.
By: /s/ Diane Johnson May
      Diane Johnson May

Title: Executive Vice President, Human Resources
Date:   12/17/2014OGS 10-K 2014 Exhibit 10.23

Exhibit 10.23

ONE GAS, INC. 

PERFORMANCE UNIT AWARD AGREEMENT

This Performance Unit Award Agreement (this “Agreement”) is made and entered into as of February ___, 2015 (the “Grant Date”) by and between ONE Gas, Inc., an Oklahoma corporation (the “Company”) and [EMPLOYEE NAME] (the “Participant”).

WHEREAS, the Company has adopted the ONE Gas, Inc. Equity Compensation Plan (the “Plan”) pursuant to which Performance Unit Awards may be granted; and

WHEREAS, the Committee has determined that it is in the best interests of the Company and its shareholders to grant the Performance Unit Award provided for herein.

NOW, THEREFORE, the parties hereto, intending to be legally bound, agree as follows:

		
	1.
	Grant of Performance Units.

1.1   The Company hereby grants to the Participant an award consisting of [NUMBER] Performance Units (“Performance Units” or the “Award”) on the terms and conditions set forth in this Agreement, the Notice of Performance Unit Award and Agreement dated February ___, 2015, a copy of which is attached hereto and incorporated herein by reference, and the Plan.   The Performance Units are contingently awarded and will be earned if and only to the extent that the performance goal described on Exhibit A (the “Performance Goal”) is met and vested and distributable only if other conditions in this Agreement are met.  Each Performance Unit represents the right to receive one share of the Company’s common stock (“Share”) or, at the Company’s option, an amount of cash as set forth in Section 6.2, in either case, at the times and subject to the conditions set forth herein.  The number of Performance Units set forth above is equal to a target number of Shares that the Participant will earn for 100% achievement of the Performance Goal (the “Target Award”).  Capitalized terms that are used but not defined herein have the meanings set forth in the Plan.

1.2   The Performance Units shall be credited to a separate account maintained for the Participant on the books and records of the Company (the “Account”).  All amounts credited to the Account shall continue for all purposes to be part of the general assets of the Company.

2.Consideration. The Award is granted in consideration of the Participant’s continued employment with the Company.  

3.Vesting.

3.1   General.  Except as provided in this Section 3, subject to Participant’s continuous employment with the Company during the period beginning on the Grant Date and ending on February ___, 2018 (the “Performance Period”) and subject to the terms of this Agreement, the Participant shall vest at the end of the Performance Period in the number of Performance Units, if

 any, earned upon, and certified following, the attainment of the Performance Goal as of the end of the Performance Period.  Any Performance Units that do not vest as of the end of the Performance Period shall be forfeited.  Performance Units that vest pursuant to the terms of this Agreement, including Sections 3.2 and 3.3 below, are hereinafter referred to as “Vested Units” and the date upon which the Performance Units vest is hereinafter referred to as a “Vesting Date.”  Unless and until the Performance Units have vested, Participant will have no right to receive any Shares subject thereto.  Prior to the actual delivery of any Shares, the Award will represent an unsecured obligation of the Company, payable only from the Company’s general assets.    

3.2        Termination of Employment.
  
(a)If prior to the end of the Performance Period, the Participant ceases to be employed by the Company on account of the Participant’s Retirement, Total Disability or death, the Participant will vest in a pro-rata portion of the Performance Units as of the last day of the Performance Period if the Performance Goal and requirements of this Agreement are met as of such date.  The pro-rata portion of the Performance Units that vest will be determined by multiplying (x) the maximum number of Performance Units in which the Participant could vest, based on the actual level at which the Performance Goal is attained and certified for the Performance Period, as if the Participant remained in the employ of the Company through the end of the Performance Period, by (y) a fraction, which fraction shall be equal to the number of full months which have elapsed under the Performance Period at the time of such termination of employment by the number of full months in the Performance Period.  If the Participant’s employment with the Company terminates prior to the end of the Performance Period for any other reason, Participant shall immediately forfeit any and all Performance Units that have not vested or do not vest on or prior to the Participant’s termination date and neither the Company nor any Subsidiary shall have any further obligations to the Participant under this Agreement.   For purposes of this Agreement, employment with any Subsidiary of the Company shall be treated as employment with the Company.  Likewise, a termination of employment shall not be deemed to occur by reason of a transfer of employment between the Company and any Subsidiary.  For purposes of this Agreement:

		
	(i)
	“Retirement” means a voluntary termination of employment of the Participant with the Company by the Participant if at the time of such termination of employment the Participant has both completed five (5) years of service with the Company and attained age fifty (50).

		
	(ii)
	“Total Disability” means that the Participant is permanently and totally disabled and unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve (12) months, and has established such disability to the extent and in the manner and form as may be required by the Committee.  

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3.3   Change in Control.  If a Change in Control occurs prior to the end of the Performance Period and when the Participant is employed by the Company, then the Performance Period will end on the date of the Change in Control and the Performance Units will be deemed vested at the Target Award level as of the date of the Change in Control (the “Change in Control Date”).  Notwithstanding the foregoing, the provisions set forth in the Plan applicable to a Change in Control shall apply to the Award, and in the event of a Change in Control, the Committee, in its sole discretion and to the extent permitted by Section 409A, may take such actions as it deems appropriate pursuant to the Plan.  For purposes of this Agreement, the term “Change in Control” shall have the same meaning as provided in the Plan.

3.4   Certification.  Except in the event of a Change in Control, the Committee shall, within a reasonably practicable time following the end of the Performance Period, certify to the extent, if any, to which the Performance Goal has been achieved with respect to the Performance Period and the number of Performance Units, if any, earned upon attainment of the Performance Goal.  Such certification shall be final, conclusive and binding on the Participant, and on all other persons, to the maximum extent permitted by law.  

4.Transfer Restrictions.  

4.1   Except as provided in Section 4.2, during the Performance Period and until such time as the Shares underlying the Vested Units have been issued, the Performance Units, related Shares or the rights relating thereto may not be sold, pledged, assigned, transferred or otherwise disposed of by the Participant in any manner other than by will or by laws of descent and distribution.   Except as provided in Section 4.2, any attempt to sell, pledge, assign, transfer or otherwise dispose of the Performance Units, related Shares or the rights relating thereto shall be wholly ineffective and, if any such attempt is made, the Performance Units, related Shares or the rights relating thereto will be forfeited by the Participant and all of the Participant's rights to such units or related Shares shall immediately terminate without any payment or consideration by the Company.

4.2   Notwithstanding the foregoing, the Participant may transfer any part or all of the Participant’s rights in the Performance Units to members of the Participant’s immediate family, or to one or more trusts for the benefit of such immediate family members, or partnerships in which such immediate family members are the only partners if the Participant does not receive any consideration for the transfer.  In the event of any such transfer, Performance Units shall continue to be subject to the same terms and conditions otherwise applicable hereunder and under the Plan immediately prior to transfer, except that such rights shall not be further transferable by the transferee inter vivos, except for transfer back to the Participant.  For any such transfer to be effective, the Participant must provide prior written notice thereof to the Committee and the Participant shall furnish to the Committee such information as it may request with respect to the transferee and the terms and conditions of any such transfer.  For purposes of this Agreement, “immediate family” shall mean the Participant’s spouse, children and grandchildren.

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5.Dividend Equivalents.  During the Performance Period, the Participant's Account shall be credited with an amount equal to all ordinary cash dividends (“Dividend Equivalents”) that would have been paid to the Participant if one Share had been issued on the Grant Date for each Performance Unit granted to the Participant as set forth in this Agreement.   The Dividend Equivalents credited to the Participant’s Account will be deemed to be reinvested in additional Performance Units (or fractional units) and will be subject to the same terms and conditions as the Performance Units to which they are attributable and shall vest or be forfeited (if applicable) and settled at the same time as the Performance Units to which they are attributable. Such additional Performance Units shall also be credited with additional Dividend Equivalents as any further dividends are declared.  

6.Time and Form of Payment with Respect to Vested Units

6.1   Unless an election is made pursuant to Section 7 below and subject to Section 10 and Section 23.2 and subject to certification by the Committee that the Performance Goal has been achieved and other vesting conditions have been satisfied, the Participant will receive a distribution with respect to the Vested Units within 75 days following the earlier of (i) the last day of the Performance Period (the “Distribution Date”) or (ii) the Change in Control Date.  The Vested Units will be settled and distributed in Shares (either in book-entry form or otherwise) or, at the Company’s option, paid in an amount of cash as set forth in Section 6.2.   All distributions in Shares shall be in the form of whole Shares, and any fractional Share shall be distributed in cash in an amount equal to the value of such fractional Share determined based on the Fair Market Value of a Share on the Vesting Date.  

6.2   If the Company elects to settle the Participant’s Vested Units in cash, the amount of cash payable with respect to each Vested Unit shall be equal to the Fair Market Value of a Share on the Vesting Date.   

6.3   To the extent that the Participant does not vest in any Performance Units on or before the end of the Performance Period, all interest in such Performance Units and any additional Performance Units attributable to Dividend Equivalents shall be forfeited.  The Participant has no right or interest in any Performance Units that are forfeited.

7.Deferral Election for Officers.  

7.1   If the Participant is an officer of the Company, the Participant may irrevocably elect to defer the Distribution Date of Performance Units, Shares and cash that the Participant becomes entitled to receive under this Agreement (the “Deferred Amounts”) to a later date, by filing with the Committee, on or before the deferral election date (the “Election Deadline”) described in Section 7.2 below, a signed written irrevocable election (the “Election”) which shall be in the form substantially the same as attached hereto as Exhibit C, or as otherwise approved by the Committee. 

4

7.2   Any such Election shall be filed with the Committee on or before the Election Deadline, which shall be August ___, 2017, the date that is six (6) months before the end of the Performance Period, and shall become effective and irrevocable on such date provided that the Participant performs services for the Company continuously from the later of the beginning of the Performance Period or the date the Performance Goal was established through the Election Deadline.  Notwithstanding the foregoing, in no event shall the Participant’s Election become effective if any portion of the Deferred Amounts has become readily ascertainable (within the meaning of Section 409A) and is substantially certain to be paid the Participant as of the Election Deadline.  To defer the Distribution Date, the Participant must elect to defer one-hundred percent (100%) of the Deferred Amounts.  Subject to Section 23.2, the Deferred Amounts shall be distributed to Participant at the time and in the form set forth in the Election (the “Deferred Date”).  Notwithstanding a Participant’s Election pursuant to this Section 7, if a Change in Ownership or Control (within the meaning of Section 409A) occurs prior to the Deferred Date, the Deferred Amounts will be distributed to the Participant on the date of the Change in Ownership or Control.  

7.3   This Section 7 shall be applicable solely to the Award and shall not apply to any other compensation payable to the Participant under the Plan or otherwise.  The right to make a deferral election under this Section 7 is expressly limited to officers of the Company or any subset thereof as determined by the Committee from time to time.  This Agreement shall not permit a subsequent election to delay or modify the form of payment unless authorized and agreed upon in writing by the Company and Participant and such subsequent election complies with Section 409A.

8.Conditions to Issuance or Transfer of Shares.  The issuance and transfer of Shares shall be subject to compliance by the Company and the Participant with all applicable laws, rules and regulations (“Applicable Laws”) and also to such approvals by governmental agencies as may be deemed appropriate to comply with relevant securities laws and regulations.  No Shares shall be issued or transferred unless and until any then applicable requirements of Applicable Laws and regulatory agencies have been fully complied with to the satisfaction of the Company and its counsel.   

9.Tax Withholding.  Participant shall be required to pay to the Company, and the Company shall have the right to deduct from any compensation paid to the Participant pursuant to the Plan, the amount of any required federal, state and local taxes, domestic or foreign, including payroll taxes, in respect of the Award and to take all such other action as the Committee deems necessary to satisfy all obligations for the payment of such withholding taxes.  The Company shall have no obligation to issue any Shares to any Participant unless and until the Participant has made arrangements, satisfactory to the Company in its sole discretion, to satisfy the Participant’s tax liability resulting from the vesting or settlement of the Vested Units.  The amount of such withholding shall be determined by the Company.  The Committee, in its sole discretion, may permit or require the Participant to satisfy any such tax withholding obligation by any of, or a combination of, the following means: 

5

9.1     tendering a cash payment or check payable to the Company.

9.2      authorizing the Company to withhold an amount from any cash amounts otherwise due or to become due from the Company to the Participant.

9.3    authorizing the Company to withhold Shares from the Shares otherwise issuable to the Participant as a result of the vesting of the Performance Units; provided, however, that no Shares shall be withheld with a value exceeding the minimum amount of tax required to be withheld by Applicable Law.

9.4    delivering to the Company previously owned and unencumbered Shares having a then current Fair Market Value not exceeding the minimum amount of tax required to be withheld by Applicable Law.  

10.Rights as Shareholder. Except as otherwise provided in the Agreement, the Participant shall not have any of the rights or privileges of a shareholder with respect to the Shares underlying the Performance Units unless and until the Performance Units vest and certificates representing such Shares (which may be in book-entry form) have been issued and recorded on the Company’s records, and delivered to the Participant or to an escrow account for the Participant’s benefit.  After such issuance, recordation and delivery, Participant will have the rights of a shareholder of the Company with respect to such Shares, including without limitation, voting rights and the right to receipt of dividends and distributions on such Shares.    

11.No Right to Continued Service. Neither the Plan nor this Agreement shall confer upon the Participant to serve as an employee or other service provider of the Company.  Further, nothing in the Plan or this Agreement shall be construed to limit the discretion of the Company to terminate the services of the Participant at any time, with or without Cause. 

12.Adjustments.  In the event of a change in capitalization described in Section 15 of the Plan prior to the end of the Performance Period, other than a dividend described in Section 5 above, the Performance Units shall be equitably adjusted or terminated in any manner contemplated by the Plan to reflect the effect of such event or change in the Company’s capital structure in such a way as to preserve the value of the Award.  

13.Required Participant Repayment/Reduction Provision.  Notwithstanding anything in the Plan or this Agreement to the contrary, all or a portion of the Award made to the Participant under this Agreement is subject to being called for repayment to the Company or reduced in any situation where the Board or a committee thereof determines that fraud, negligence, or intentional misconduct by the Participant was a contributing factor to the Company having to restate all or a portion of its financial statement(s). The Committee may determine whether the Company shall effect any such repayment or reduction: (i) by seeking repayment from the Participant, (ii) by reducing (subject to Applicable Law and the Plan’s terms and conditions or any other applicable plan, program, or arrangement) the amount that would otherwise be awarded or payable to the Participant under the Award, the Plan or any other compensatory plan, 

6

program, or arrangement maintained by the Company, (iii) by withholding payment of future increases in compensation (including the payment of any discretionary bonus amount) or grants of compensatory awards that would otherwise have been made in accordance with the Company’s otherwise applicable compensation practices, or (iv) by any combination of the foregoing. The determination regarding the Participant’s conduct, and repayment or reduction under this provision shall be within the Committee’s sole discretion and shall be final and binding on the Participant and the Company. The Participant, in consideration of the grant of the Award, and by the Participant's execution of this Agreement, acknowledges the Participant's understanding and agreement to this provision, and hereby agrees to make and allow an immediate and complete repayment or reduction in accordance with this provision in the event of a call for repayment or other action by the Company or Committee to effect its terms with respect to the Participant, the Award and/or any other compensation described herein.

14.Company Policies.  The Participant agrees that the Award will be subject to any applicable insider trading policies, retention policies and other policies that may be implemented by the Board, from time to time.

15.Participant Undertaking.  The Participant agrees to take whatever additional actions and execute whatever additional documents the Company may in its reasonable judgment deem necessary or advisable in order to carry out or effect one or more of the obligations or restrictions imposed on the Participant pursuant to the terms of this Agreement.  It is intended by the Company that the Plan and Shares covered by the Award are to be registered under the Securities Act of 1933, as amended, prior to the grant date; provided that in the event such registration is for any reason not effective for such Shares, the Participant agrees that all Shares acquired pursuant to the grant will be acquired for investment and will not be available for sale or tender to any third party.

16.Beneficiary.  The Participant may designate a Beneficiary to receive any rights of the Participant which may become vested in the event of the Participant’s death under procedures and in the form established by the Committee; and in the absence of such designation of a Beneficiary, any such rights shall be deemed to be transferred to the Participant’s estate.  

17.Notices. Any notice required to be delivered to the Company under this Agreement shall be in writing and addressed to the Vice President of Human Resources of the Company at the Company's principal corporate offices. Any notice required to be delivered to the Participant under this Agreement shall be in writing and addressed to the Participant at the Participant's address as shown in the records of the Company. Either party may designate another address in writing (or by such other method approved by the Company) from time to time.  Any notice shall be delivered by hand, sent by telecopy or enclosed in a properly sealed envelope addressed as stated above, registered and deposited, postage prepaid, in a post office regularly maintained by the United States Postal Service. 

18.Incorporation of the Plan; Conflicts. The Performance Units and the Shares issued to Participant hereunder are subject to the terms and conditions set forth in this Agreement and the 

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Plan, which is incorporated herein by reference. In the event of any inconsistency between (1) the Plan and this Agreement, the Plan will control, or (2) the resolutions and records of the Board or Committee and this Agreement, the resolutions and records of the Board or Committee will control.  

19.Successors and Assigns. The Company may assign any of its rights under this Agreement, and this Agreement will be binding upon and inure to the benefit of the Company’s successors and assigns. Subject to the restrictions on transfer set forth herein and the Plan, this Agreement will be binding upon and inure to the benefit of the heirs, legatees, legal representatives, successors and assigns of the parties hereto.  

20.No Impact on Other Benefits. The Company does not intend for the value of the Award or any Vested Units to be included in the Participant’s normal or expected compensation for purposes of calculating any severance, retirement, welfare, insurance or similar employee benefit; provided, however, that if there is any inconsistency between this Agreement and the terms of another benefit plan, the benefit plan document will control.  

21.Discretionary Nature of Plan. The Plan is discretionary and may be amended, cancelled or terminated by the Board at any time, in its discretion. The grant of the Performance Units in this Agreement does not create any contractual right or other right to receive any Performance Units or other awards in the future. Future awards, if any, will be at the Committee’s sole discretion. Any amendment, modification, or termination of the Plan shall not constitute a change or impairment of the terms and conditions of the Participant's employment with the Company. 

22.Amendment. In accordance with the Plan, the Committee may amend or otherwise modify, suspend, discontinue or terminate this Agreement at any time, prospectively or retroactively.  

23.Section 409A. 

23.1   This Award and Agreement is intended to comply with Section 409A or an exemption thereunder and shall be construed and interpreted in a manner that is consistent with the requirements for avoiding additional taxes or penalties under Section 409A.   Notwithstanding any other provision of the Agreement, any distributions or payments due hereunder may only be made upon an event and in a manner that complies with Section 409A or an applicable exemption. Any distributions or payments due hereunder upon a termination of employment shall only be made upon a "separation from service" as defined in Section 409A.  The right to a series of installment payments under this Agreement shall be treated as a right to a series of separate payments.  Except as provided in Section 7, in no event may the Participant, directly or indirectly, designate the calendar year of settlement, distribution or payment.   

23.2   If an Award is subject to Section 409A and Participant becomes entitled to settlement of the Award on account of a separation from service and is a “specified employee” within the 

8

meaning of Section 409A on the date of the separation from service, then to the extent necessary to prevent any accelerated or additional tax under Section 409A, such settlement will be delayed until the earlier of: (a) the date that is six months following the Participant's separation from service and (b) the Participant’s death (the “Delayed Payment Date”) and the accumulated amounts shall be distributed or paid in a lump sum payment on the Delayed Payment Date. 

23.3   The Company does not represent that the Award or this Agreement comply with Section 409A and in no event shall the Company be liable for all or any portion of any taxes, penalties, interest or other expenses that may be incurred by the Participant on account of non-compliance with Section 409A. 

23.4   To the extent that any provision of the Agreement would cause a conflict with the requirements of Section 409A, or would cause the administration of the Agreement to fail to satisfy Section 409A, such provision shall be deemed null and void to the extent permitted by Applicable Law.

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

25.Severability. The invalidity or unenforceability of any provision of the Plan or this Agreement shall not affect the validity or enforceability of any other provision of the Plan or this Agreement, and each provision of the Plan and this Agreement shall be severable and enforceable to the extent permitted by law.

26.Governing Law. This Agreement will be construed and interpreted in accordance with the laws of the State of Oklahoma without regard to the conflict of laws provisions thereof.    

27.Counterparts. This Agreement may be executed in one or more counterparts, including by way of electronic signature, subject to Applicable Law, each of which shall be deemed an original and all of which together will constitute one instrument. 

28.Administration of Award; Acceptance. As a condition of receiving this Award, the Participant agrees that the Committee shall have full and final authority to construe and interpret the Plan and this Agreement, and to make all other decisions and determinations as may be required under the Plan or this Agreement as they may deem necessary or advisable for administration of the Plan or this Agreement, and that all such interpretations, decisions and determinations shall be final and binding on the Participant, the Company and all other interested persons.  Any dispute regarding the interpretation of this Agreement shall be submitted by the Participant or the Company to the Committee for review.  The resolution of such dispute by the Committee shall be final and binding on the Participant and the Company.  Day-to-day authority and responsibility has been delegated to the Company’s Benefit Plan Administration Committee and its authorized representatives, and all actions taken thereby shall be entitled to the same deference as if taken by the Committee itself.

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The Participant hereby acknowledges receipt of this Agreement, the Notice of Performance Unit Award and Agreement dated February ____, 2015, and a copy of the Plan.  Participant agrees to be bound by all of the provisions set forth in this Agreement and the Plan and acknowledges that there may be adverse tax consequences upon the vesting or settlement of the Performance Units or disposition of the underlying Shares and that Participant has been advised to consult a tax advisor prior to such vesting, settlement or disposition.  Participant and accepts the Award under the terms and conditions stated in this Agreement, subject to all terms and provisions of the Plan, by electronic acceptance of the grant. 

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Exhibit A
Performance Unit Performance Goal
2015-2018 Performance Period
Subject to the terms of the Agreement, Participant shall vest in a percentage of the Target Award (including any Dividend Equivalents) at the end of the Performance Period based on the Company’s ranking for Total Stockholder Return against the ONE Gas Peer Group listed in Exhibit C, all as determined by the Committee in its sole discretion.
        
	
		
	ONE Gas Total Stockholder Return (TSR): vs. ONE Gas Peer Group

	ONE Gas TSR Ranking vs. ONE Gas Peer Group
	Percentage of Performance Units Earned

	90th percentile and above
75th percentile
50th percentile
25th percentile
Below 25th percentile
	200%
150%
100%
50%
0%

If ONE Gas’s TSR ranking at the end of the Performance Period is between the stated percentile levels in the above table, the percentage of the Performance Units earned will be interpolated between the earning levels.  No Performance Units are earned if ONE Gas’s TSR ranking at the end of the Performance Period is below the 25th percentile.

Exhibit B
Illustration of Hypothetical 2015-2018 Performance Period
Performance Unit Award Calculation
Illustration assumes 500 Performance Units Granted in February 2015

	
	
	Total Stockholder Return (TSR) vs. ONE Gas Peer Group

	

Hypothetical 2015-2018 ONE Gas TSR Ranking = 40th percentile

A 40th percentile TSR ranking earns 80% of Performance Units granted (i.e., 500 units) 
as interpolated between 50% and 100% from Table A (see chart below)

400 Performance Units earned*

	
	
	Total Performance Units Earned

	

400 Performance Units

400* Performance Units earned out of 500 units granted = 80% “earn-out” 
[80% of 500 shares paid and distributed in the form of Shares]

*In addition, applicable Dividend Equivalents will be added with an 80% “earn-out”.

Exhibit C

2015-2018 ONE GAS TSR Peer Group

	
						
	Company Name
	Sym
	 
	 
	 
	 

	AGL Resources Inc.
	AGL
	 
	 
	 
	 

	Atmos Energy Corp
	ATO
	 
	 
	 
	 

	Avista Corp
	AVA
	 
	 
	 
	 

	Laclede Group Inc
	LG
	 
	 
	 
	 

	New Jersey Resources Corp
	NJR
	 
	 
	 
	 

	Northwest Natural Gas
	NWN
	 
	 
	 
	 

	ONE Gas, Inc.
	OGS
	 
	 
	 
	 

	Piedmont Natural Gas Co
	PNY
	 
	 
	 
	 

	Questar Corp
	STR
	 
	 
	 
	 

	South Jersey Industries Inc
	SJI
	 
	 
	 
	 

	Southwest Gas Corp
	SWX
	 
	 
	 
	 

	Vectren Corp
	VVC
	 
	 
	 
	 

	WGL Holdings Inc
	WGL
	 
	 
	 
	 

In the event that any of the Peer Group companies are not available for performance comparison either by going out of business, being sold, being merged into another company or any other reason, then that company will be dropped from the list and the performance comparison will be made with the remaining Peer Group companies.

Exhibit D

ONE GAS, Inc. Equity Compensation Plan
Performance Unit Deferral Election

INSTRUCTIONS:  This Deferral Election must be completed and returned to [CONTACT] at ONE Gas, Inc. no later than August __, 2017 (the “Election Deadline”).  This election becomes irrevocable as of the Election Deadline; provided, however, this election shall only become effective to the extent permitted by Section 409A.    

This Election is made by the undersigned Participant pursuant to the terms of the ONE GAS, Inc. Equity Compensation Plan (the “Plan”) and that certain Performance Unit Award Agreement issued to me under the Plan on the __ day of February, 2015 (the “Agreement”).  Capitalized terms that are used but not defined herein have the meanings set forth in the Agreement.

1.    Irrevocable Elections as to the Time and Form of Payment

I hereby irrevocably elect to defer the payment and my receipt of all Performance Units, Shares and cash that I may become entitled to receive pursuant to the Agreement (the “Deferred Amounts”) from the regularly scheduled time of payment set forth in Section 6 of the Agreement until a later date as follows:

A.     Specified Time of Payment Election (Put initials by your choice)

___    I elect to have the Deferred Amounts deferred and paid to me on the later of (i) the date of my separation from service as an employee of the Company, or (ii) [________, 20__] in the form specified below.

___    I elect to have the Deferred Amounts deferred and paid to me on the date of my separation from service as an employee of the Company in the form specified below. 

B.     Form of Payment Election (Put initials by your choice) 

___      I elect to receive the Deferred Amounts in a single lump sum payment.

____    I elect to receive the Deferred Amounts in ______(specify 2, 3, 4 or 5) equal annual installments commencing on the Specified Time of Payment that I have elected in Part A above, until fully paid. The number of Shares or cash received in each installment will equal the number and amount, respectively, that have not been paid as of the date immediately preceding the installment payment date, divided by the number of installments remaining to be paid as of the date immediately preceding the installment payment date.  The resulting number shall

 be rounded down to the next whole number, except that the final installment shall be rounded up to the next whole number.

C.     Election in the Event of Death (Put initials by your choice)

___    In the event of my death prior to, or after, the Specified Time of Payment that I have elected above, I elect to have my named beneficiaries (or my estate, if I do not have any designated beneficiaries) receive payment and transfer of the Deferred Amounts in a single lump sum within 60 days following my death.

___    In the event of my death prior to, or after, the Specified Time of Payment that I have elected above, I elect to have my named beneficiaries (or my estate, if I do not have any designated beneficiaries) receive payment and transfer of the Deferred Amounts in ______ (specify 2, 3, 4 or 5) equal annual installments commencing within 60 days following my death, until fully paid. The number of Shares or cash received in each installment will equal the number and amount, respectively, that have not been paid as of the date immediately preceding the installment payment date, divided by the number of installments remaining to be paid as of the same date.  The resulting number shall be rounded down to the next whole number, except that the final installment shall be rounded up to the next whole number.

D.    Change in Ownership or Control (Mandatory Distribution)

Notwithstanding the above elections, if a Change in Ownership or Control (within the meaning of Section 409A) occurs prior to the full distribution of the Deferred Amounts, all Deferred Amounts that have not been paid and transferred will be paid and transferred on the date of the Change in Ownership or Control.  In the event Shares no longer exist at the time of payment and transfer, each of the deferred Performance Units shall be converted in a manner that is consistent with the manner in which Shares held by shareholders of the Company were treated with respect to the Change in Ownership or Control.

2.    Additional Terms

A.    Unforeseeable Emergency.  You may request an accelerated payment of all or a portion of the Deferred Amounts if you experience an Unforeseeable Emergency (as defined in the Plan), subject to the requirements set forth in Plan Section 13.5.   If approved, payment shall be made in a single lump sum within 90 days after the approval date.  
B.    Specified Employee.  If you become entitled to a distribution on account of a separation from service and you are “specified employee” (within the meaning of Section 409A) on the date of your separation from service, payment of all or a portion of your Deferred Amounts may be delayed in accordance with Plan Section 13.4.    

C.    Re-deferrals and Changing the Form of Payment. You may, at the Committee’s discretion, be permitted to make a re-deferral election with respect to the amounts deferred hereunder in accordance with Plan Section 13.3.
E.     Withholding.  You will be required to satisfy any tax withholding obligations relating to the Deferred Amounts, and delivery of the Shares or cash will be conditional upon your satisfaction of such obligations. 
 
3.    Acknowledgment

By executing this Election, I acknowledge that:

		
	A.
	I have read the terms of the Plan, the Agreement and this Election and agree to all the terms and conditions.  

		
	B.
	I understand that any amounts that I defer hereunder are unfunded and unsecured and subject to the claims of the Company’s creditors in the event of the Company’s insolvency.

		
	C.
	I understand that the Plan, the Agreement and this Election are intended to comply with Section 409A and that they will be interpreted accordingly.  However, I understand that the Company will have no liability with respect to any failure to comply with Section 409A. 

		
	D.
	I understand that this Election will become irrevocable as of the Election Deadline.  

		
	E.
	I have consulted with my own tax advisor regarding the tax consequences of participating in the Plan and making this election.

I hereby make this election as of this ___ day of ____, 20__.  

_____________________________________
Participant Signature

_____________________________________
Print Participant’s Name

_____________________________________
Employee ID Number

Copy received this ____ day of ________, 20__,

______________________________________
For the Committee

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