Document:

Form of Award Agreement

 Exhibit 10.3 
  
 XENOGEN CORPORATION 
  
 2004 EQUITY INCENTIVE PLAN 
  
 STOCK OPTION AWARD AGREEMENT 
  
 Unless otherwise defined herein, the terms defined in the 2004 Equity Incentive Plan will have the same defined meanings in this Award Agreement.

  

	I.	NOTICE OF STOCK OPTION GRANT 

  
 Name: 
  
 Address: 
  
 You have been granted an option to purchase Common Stock of the Company, subject to the terms and conditions of the Plan and this Award Agreement, as
follows: 
  

					
	 Grant Number
	  	 	 	  

			
	 Date of Grant
	  	 	 	  

			
	 Vesting Commencement Date
	  	 	 	  

			
	 Exercise Price per Share
	  	$	 	  

			
	 Total Number of Shares Granted
	  	 	 	  

			
	 Total Exercise Price
	  	$	 	  

		
	 Type of Option:
	  	         Incentive Stock Option
		
	 	  	         Nonstatutory Stock Option
			
	 Term/Expiration Date:
	  	 	 	  

  
 Vesting
Schedule: 
  
 Subject to accelerated vesting as set forth
below or in the Plan, this Option may be exercised, in whole or in part, in accordance with the following schedule: 
  
 25% of the Shares subject to the Option will vest twelve months after the Vesting Commencement Date, and 1/48 of the Shares subject to the Option will
vest on the first day of each month thereafter, subject to Participant continuing to be a Service Provider through such dates. 
  
 Termination Period: 
  
 This Option shall be exercisable for thirty (30) days after Participant ceases to be a Service Provider, unless such termination is due to
Participant’s death or Disability, in which case this 

 
Option shall be exercisable for one (1) year after Participant ceases to be Service Provider. Notwithstanding the foregoing, in no event may this Option be
exercised after the Term/Expiration Date as provided above. 
  

	II.	AGREEMENT 

  
 A. Grant of Option.  
  
 The Administrator hereby grants to individual named in the Notice of Grant attached as Part I of this Agreement (the “Participant”) an option
(the “Option”) to purchase the number of Shares, as set forth in the Notice of Grant, at the exercise price per share set forth in the Notice of Grant (the “Exercise Price”), subject to the terms and conditions of the Plan, which
is incorporated herein by reference. Subject to Section 17(c) of the Plan, in the event of a conflict between the terms and conditions of the Plan and the terms and conditions of this Award Agreement, the terms and conditions of the Plan will
prevail. 
  
 If designated in the Notice of Grant as an Incentive
Stock Option (“ISO”), this Option is intended to qualify as an Incentive Stock Option under Section 422 of the Code. However, if this Option is intended to be an Incentive Stock Option, to the extent that it exceeds the $100,000 rule of
Code Section 422(d) it will be treated as a Nonstatutory Stock Option (“NSO”). 
  
 B. Exercise of Option. 
  
 (a) Right to Exercise. This Option is exercisable during its term in accordance with the Vesting Schedule set out in the Notice of Grant and the applicable provisions of the Plan and this Award Agreement. 
  
 (b) Method of Exercise. This Option is exercisable by delivery of an
exercise notice, in the form attached as Exhibit A (the “Exercise Notice”), which will state the election to exercise the Option, the number of Shares in respect of which the Option is being exercised (the “Exercised
Shares”), and such other representations and agreements as may be required by the Company pursuant to the provisions of the Plan. The Exercise Notice will be completed by Participant and delivered to the Company. The Exercise Notice will be
accompanied by payment of the aggregate Exercise Price as to all Exercised Shares together with any applicable withholding taxes. This Option will be deemed to be exercised upon receipt by the Company of such fully executed Exercise Notice
accompanied by such aggregate Exercise Price. 
  
 No Shares will
be issued pursuant to the exercise of this Option unless such issuance and exercise comply with Applicable Laws. Assuming such compliance, for income tax purposes the Exercised Shares will be considered transferred to Participant on the date the
Option is exercised with respect to such Exercised Shares. 
  
 C.
Method of Payment. 
  
 Payment of the aggregate Exercise
Price will be by any of the following, or a combination thereof, at the election of Participant: 
  

	 	1.	cash; 

  

	 	2.	check; 

  

 -2- 

 3. consideration received by the Company under a formal cashless exercise program adopted by the Company
in connection with the Plan; or 
  
 4. surrender of other Shares
which, (i) in the case of Shares acquired from the Company, either directly or indirectly, have been owned by the Participant and not subject to a substantial risk of forfeiture for more than six (6) months on the date of surrender, and (ii) have a
Fair Market Value on the date of surrender equal to the aggregate Exercise Price of the Exercised Shares. 
  
 D. Non-Transferability of Option. 
  
 This Option may not be transferred in any manner otherwise than by will or by the laws of descent or distribution and may be exercised during the lifetime
of Participant only by Participant. The terms of the Plan and this Award Agreement will be binding upon the executors, administrators, heirs, successors and assigns of Participant. 
  
 E. Term of Option. 
  
 This Option may be exercised only within the term set out in the Notice of Grant, and may be exercised during such term only in accordance with the Plan
and the terms of this Award Agreement. 
  
 F. Tax Obligations.
 
  
 1. Withholding Taxes. Participant agrees to make
appropriate arrangements with the Company (or the Parent or Subsidiary employing or retaining Participant) for the satisfaction of all Federal, state, and local income and employment tax withholding requirements applicable to the Option exercise.
Participant acknowledges and agrees that the Company may refuse to honor the exercise and refuse to deliver Shares if such withholding amounts are not delivered at the time of exercise. 
  
 2. Notice of Disqualifying Disposition of ISO Shares. If the Option granted to Participant herein is an ISO, and if
Participant sells or otherwise disposes of any of the Shares acquired pursuant to the ISO on or before the later of (1) the date two years after the Grant Date, or (2) the date one year after the date of exercise, Participant will immediately notify
the Company in writing of such disposition. Participant agrees that Participant may be subject to income tax withholding by the Company on the compensation income recognized by Participant. 
  
 G. Entire Agreement; Governing Law. 
  
 The Plan is incorporated herein by reference. The Plan and this Award
Agreement constitute the entire agreement of the parties with respect to the subject matter hereof and supersede in their entirety all prior undertakings and agreements of the Company and Participant with respect to the subject matter hereof, and
may not be modified adversely to Participant’s interest except by means of a writing signed by the Company and Participant. This Award Agreement is governed by the internal substantive laws, but not the choice of law rules, of California.

  

 -3- 

 H. NO GUARANTEE OF CONTINUED SERVICE. 
  
 PARTICIPANT ACKNOWLEDGES AND AGREES THAT THE VESTING OF SHARES PURSUANT TO
THE VESTING SCHEDULE HEREOF IS EARNED ONLY BY CONTINUING AS AN EMPLOYEE, CONSULTANT OR NON-EMPLOYEE DIRECTOR AT THE WILL OF THE COMPANY (AND NOT THROUGH THE ACT OF BEING HIRED, BEING GRANTED AN OPTION OR PURCHASING SHARES HEREUNDER). PARTICIPANT
FURTHER ACKNOWLEDGES AND AGREES THAT THIS AGREEMENT, THE TRANSACTIONS CONTEMPLATED HEREUNDER AND THE VESTING SCHEDULE SET FORTH HEREIN DO NOT CONSTITUTE AN EXPRESS OR IMPLIED PROMISE OF CONTINUED ENGAGEMENT AS AN EMPLOYEE, CONSULTANT OR NON-EMPLOYEE
DIRECTOR FOR THE VESTING PERIOD, FOR ANY PERIOD, OR AT ALL, AND WILL NOT INTERFERE WITH PARTICIPANT’S RIGHT OR THE COMPANY’S RIGHT TO TERMINATE PARTICIPANT’S RELATIONSHIP AS AN EMPLOYEE, CONSULTANT OR NON-EMPLOYEE DIRECTOR AT ANY
TIME, WITH OR WITHOUT CAUSE. 
  
 By Participant’s signature
and the signature of the Company’s representative below, Participant and the Company agree that this Option is granted under and governed by the terms and conditions of the Plan and this Award Agreement. Participant has reviewed the Plan and
this Award Agreement in their entirety, has had an opportunity to obtain the advice of counsel prior to executing this Award Agreement and fully understands all provisions of the Plan and Award Agreement. Participant hereby agrees to accept as
binding, conclusive and final all decisions or interpretations of the Administrator upon any questions relating to the Plan and Award Agreement. Participant further agrees to notify the Company upon any change in the residence address indicated
below. 
  

			
	 PARTICIPANT:
	 	XENOGEN CORPORATION
		
	  

 Signature
	 	  

 By

		
	  

 Print Name
	 	  

 Title

		
	  

 Residence Address
	 	 
		
	
	 	 

  

 -4- 

 EXHIBIT A 
  
 XENOGEN CORPORATION 
  
 2004 EQUITY INCENTIVE PLAN 
  
 EXERCISE NOTICE 
  
 Xenogen Corporation 
 [Address] 
  
 Attention: [Title] 
  
 1. Exercise of Option. Effective as of today,
                    ,     , the undersigned (“Purchaser”) hereby elects to purchase
                     shares (the “Shares”) of the Common Stock of Xenogen Corporation (the “Company”) under and pursuant
to the 2004 Equity Incentive Plan (the “Plan”) and the Award Agreement dated,                      (the “Award
Agreement”). The purchase price for the Shares will be $            , as required by the Award Agreement. 
  
 2. Delivery of Payment. Purchaser herewith delivers to the Company the full purchase price for the Shares any
required withholding taxes to be paid in connection with the exercise of the Option. 
  
 3. Representations of Purchaser. Purchaser acknowledges that Purchaser has received, read and understood the Plan and the Award Agreement and agrees to abide by and be bound by their terms and conditions.

  
 4. Rights as Shareholder. Until the issuance (as
evidenced by the appropriate entry on the books of the Company or of a duly authorized transfer agent of the Company) of the Shares, no right to vote or receive dividends or any other rights as a shareholder will exist with respect to the Optioned
Stock, notwithstanding the exercise of the Option. The Shares so acquired will be issued to Participant as soon as practicable after exercise of the Option. No adjustment will be made for a dividend or other right for which the record date is prior
to the date of issuance, except as provided in Section 13 of the Plan. 
  
 5. Tax Consultation. Purchaser understands that Purchaser may suffer adverse tax consequences as a result of Purchaser’s purchase or disposition of the Shares. Purchaser represents that Purchaser has consulted with any tax
consultants Purchaser deems advisable in connection with the purchase or disposition of the Shares and that Purchaser is not relying on the Company for any tax advice. 
  
 6. Entire Agreement; Governing Law. The Plan and Award Agreement are incorporated herein by reference. This
Agreement, the Plan and the Award Agreement constitute the entire agreement of the parties with respect to the subject matter hereof and supersede in their entirety all prior undertakings and agreements of the Company and Purchaser with respect to
the subject matter 

 
hereof, and may not be modified adversely to the Purchaser’s interest except by means of a writing signed by the Company and Purchaser. This agreement
is governed by the internal substantive laws, but not the choice of law rules, of California. 
  

			
	Submitted by:	 	Accepted by:
		
	PURCHASER:	 	XENOGEN CORPORATION
		
	  

 Signature
	 	  

 By

		
	  

 Print
Name
	 	  

 Its

		
	Address:	 	Address:
		
	  

  

	 	 
		
	 	 	  

 Date
Received

  

 -2-Form of Restricted Stock Purchase Agreement

 Exhibit 10.5 
  
 XENOGEN CORPORATION 
  
 2004 DIRECTOR STOCK PLAN 
  
 RESTRICTED STOCK AGREEMENT 
  
 Unless otherwise defined herein, capitalized terms defined in the 2004 Director Stock Plan shall have the same defined meanings in this Restricted Stock
Agreement (the “Agreement”). 
  

	I.	NOTICE OF RESTRICTED STOCK GRANT 

  
 Name:  
  
 Address: 
  
 The undersigned Outside Director has been granted Restricted Shares, subject to the terms and conditions of the Plan and this Restricted Stock Agreement,
as follows: 
  

			
	Grant Date:	  	  

	Vesting Commencement Date:	  	  

	Restricted Shares:	  	  

  
 Vesting
Schedule: 
  
 100% of the Restricted Shares shall vest on the
one-year anniversary of the Vesting Commencement Date, subject to the Outside Director’s continued service as a member of the Board through the vesting date. 
  

	II.	TERMS OF THE AGREEMENT 

  
 1. Grant. The Company hereby grants to the individual named in the Notice of Restricted Stock Grant an award for that number of Restricted Shares
set forth in the Notice of Restricted Stock Grant in exchange for the par value ($0.001 per Share) of the Restricted Shares, commencing on the date hereof, subject to all of the terms and conditions in this Agreement and the Plan, which is
incorporated herein by reference. 
  
 2. Shares Held in
Escrow. Unless and until the Restricted Shares shall have vested in the manner set forth in Sections 3 or 4 herein, such Shares shall be issued in the name of the Outside Director and held by the Secretary or Assistant Secretary of the Company
or such other person as the Company may designate as escrow agent (the “Escrow Agent”), and shall not be sold, transferred, assigned, or otherwise disposed of, and shall not be pledged, alienated, or otherwise hypothecated. The
Company may instruct the transfer agent for its Common Stock to place a legend on the 

 
certificates representing the Restricted Shares or otherwise note on its records as to the restrictions on transfer set forth in this Agreement and the Plan.
The certificate or certificates representing such Shares shall not be delivered by the Escrow Agent to the Outside Director unless and until the Shares have vested and all other terms and conditions in this Agreement have been satisfied. The
Restricted Shares will be released from escrow as soon as practicable after the Shares vest. 
  
 3. Vesting Schedule. Except as provided in Section 4, and subject to Section 5, the Restricted Shares awarded by this Agreement shall vest in the Outside Director according to the vesting schedule set forth in
the Notice of Restricted Stock Grant. 
  
 4. Committee
Discretion. The Administrator, in its absolute discretion, may accelerate the vesting of the balance, or some lesser portion of the balance, of the unvested Restricted Shares at any time. If so accelerated, such Shares shall be considered as
having vested as of the date specified by the Administrator. 
  
 5. Forfeiture. Except as provided in Section 4, and notwithstanding any contrary provision of this Agreement, the balance of the Restricted Shares which have not vested at the time of the Outside Director’s termination of status
as a member of the Company’s Board (“Termination of Service”) will thereupon be forfeited and automatically transferred to and reacquired by the Company at no cost to the Company. Upon a Termination of Service, the Company will
become the legal and beneficial owner of the Restricted Shares being forfeited and reacquired by the Company and all rights and interests therein or relating thereto, and the Company will have the right to retain and transfer to its own name the
number of Restricted Shares being reacquired by the Company. 
  
 The Outside Director hereby appoints the Escrow Agent with full power of substitution, as the Outside Director’s true and lawful attorney-in-fact with irrevocable power and authority in the name and on behalf of the Outside Director to
take any action and execute all documents and instruments, including, without limitation, stock powers which may be necessary to transfer the certificate or certificates evidencing such unvested Shares to the Company upon such Termination of
Service. 
  
 6. Death of Outside Director. Any distribution
or delivery to be made to the Outside Director under this Agreement shall, if the Outside Director is then deceased, be made to the Outside Director’s designated beneficiary, or if no beneficiary survives the Outside Director, to the
administrator or executor of the Outside Director’s estate. Any designation of a beneficiary by the Outside Director shall be effective only if such designation is made in a form and manner acceptable to the Committee. Any transferee must
furnish the Company with (a) written notice of his or her status as transferee, and (b) evidence satisfactory to the Company to establish the validity of the transfer and compliance with any laws or regulations pertaining to said transfer.

  
 7. Rights as Stockholder. Neither the Outside Director
nor any person claiming under or through the Outside Director shall have any of the rights or privileges of a stockholder of the Company in respect of any Shares deliverable hereunder unless and until certificates representing such Shares shall have
been issued, recorded on the records of the Company or its transfer agents or registrars, and delivered to the Outside Director or the Escrow Agent. Except as provided in 
  

 -2- 

 Section 8, after such issuance, recordation and delivery, the Outside Director shall have all the rights of a stockholder
of the Company with respect to voting such Shares and receipt of dividends and distributions on such Shares. 
  
 8. Changes in Stock. In the event of any dividend or other distribution (whether in the form of cash, Shares, other securities, or other property),
recapitalization, stock split, reverse stock split, reorganization, merger, consolidation, split-up, spin-off, combination, repurchase, or exchange of Shares or other securities of the Company, or other change in the corporate structure of the
Company affecting the Shares occurs, and by virtue of any such change the Outside Director shall in his or her capacity as owner of unvested Restricted Shares which have been awarded to him or her (the “Prior Shares”) be entitled to
new or additional or different shares of stock, securities or cash; such new or additional or different shares, securities or cash shall thereupon be considered to be unvested Restricted Shares and shall be subject to all of the conditions and
restrictions which were applicable to the Prior Shares pursuant to this Agreement and the Plan. If the Outside Director receives rights or warrants with respect to any Prior Shares, such rights or warrants may be held or exercised by the Outside
Director, provided that until such exercise any such rights or warrants and after such exercise any shares or other securities acquired by the exercise of such rights or warrants shall be considered to be unvested Restricted Shares and shall be
subject to all of the conditions and restrictions which were applicable to the Prior Shares pursuant to the Plan and this Agreement. The Administrator in its absolute discretion at any time may accelerate the vesting of all or any portion of such
new or additional shares of stock, securities, cash, rights or warrants to purchase securities or shares or other securities acquired by the exercise of such rights or warrants. 
  
 9. Tax Consequences. Set forth below is a brief summary, as of the date of grant of Restricted Shares, of some of the
federal tax consequences arising from the grant of Restricted Shares and the disposition of such Shares. THIS SUMMARY IS NECESSARILY INCOMPLETE, AND THE TAX LAWS AND REGULATIONS ARE SUBJECT TO CHANGE. 
  
 9.1 Grant of Restricted Shares. Generally, no income will be
recognized by the Outside Director in connection with the grant of unvested Restricted Shares, unless an election under Section 83(b) of the Internal Revenue Code of 1986, as amended (the “Code”) is filed with the Internal Revenue
Service within thirty (30) days of the Grant Date. Otherwise, as the Restricted Shares vest, the Outside Director will recognize compensation income in an amount equal to the difference between the fair market value of the Restricted Shares at the
time the Shares vest and the amount paid for the Shares, if any (the “Spread”). 
  
 9.2 Section 83(b) Election. The Outside Director may elect to be taxed (and commence his capital gains holding period for the Restricted Shares) at
the time the Restricted Shares are granted rather than when any applicable forfeiture expires by filing an election under Section 83(b) of the Code with the United States Internal Revenue Service within thirty (30) days from the Grant Date. The form
for making this election is attached as Appendix B hereto. THE OUTSIDE DIRECTOR ACKNOWLEDGES THAT IT IS THE OUTSIDE DIRECTOR’S SOLE RESPONSIBILITY AND NOT THE COMPANY’S TO FILE TIMELY THE ELECTION UNDER SECTION 83(b), EVEN IF THE
OUTSIDE DIRECTOR REQUESTS THE COMPANY OR ITS REPRESENTATIVES TO MAKE THIS FILING ON HIS OR HER BEHALF. If the Outside 
  

 -3- 

 Director files an election under Section 83(b), the Outside Director must pay the applicable income tax on any excess of
the fair market value of the Restricted Shares at the time of the Grant Date over the amount paid for the unvested Restricted Shares, if any. However, if the Outside Director’s service with the Company subsequently terminates before the
Restricted Shares vest, the Outside Director will not be entitled to any refund of the taxes paid on the unvested Restricted Shares. 
  
 The Outside Director has reviewed with the Outside Director’s own tax advisors the federal, state, local and foreign tax consequences of this
investment and the transactions contemplated by this Agreement. The Outside Director is relying solely on such advisors and not on any statements or representations of the Company or any of its agents. The Outside Director understands that the
Outside Director (and not the Company) shall be responsible for the Outside Director’s own tax liability that may arise as a result of the transactions contemplated by this Agreement. 
  
 10. Address for Notices. Any notice to be given to the Company under
the terms of this Agreement shall be addressed to the following, or at such other address as the Company may hereafter designate in writing: 
  
 Xenogen Corporation 
 860 Atlantic Avenue

 Alameda, California 94501 
 Attention: Secretary 
  
 11. Grant is Not
Transferable. Except as provided in Section 6, this grant and the rights and privileges conferred hereby shall not be transferred, assigned, pledged, hypothecated, or disposed of in any manner (whether by operation of law or otherwise) and shall
not be subject to sale under execution, attachment or similar process. Upon any attempt to transfer, assign, pledge, hypothecate or otherwise dispose of this grant, or of any right or privilege conferred hereby, or upon any attempted sale under any
execution, attachment or similar process, this grant and the rights and privileges conferred hereby immediately shall become null and void. 
  
 12. Binding Agreement. Subject to the limitation on the transferability of this grant contained herein, this Agreement shall be binding upon and
inure to the benefit of the heirs, legatees, legal representatives, successors and assigns of the parties hereto. 
  
 13. Conditions for Issuance of Certificates for Stock. The Shares deliverable to the Outside Director may be either previously authorized but
unissued Shares or issued Shares that have been reacquired by the Company. The Company shall not be required to issue any certificate or certificates for Shares hereunder unless the issuance and delivery of such Shares will comply with all relevant
provisions of law, including, without limitation, the Securities Act of 1933, as amended, the Exchange Act, the rules and regulations promulgated thereunder, state securities laws, and the requirements of any stock exchange upon which the Shares may
then be listed, and will be further subject to the approval of counsel for the Company with respect to such compliance. Inability of the Company to obtain authority from any regulatory body having jurisdiction, which authority is deemed by the
Company’s counsel to be necessary to the lawful issuance and sale of any Shares 
  

 -4- 

 hereunder, will relieve the Company of any liability in respect of the failure to issue or sell such Shares as to which
such requisite authority will not have been obtained. The Company has no obligation to register any Shares issued pursuant to this Plan under the securities laws of any jurisdiction. 
  
 14. Plan Governs. This Agreement is subject to all terms and provisions of the Plan. In the event of a conflict
between one or more provisions of this Agreement and one or more provisions of the Plan, the provisions of the Plan shall govern. 
  
 15. Captions. Captions provided herein are for convenience only and are not to serve as a basis for interpretation or construction of this
Agreement. 
  
 16. Agreement Severable. In the event that
any provision in this Agreement shall be held invalid or unenforceable, such provision shall be severable from, and such invalidity or unenforceability shall not be construed to have any effect on, the remaining provisions of this Agreement.

  
 17. Modifications to the Agreement. This Agreement
constitutes the entire understanding of the parties on the subjects covered. The Outside Director expressly warrants that he or she is not executing this Agreement in reliance on any promises, representations, or inducements other than those
contained herein. Modifications to this Agreement or the Plan can be made only in an express written contract executed by a duly authorized officer of the Company. 
  

 -5- 

 By Outside Director’s signature below, Outside Director represents that he or she is familiar with the terms and
provisions of the Plan, and hereby accepts this Agreement subject to all of the terms and provisions thereof. Outside Director has reviewed the Plan and this Agreement in their entirety, has had an opportunity to obtain the advice of counsel prior
to executing this Agreement and fully understands all provisions of this Agreement. Outside Director agrees to accept as binding, conclusive and final all decisions or interpretations of the Administrator upon any questions arising under the Plan or
this Agreement. Outside Director further agrees to notify the Company upon any change in the residence indicated in the Notice of Restricted Stock Grant. 
  

			
	OUTSIDE DIRECTOR	  	XENOGEN CORPORATION
		
	  

	  	  

	Signature	  	By
		
	  

	  	  

	Print Name	  	Title
		
	  

	  	 
	  

	  	 
	  

	  	 
	Residence Address	  	 

  

 -6- 

 APPENDIX A 
  
 ELECTION UNDER SECTION 83(b)  
 OF THE INTERNAL REVENUE CODE OF 1986 
  
 The undersigned taxpayer hereby elects, pursuant to the above-referenced Federal Tax Code, to include in taxpayer’s gross income for the current taxable year, the amount of any compensation taxable to taxpayer in connection with his
receipt of the property described below: 
  

	1.	The name, address, taxpayer identification number and taxable year of the undersigned are as follows: 

  

					
	NAME:	  	TAXPAYER:	  	SPOUSE:
			
	ADDRESS:	  	 	  	 
			
	1. IDENTIFICATION NO.:	  	TAXPAYER:	  	SPOUSE:
			
	TAXABLE YEAR:	  	 	  	 

  

	2.	The property with respect to which the election is made is described as follows:
                                 shares (the “Shares”) of the common
stock of Xenogen Corporation (the “Company”). 

  

	3.	The date on which the property was transferred is:             , 200    .

  

	4.	The property is subject to the following restrictions: 

  
 The Shares may be forfeited to the Company, or its assignee, on certain events. This right lapses with regard to a portion of the Shares based on the
continued performance of services by the taxpayer over time. 
  

	5.	The fair market value at the time of transfer, determined without regard to any restriction other than a restriction which by its terms will never lapse, of such property is:
[                    ] 

  

	6.	The amount (if any) paid for such property is:
[                    ] 

  
 The undersigned has submitted a copy of this statement to the person for whom the services were performed in connection with the undersigned’s
receipt of the above-described property. The transferee of such property is the person performing the services in connection with the transfer of said property. 
  

The undersigned understands that the foregoing election may not be revoked except with the consent of the Commissioner. 
  

			
	Dated:             ,     	  	  

	 	  	[Name], Taxpayer
		
	The undersigned spouse of taxpayer joins in this election.	  	 
		
	Dated:             ,     	  	  

	 	  	Spouse of Taxpayer

  

 -7-

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