Document:

EX-4.01

 Exhibit 4.01 

This Note is a Global Security within the meaning of the Indenture hereinafter referred to and is registered in the name of the Depository
named below or a nominee of the Depository. This Note is not exchangeable for Notes registered in the name of a Person other than the Depository or its nominee except in the limited circumstances described herein and in the Indenture, and no
transfer of this Note (other than a transfer of this Note as a whole by the Depository to a nominee of the Depository or by a nominee of the Depository to the Depository or another nominee of the Depository) may be registered except in the limited
circumstances described herein. 
 Unless this certificate is presented by an authorized representative of The Depository Trust Company, a
New York corporation (the “Depository”), to the Company or its agent for registration of transfer, exchange, or payment, and any certificate issued is registered in the name of Cede & Co. or in such other name as is requested by
an authorized representative of the Depository (and any payment is made to Cede & Co. or to such other entity as is requested by an authorized representative of the Depository), ANY TRANSFER, PLEDGE, OR OTHER USE HEREOF FOR VALUE OR
OTHERWISE BY OR TO ANY PERSON IS WRONGFUL inasmuch as the registered owner hereof, Cede & Co., has an interest herein. 

CITIGROUP INC. 
 2.561%
Fixed Rate / Floating Rate Callable Senior Notes due May 1, 2032 
  

			
	REGISTERED	  	REGISTERED
		
		  	CUSIP: 172967MY4
		  	ISIN: US172967MY46
		
	No. R-00*	  	$        

 CITIGROUP INC., a Delaware corporation (the “Company”, which term includes any successor Person
under the Indenture), for value received, hereby promises to pay to Cede & Co., or registered assigns, the principal sum of $                on May 1, 2032
(the “Maturity Date”) and to pay interest thereon from and including May 4, 2021 or from the most recent Interest Payment Date to which interest has been paid or duly provided for. The Company shall pay interest (i) from
May 4, 2021 to, but excluding, May 1, 2031 (the “Fixed Rate Period”) at a fixed rate of 2.561% per annum semi-annually, on May 1st and November 1st of each year (each such date, a “Fixed Rate Period Interest Payment
Date”), commencing November 1, 2021 and (ii) from, and including, May 1, 2031 (the “Floating Rate Period”), at an annual rate equal to SOFR (and defined on the reverse hereof and compounding daily over each Interest
Period during the Floating Rate Period as described below) plus 1.167% quarterly, on the second business day following each Interest Period End Date (each such business day, a “Floating Rate Period Interest Payment Date” and together with
any Fixed Rate Period Payment Date, an “Interest Payment Date”), commencing August 3, 2031, until the principal hereof is paid or made available for payment and provided that the Interest Payment Date with respect to the final
Interest Period will be a redemption date or the Maturity Date. An Interest Period End Date is the 1st of each February, 

 
May, August and November, beginning on August 1, 2031 and ending on a redemption date or the Maturity Date. The interest so payable, and punctually paid or duly provided for, on any Interest
Payment Date will, as provided in the Indenture, be paid to the Person in whose name this Note is registered at the close of business on the Record Date for such interest, which shall be the Business Day immediately preceding such Interest Payment
Date. Any such interest not so punctually paid or duly provided for will forthwith cease to be payable to the holder on such Record Date and may either be paid to the Person in whose name this Note is registered at the close of business on a
subsequent Record Date, such subsequent Record Date to be not less than ten days prior to the date of payment of such defaulted interest, notice whereof shall be given to holders of Notes of this series not less than ten days prior to such
subsequent Record Date, or be paid at any time in any other lawful manner not inconsistent with the requirements of any securities exchange on which the Notes of this series may be listed, and upon such notice as may be required by such exchange,
all as more fully provided in the Indenture. 
 During the Fixed Rate Period, interest hereon will be calculated on the basis of a 360-day year comprised of twelve 30-day months, and an Interest Period shall be the period from and including an Interest Payment Date (or May 4, 2021 in the case of the
first Interest Period) to and including the day immediately preceding the next Interest Payment Date. During the Fixed Rate Period, if an Interest Payment Date falls on a day that is not a Business Day, such Interest Payment Date will be the next
succeeding Business Day, and no further interest will accrue in respect of such postponement. For these purposes, “Business Day” means any day on which commercial banks settle payments and are open for general business in The City of New
York. 
 During the Floating Rate Period, interest hereon will be calculated on the basis of the actual number of days elapsed in an interest period and a 360-day year, and an Interest Period shall be the period from and including an Interest Period End Date (or May 1, 2031 in the case of the first Interest Period during the Floating Rate Period) to, but
excluding, the next succeeding Interest Period End Date; provided that the Interest Period following an election by the Company to redeem the Notes and the final Interest Period will be the period from, and including, the immediately
preceding Interest Period End Date to, but excluding, the redemption date or the Maturity Date; and provided further that SOFR for each calendar day from, and including, the Rate Cut-Off Date (as
defined on the reverse hereof) to, but excluding, the redemption date or the Maturity Date will equal SOFR in respect of the Rate Cut-Off Date. In the event that any Interest Period End Date (other than a
redemption date or the Maturity Date) is not a Business Day, then such date will be postponed to the next succeeding Business Day, unless that day falls in the next calendar month, in which case the interest period end date will be the immediately
preceding Business Day. For these purposes, “Business Day” means any day on which commercial banks settle payments and are open for general business in The City of New York and a U.S. Government Securities Business Day (as defined on the
reverse hereof) 
 Dollar amounts resulting from such calculations will be rounded to the nearest cent, with
one-half cent being rounded upward. In the event that the Maturity Date or a redemption date is not a Business Day, then such date will be postponed to the next succeeding Business Day, and no further interest
will accrue with respect to such postponement. No interest will accrue on any amounts payable for the period from and after the due date for payment of such principal or interest. 

 Payment of the principal of and interest on this Note will be made at the office or agency of the paying
agent maintained for that purpose in The City of New York. 
 Reference is hereby made to the further provisions of this Note set forth on the reverse
hereof, which further provisions shall for all purposes have the same effect as if set forth at this place. 
 Unless the certificate of authentication
hereon has been executed by the Trustee or by an authenticating agent on behalf of the Trustee by manual signature, this Note shall not be entitled to any benefit under the Indenture or be valid or obligatory for any purpose. 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly executed under its
corporate seal. 
 Dated: May 4, 2021 
  

			
	CITIGROUP INC.
		
	By:	 	  

		 	Name:
		 	Title:

  

			
	ATTEST:
		
	By:	 	  

		 	Name:
		 	Title:

 This is one of the Notes of the series issued under the within-mentioned Indenture. 

Dated: May 4, 2021 
  

			
	THE BANK OF NEW YORK MELLON,
	as Trustee
		
	By:	 	
                     
                    

		 	Name:
		 	Title:
	
	-or-
	
	CITIBANK, N.A.,
	as Authenticating Agent
		
	By:	 	
                     
                    

		 	Name:
		 	Title:

 This Note is one of a duly authorized issue of Securities of the Company (the “Notes”), issued and
to be issued in one or more series under the senior debt indenture, dated as of November 13, 2013 (as amended and supplemented from time to time, the “Indenture”), between the Company and The Bank of New York Mellon, as trustee (the
“Trustee”, which term includes any successor trustee under the Indenture), to which Indenture and all indentures supplemental thereto reference is hereby made for a statement of the respective rights, limitations of rights, duties and
immunities thereunder of the Company, the Trustee and the holders of the Notes and of the terms upon which the Notes are, and are to be, authenticated and delivered. This Note is one of the series designated on the face hereof, initially limited in
aggregate principal to $3,000,000,000. 
 During the Floating Rate Period, this Note will bear interest for each Interest Period at a rate determined by
Citibank, N.A., London Branch, acting as Calculation Agent. The interest rate on this Note for a particular Interest Period during the Floating Rate Period will be a per annum rate equal to SOFR (compounding daily over each Interest Period as
described below) plus 1.167%. Interest during the Floating Rate Period will be calculated by multiplying the principal amount of the Notes by an accrued interest factor equal to the sum of the interest factors calculated for each day during the
applicable Interest Period; provided that in no event will the interest payable on the Notes be less than zero. The interest factor for each such day will be computed by dividing the interest rate applicable to that day by 360. The interest
rate applicable to such day will be the sum of the Accrued Interest Compounding Factor plus 1.167%. Promptly upon determination, the Calculation Agent will inform the Trustee and the Company of the interest rate for the next Interest Period. Absent
manifest error, the determination of the interest rate by the Calculation Agent shall be binding and conclusive on the holders of Notes, the Trustee and the Company. 

For the purposes of calculating interest with respect to any Interest Period during the Floating Rate Period: 

“Accrued Interest Compounding Factor” means the result of the following formula: 

 
 

 
 where 

“do”, for any Interest Period, is the number of U.S. Government Securities Business Days in the relevant Interest Period. 

“i” is a series of whole numbers from one to do, each representing the relevant U.S. Government Securities Business Days in
chronological order from, and including, the first U.S. Government Securities Business Day in the relevant Interest Period. 

“SOFRi”, for any day “i” in the relevant Interest Period, is a reference rate equal to SOFR in respect of that day.

 “ni”, for any day “i” in the relevant Interest Period, is the
number of calendar days from, and including, such U.S. Government Securities Business Day “i” to, but excluding, the following U.S. Government Securities Business Day. 

“d” is the number of calendar days in the relevant Interest Period. 

“U.S. Government Securities Business Day” means any day except for a Saturday, Sunday or a day on which the Securities Industry and
Financial Markets Association (SIFMA) recommends that the fixed income departments of its members be closed for the entire day for purposes of trading in U.S. government securities. 

“SOFR” means, with respect to any day, the rate determined by the Calculation Agent in accordance with the following provisions:

 (1) the Secured Overnight Financing Rate for trades made on such day that appears at approximately 3:00 p.m. (New York City time) on the
NY Federal Reserve’s Website on the U.S. Government Securities Business Day immediately following such U.S. Government Securities Business Day; or 

(2) if the rate specified in (1) above does not so appear, unless a Benchmark Transition Event and its related Benchmark Replacement Date
have occurred as described in (3) below, the Secured Overnight Financing Rate published on the NY Federal Reserve’s Website for the first preceding U.S. Government Securities Business Day for which the Secured Overnight Financing Rate was
published on the NY Federal Reserve’s Website; or 
 (3) if a Benchmark Transition Event and its related Benchmark Replacement Date have
occurred prior to the relevant interest period end date, the Calculation Agent will use the Benchmark Replacement to determine the rate and for all other purposes relating to the Notes. 

In connection with the SOFR definition above, the following definitions apply: 

“Benchmark” means, initially, SOFR; provided that if a Benchmark Transition Event and its related Benchmark Replacement Date have
occurred with respect to SOFR or the then-current Benchmark, then “Benchmark” means the applicable Benchmark Replacement. 

“Benchmark Replacement” means the first alternative set forth in the order below that can be determined by Citigroup (or one of its
affiliates) as of the Benchmark Replacement Date: 
 (1) the sum of: (a) the alternate rate of interest that has been selected or
recommended by the Relevant Governmental Body as the replacement for the then-current Benchmark for the applicable Corresponding Tenor and (b) the Benchmark Replacement Adjustment; or 

(2) the sum of: (a) the ISDA Fallback Rate and (b) the Benchmark Replacement Adjustment; or 

(3) the sum of: (a) the alternate rate of interest that has been selected by the Company (or one of its affiliates) as the replacement for
the then-current Benchmark for the applicable 

 
Corresponding Tenor giving due consideration to any industry-accepted rate of interest as a replacement for the then-current Benchmark for U.S. dollar-denominated floating rate notes at such time
and (b) the Benchmark Replacement Adjustment. 
 “Benchmark Replacement Adjustment” means the first alternative set forth in
the order below that can be determined by the Company (or one of its affiliates) as of the Benchmark Replacement Date: 
 (1) the spread
adjustment, or method for calculating or determining such spread adjustment, (which may be a positive or negative value or zero) that has been selected or recommended by the Relevant Governmental Body for the applicable Unadjusted Benchmark
Replacement; 
 (2) if the applicable Unadjusted Benchmark Replacement is equivalent to the ISDA Fallback Rate, then the ISDA Fallback
Adjustment; 
 (3) the spread adjustment (which may be a positive or negative value or zero) that has been selected by the Company (or one of
its affiliates) giving due consideration to any industry-accepted spread adjustment, or method for calculating or determining such spread adjustment, for the replacement of the then-current Benchmark with the applicable Unadjusted Benchmark
Replacement for U.S. dollar-denominated floating rate notes at such time. 
 “Benchmark Replacement Conforming Changes” means,
with respect to any Benchmark Replacement, any technical, administrative or operational changes that the Company (or one of its affiliates) decides may be appropriate to reflect the adoption of such Benchmark Replacement in a manner substantially
consistent with market practice (or, if the Company (or such affiliate) decides that adoption of any portion of such market practice is not administratively feasible or if the Company (or such affiliate) determines that no market practice for use of
the Benchmark Replacement exists, in such other manner as the Company (or such affiliate) determines is reasonably necessary). 

“Benchmark Replacement Date” means the earliest to occur of the following events with respect to the then-current Benchmark: 

(1) in the case of clause (1) or (2) of the definition of “Benchmark Transition Event,” the later of (a) the date of the
public statement or publication of information referenced therein and (b) the date on which the administrator of the Benchmark permanently or indefinitely ceases to provide the Benchmark; or 

(2) in the case of clause (3) of the definition of “Benchmark Transition Event,” the date of the public statement or publication
of information referenced therein. 
 For the avoidance of doubt, if the event giving rise to the Benchmark Replacement Date occurs on the
same day as, but earlier than, the Reference Time in respect of any determination, the Benchmark Replacement Date will be deemed to have occurred prior to the Reference Time for such determination. 

 “Benchmark Transition Event” means the occurrence of one or more of the following
events with respect to the then-current Benchmark: 
 (1) a public statement or publication of information by or on behalf of the
administrator of the Benchmark announcing that such administrator has ceased or will cease to provide the Benchmark, permanently or indefinitely, provided that, at the time of such statement or publication, there is no successor administrator that
will continue to provide the Benchmark; 
 (2) a public statement or publication of information by the regulatory supervisor for the
administrator of the Benchmark, the central bank for the currency of the Benchmark, an insolvency official with jurisdiction over the administrator for the Benchmark, a resolution authority with jurisdiction over the administrator for the Benchmark
or a court or an entity with similar insolvency or resolution authority over the administrator for the Benchmark, which states that the administrator of the Benchmark has ceased or will cease to provide the Benchmark permanently or indefinitely,
provided that, at the time of such statement or publication, there is no successor administrator that will continue to provide the Benchmark; or 

(3) a public statement or publication of information by the regulatory supervisor for the administrator of the Benchmark announcing that the
Benchmark is no longer representative. 
 “Business Day” means any weekday that is not a legal holiday in New York City and is not
a day on which banking institutions in New York City are authorized or required by law or regulation to be closed and is a U.S. Government Securities Business Day. 

“Corresponding Tenor” with respect to a Benchmark Replacement means a tenor (including overnight) having approximately the same
length (disregarding business day adjustment) as the applicable tenor for the then-current Benchmark. 
 “ISDA” means the
International Swaps and Derivatives Association, Inc. or any successor thereto. 
 “ISDA Definitions” means the 2006 ISDA
Definitions published by ISDA, as amended or supplemented from time to time, or any successor definitional booklet for interest rate derivatives published from time to time. 

“ISDA Fallback Adjustment” means the spread adjustment (which may be a positive or negative value or zero) that would apply for
derivatives transactions referencing the ISDA Definitions to be determined upon the occurrence of an index cessation event with respect to the Benchmark for the applicable tenor. 

“ISDA Fallback Rate” means the rate that would apply for derivatives transactions referencing the ISDA Definitions to be effective
upon the occurrence of an index cessation date with respect to the Benchmark for the applicable tenor excluding the applicable ISDA Fallback Adjustment. 

“NY Federal Reserve” means the Federal Reserve Bank of New York. 

“NY Federal Reserve’s Website” means the website of the NY Federal Reserve, currently at http://www.newyorkfed.org, or any
successor website of the NY Federal Reserve or the website of any successor administrator of the Secured Overnight Financing Rate. 

“Rate Cut-Off Date” means the second U.S. Government Securities Business Day prior to a
redemption date or the Maturity Date. 

 “Reference Time” with respect to any determination of the Benchmark means the time
determined by Citigroup (or one of its affiliates) in accordance with the Benchmark Replacement Conforming Changes. 
 “Relevant
Governmental Body” means the Federal Reserve Board and/or the NY Federal Reserve, or a committee officially endorsed or convened by the Federal Reserve Board and/or the NY Federal Reserve or any successor thereto. 

“Unadjusted Benchmark Replacement” means the Benchmark Replacement excluding the Benchmark Replacement Adjustment. 

Upon request from any Noteholder, the Calculation Agent will provide the interest rate in effect on this Note for the current Interest Period during the
Floating Rate Period and, if it has been determined, the interest rate to be in effect for the next Interest Period during the Floating Rate Period. 
 If
an event of default (as defined in the Indenture) with respect to Notes of this series shall occur and be continuing, the principal of the Notes of this series may be declared due and payable in the manner and with the effect provided in the
Indenture. 
 Sections 12.02 and 12.03 of the Indenture containing provisions for defeasance apply to this Note. At any time the entire indebtedness of this
Note may be defeased upon compliance by the Company with certain conditions set forth in Section 12.04 of the Indenture. 
 The
Indenture contains provisions permitting the Company and the Trustee, without the consent of the holders of the Securities, to establish, among other things, the form and terms of any series of Securities issuable thereunder by one or more
supplemental indentures, and, with the consent of the holders of a majority in aggregate principal amount of Securities at the time outstanding which are affected thereby, to modify the Indenture or any supplemental indenture or the rights of the
holders of Securities of such series to be affected, provided that no such modification will (i) extend the fixed maturity of any Securities, reduce the rate or extend the time of payment of interest thereon, reduce the principal amount thereof
or the premium, if any, thereon, reduce the amount of the principal of Original Issue Discount Securities payable on any date, change the currency in which Securities are payable, or impair the right to institute suit for the enforcement of any such
payment on or after the maturity thereof, without the consent of the holder of each Security so affected, or (ii) reduce the aforesaid percentage of Securities of any series the consent of the holders of which is required for any such
modification without the consent of the holders of all Securities of such series then outstanding, or (iii) modify the rights, duties or immunities of the Trustee unless the Trustee agrees to such modification. 

No reference herein to the Indenture and no provision of this Note or of the Indenture shall alter or impair the obligation of the Company, which is absolute
and unconditional, to pay the principal of and interest on this Note at the times, place and rate, and in the coin or currency, herein prescribed. 
 This
Note is a Global Security registered in the name of a nominee of the Depository. This Note is exchangeable for Notes registered in the name of a person other than the Depository or its nominee only in the limited circumstances hereinafter described.
Unless and until it is exchanged in whole or in part for definitive Notes in certificated form, this Note may not be transferred except as a whole by the Depository to a nominee of the Depository or by a nominee of the Depository to the Depository
or another nominee of the Depository. 

 The Notes represented by this Global Security are exchangeable for definitive Notes in certificated form of
like tenor as such Notes in denominations of $1,000 and whole multiples of $1,000 in excess thereof only if (i) the Depository notifies the Company that it is unwilling or unable to continue as Depository for the Notes and the Company is unable
to appoint a successor depository or (ii) the Depository ceases to be a clearing agency registered under the Securities Exchange Act of 1934, as amended, or (iii) the Company in its sole discretion decides to allow the Notes to be
exchanged for definitive Notes in registered form. Any Notes that are exchangeable pursuant to the preceding sentence are exchangeable for certificated Notes issuable in authorized denominations and registered in such names as the Depository shall
direct. As provided in the Indenture and subject to certain limitations therein set forth, the transfer of definitive Notes in certificated form is registrable in the register maintained by the Company in The City of New York for such purpose, upon
surrender of the definitive Note for registration of transfer at the office or agency of the registrar, duly endorsed by, or accompanied by a written instrument of transfer in form satisfactory to the Company and the registrar duly executed by, the
holder thereof or his attorney duly authorized in writing, and thereupon one or more new Notes of this series and of like tenor, of authorized denominations and for the same aggregate principal amount, will be issued to the designated transferee or
transferees. Subject to the foregoing, this Note is not exchangeable, except for a Global Security or Global Securities of this issue of the same principal amount to be registered in the name of the Depository or its nominee. 

No service charge shall be made for any such registration of transfer or exchange, but the Company may require payment of a sum sufficient to cover any tax or
other governmental charge payable in connection therewith. 
 Prior to due presentment of this Note for registration of transfer, the Company, the Trustee
and any agent of the Company or the Trustee may treat the Person in whose name this Note is registered as the owner hereof for all purposes, whether or not this Note be overdue, and neither the Company, the Trustee nor any such agent shall be
affected by notice to the contrary. 
 The Company will pay additional amounts (“Additional Amounts”) to the beneficial owner of any Note that is
a non-United States person in order to ensure that every net payment on such Note will not be less, due to payment of U.S. withholding tax, than the amount then due and payable. For this purpose, a “net
payment” on a Note means a payment by the Company or a paying agent, including payment of principal and interest, after deduction for any present or future tax, assessment or other governmental charge of the United States. These Additional
Amounts will constitute additional interest on the Note.     
 The Company will not be required to pay Additional Amounts, however, in
any of the circumstances described in items (1) through (13) below. 
 (1)    Additional Amounts will not be
payable if a payment on a Note is reduced as a result of any tax, assessment or other governmental charge that is imposed or withheld solely by reason of the beneficial owner: 

(a) having a relationship with the United States as a citizen, resident or otherwise; 

(b) having had such a relationship in the past; or 

 (c) being considered as having had such a relationship. 

(2)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment or
other governmental charge that is imposed or withheld solely by reason of the beneficial owner: 
 (a) being treated as present in or engaged
in a trade or business in the United States; 
 (b) being treated as having been present in or engaged in a trade or business in the United
States in the past; or 
 (c) having or having had a permanent establishment in the United States. 

(3)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment or
other governmental charge that is imposed or withheld in whole or in part by reason of the beneficial owner being or having been any of the following (as such terms are defined in the Internal Revenue Code of 1986, as amended): 

(a) personal holding company; 

(b) foreign private foundation or other foreign tax-exempt organization; 

(c) passive foreign investment company; 

(d) controlled foreign corporation; or 

(e) corporation which has accumulated earnings to avoid United States federal income tax. 

(4)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment or
other governmental charge that is imposed or withheld solely by reason of the beneficial owner owning or having owned, actually or constructively, 10 percent or more of the total combined voting power of all classes of stock of the Company
entitled to vote or by reason of the beneficial owner being a bank that has invested in a Note as an extension of credit in the ordinary course of its trade or business. 

For purposes of items (1) through (4) above, “beneficial owner” means a fiduciary, settlor, beneficiary, member or shareholder of the holder if
the holder is an estate, trust, partnership, limited liability company, corporation or other entity, or a person holding a power over an estate or trust administered by a fiduciary holder. 

(5)    Additional Amounts will not be payable to any beneficial owner of a Note that is a: 

(a) fiduciary; 
 (b) partnership;

 (c) limited liability company; or 

(d) other fiscally transparent entity 

or that is not the sole beneficial owner of the Note, or any portion of the Note. However, this exception to the obligation to pay Additional
Amounts will only apply to the extent that a beneficiary or settlor in relation to the fiduciary, or a beneficial owner or member of the partnership, limited liability company or other fiscally transparent entity, would not have been entitled to the
payment of an Additional Amount had the beneficiary, settlor, beneficial owner or member received directly its beneficial or distributive share of the payment. 

 (6) Additional Amounts will not be payable if a payment on a Note is reduced as a result of
any tax, assessment or other governmental charge that is imposed or withheld solely by reason of the failure of the beneficial owner or any other person to comply with applicable certification, identification, documentation or other information
reporting requirements. This exception to the obligation to pay Additional Amounts will only apply if compliance with such reporting requirements is required by statute or regulation of the United States or by an applicable income tax treaty to
which the United States is a party as a precondition to exemption from such tax, assessment or other governmental charge. 

(7)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment or
other governmental charge that is collected or imposed by any method other than by withholding from a payment on a Note by the Company or a paying agent. 

(8)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment or
other governmental charge that is imposed or withheld by reason of a change in law, regulation, or administrative or judicial interpretation that becomes effective more than 15 days after the payment becomes due or is duly provided for, whichever
occurs later. 
 (9)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax,
assessment or other governmental charge that is imposed or withheld by reason of the presentation by the beneficial owner of a Note for payment more than 30 days after the date on which such payment becomes due or is duly provided for, whichever
occurs later. 
 (10)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any:

 (a) estate tax; 
 (b)
inheritance tax; 
 (c) gift tax; 

(d) sales tax; 
 (e) excise tax;

 (f) transfer tax; 
 (g)
wealth tax; 
 (h) personal property tax; or 

(i) any similar tax, assessment, withholding, deduction or other governmental charge. 

(11)    Additional Amounts will not be payable if a payment on a Note is reduced as a result of any tax, assessment, or
other governmental charge required to be withheld by any paying agent from a payment of principal or interest on a Note if such payment can be made without such withholding by any other paying agent. 

(12)     Additional Amounts will not be payable if a payment on a Note is reduced as a result of any withholding,
deduction, tax, duty assessment or other governmental charge that would not have been imposed but for a failure by the holder or beneficial owner of a Note (or any financial institution through which the holder or beneficial owner holds the Note or
through which payment on the Note is made) to take any action (including entering into an agreement with the Internal Revenue Service, or a governmental authority of another jurisdiction if the holder is entitled to the benefits of an
intergovernmental agreement between that jurisdiction and the United States) or to comply with any applicable certification, documentation, information or other reporting requirement or agreement concerning accounts maintained by the holder or
beneficial owner (or any such financial institution), or concerning ownership of the holder or beneficial owner, or any substantially similar requirement or agreement. 

 (13)    Additional Amounts will not be payable if a payment on a Note is
reduced as a result of any combination of items (1) through (12) above. 
 Except as specifically provided herein, the Company will not
be required to make any payment of any tax, assessment or other governmental charge imposed by any government or a political subdivision or taxing authority of such government. 

As used in this Note, “United States person” means: 
  

	 	(a)	 any individual who is a citizen or resident of the United States; 

 

	 	(b)	 any corporation, partnership or other entity created or organized in or under the laws of the United States or
any political subdivision thereof; 

  

	 	(c)	 any estate if the income of such estate falls within the federal income tax jurisdiction of the United States
regardless of the source of such income; and 

  

	 	(d)	 any trust if (i) a United States court is able to exercise primary supervision over its administration and
one or more United States persons have the authority to control all of the substantial decisions of the trust; or (ii) it has a valid election in effect under applicable United States Treasury regulations to be treated as a United States
person. 

 Additionally, “non-United States person” means a person who
is not a United States person, and “United States” means the states of the United States of America and the District of Columbia, but excluding its territories and its possessions. 

Except as provided below, the Notes may not be redeemed prior to maturity. 

(1)    The Company may, at its option, redeem the Notes if: 

 

	 	(a)	 the Company becomes or will become obligated to pay Additional Amounts as described above;

  

	 	(b)	 the obligation to pay Additional Amounts arises as a result of any change in the laws, regulations or rulings
of the United States, or an official position regarding the application or interpretation of such laws, regulations or rulings, which change is announced or becomes effective on or after April 27, 2021; and 

 

	 	(c)	 the Company determines, in its business judgment, that the obligation to pay such Additional Amounts cannot be
avoided by the use of reasonable measures available to it, other than substituting the obligor under the Notes or taking any action that would entail a material cost to the Company. 

 

	 	(2)	 The Company may also redeem the Notes, at its option, if: 

 

	 	(a)	 any act is taken by a taxing authority of the United States on or after April 27, 2021 whether or not such
act is taken in relation to the Company or any subsidiary, that results in a substantial probability that the Company will or may be required to pay Additional Amounts as described above; 

	 	(b)	 the Company determines, in its business judgment, that the obligation to pay such Additional Amounts cannot be
avoided by the use of reasonable measures available to it, other than substituting the obligor under the Notes or taking any action that would entail a material cost to the Company; and 

 

	 	(c)	 the Company receives an opinion of independent counsel to the effect that an act taken by a taxing authority of
the United States results in a substantial probability that the Company will or may be required to pay the Additional Amounts described above, and delivers to the Trustee a certificate, signed by a duly authorized officer, stating that based on such
opinion the Company is entitled to redeem the Notes pursuant to their terms. 

 Any redemption of the Notes as set forth in clauses
(1) or (2) above shall be in whole, and not in part, and will be made at a redemption price equal to 100% of the principal amount of the Notes Outstanding plus accrued and unpaid interest thereon to the date of redemption. 

 

	 	(3)	 The Company may also redeem the Notes, at its option, in whole at any time or in part from time to time, on or
after November 4, 2021 (or, if additional notes are issued after May 4, 2021, beginning six months after the issue date of such additional notes) and prior to May 1, 2031, at a redemption price equal to the sum of (i) 100% of the
principal amount of the Notes being redeemed plus accrued and unpaid interest thereon to, but excluding the date of redemption; and (ii) the Make-Whole Amount, if any, with respect to such Notes. The Reinvestment Rate will equal the Treasury
Yield calculated to May 1, 2031, plus 0.150%. 

  

	 	•	 	 “Make-Whole Amount” means the excess, if any, of: (i) the aggregate present value as of the date
of such redemption of each dollar of principal being redeemed and the amount of interest (exclusive of interest accrued to the date of redemption) that would have been payable in respect of each such dollar if such redemption had not been made,
determined by discounting, on a semi-annual basis, such principal and interest at the Reinvestment Rate (as defined below) (determined on the third business day preceding the date that notice of such redemption is given) from the respective dates on
which such principal and interest would have been payable if such redemption had not been made, to the date of redemption, over (ii) the aggregate principal amount of the Notes being redeemed. 

 

	 	•	 	 “Reinvestment Rate” means the yield on Treasury securities at a constant maturity corresponding to the
remaining life (as of the date of redemption, and rounded to the nearest month) to May 1, 2031, of the principal being redeemed (the “Treasury Yield”), plus 0.150%. For purposes of the Notes, the Treasury Yield shall be equal to the
arithmetic mean of the yields published in the Statistical Release (as defined below) under the heading “Week Ending” for “U.S. Government Securities — Treasury Constant Maturities” with a maturity equal to such
remaining life; provided that if no published maturity exactly corresponds to such remaining life, then the Treasury Yield shall be interpolated or extrapolated on a straight-line basis from the arithmetic means of the yields for the next shortest
and next longest published maturities. For purposes of calculating the Reinvestment Rate, the most recent Statistical Release published prior to the date of determination of the Make-Whole Amount shall be used. If the format or content of the
Statistical Release changes in a manner that precludes determination of the Treasury Yield in the above manner, then the Treasury Yield shall be determined in the manner that most closely approximates the above manner, as reasonably determined by
the Company. 

	 	•	 	 “Statistical Release” means the statistical release designated “H.15(519)” or any successor
publication which is published weekly by the Federal Reserve and which reports yields on actively traded United States government securities adjusted to constant maturities or, if such statistical release is not published at the time of any
determination under the Indenture, then such other reasonably comparable index which shall be designated by the Company. 

  

	 	(4)	 The Company may also redeem the Notes, at its option, (i) in whole, but not in part, on May 1, 2031,
or (ii) in whole at any time or in part from time to time, on or after April 1, 2032 at a redemption price equal to 100% of the principal amount of the Notes being redeemed plus accrued and unpaid interest thereon to, but excluding, the
date of redemption. 

 Holders shall be given not less than 15 days’ nor more than 60 days’ prior notice by the Trustee of the
date fixed for such redemption described in (1) and (2) above. Holders shall be given not less than 5 days’ nor more than 30 days’ prior notice by the Trustee of the date fixed for such redemption described in (3) and (4) above.

 All terms used in this Note which are defined in the Indenture shall have the meanings assigned to them in the Indenture. The Notes are governed by the
laws of the State of New York. 

 Schedule 1 

Redemptions and Amount of Securities 
  

													
	 Date of
 partial

redemption
	  	Aggregate
principal amount
of Securities then
redeemed	 	  	Remaining
principal amount
of this Global
Security	 	  	Authorized Signatureexhibit102

 

 

 

 

 

 

 

 

 

 

 

 

 

 
1 
Form 3 
3/21 
 
 
Exhibit 
10.2 
FORM 
OF 
2021 
SPECIAL 
PANDEMIC 
RECOGNITION 
AWARD 

RESTRICTED 
STOCK
 
UNIT 
AGREEMENT 
PURSUANT 
TO 
THE
 
HENRY 
SCHEIN, 
INC. 
2020 
STOCK 
INCENTIVE 
PLAN 

(AS 
AMENDED 
AND 
RESTATED 
EFFECTIVE 
AS 
OF 
MAY 
21, 
2020) 

 
THIS AGREEMENT (the “Agreement”) is made as of [Grant 
Date] (the “Grant Date”), by and between Henry Schein, 
Inc. (the “Company”) and 
[Participant Name] (the “Participant”). Additional country-specific 
terms and conditions that govern the grant made hereunder 
are attached hereto on Annex 1, 
which terms and conditions are incorporated by reference 
herein and made a part of the Agreement. 
 
W 
I 
T 
N 
E 
S 
S 
E 
T 
H: 
WHEREAS
, the Company has adopted the Henry Schein, Inc. 
2020 Stock Incentive Plan (as amended and restated effective as 
of May 21, 2020), 
as amended from time to time (the “Plan”) (a copy 
of which is on file with the Company’s Corporate Human Resources Department and is available 
for 
Participant to review upon request at reasonable intervals 
as determined by the Company), which is administered 
by a Committee appointed by the Company’s 
Board of Directors (the “Committee”); 

WHEREAS,
 
pursuant to Section 9(d) of the Plan, the Committee may 
grant Restricted Stock Units to Key Employees under 
the Plan; 

WHEREAS
, the shares of the Company’s common stock are traded on the Nasdaq Stock 
Market under the symbol “HSIC”; and 
WHEREAS
, the Participant is a Key Employee of the Company 
or a Subsidiary. 
NOW, 
THEREFORE
, for and in consideration of the mutual promises herein 
contained, and for other good and valuable consideration, 
the receipt 
and sufficiency of which are hereby acknowledged, the parties agree 
as follows: 
1.
 
Grant 
of 
Restricted 
Stock 
Units
. 
Subject to the restrictions and other conditions set forth 
herein, in the Plan and Annex 1, the Committee has authorized 
this grant of [Shares 
Granted] Restricted Stock Units to the Participant on the Grant 
Date. 
2.
 
Vesting 
and 
Payment
. 
(a)
 
Except as set forth in Sections 2(c) and 2(d), fifty percent (50%) 
of the Restricted Stock Units shall vest on the first 
anniversary of the Grant Date, and fifty percent (50%) 
of the Restricted Stock Units shall vest on the second anniversary 
of the Grant Date (each, a “Scheduled 
Payment Date”); in each case, provided that the Participant 
has not had a Termination of Employment at any time prior to
 
the applicable Scheduled Payment 
Date. 
(b)
 
Except as set forth in Section 2(c), there shall be no 
proportionate or partial vesting in the periods prior to the vesting 
date 
and all vesting shall occur only on the vesting date; provided 
that no Termination of Employment has occurred prior to such date. 
(c)
 
The Restricted Stock Units shall vest on a pro-rated basis upon 
the Participant’s Retirement, unless otherwise provided 
expressly in a written agreement between the Participant and 
the Company (or a Subsidiary). 
For purposes of this Section 2(c), the Participant shall 
qualify for 
“Retirement” if (i) the Participant’s age (minimum 55) plus years of service with 
the Company and its Subsidiaries equal or exceed 70, (ii) 
the Participant has 
provided written notice of the Participant’s retirement to the Company at least 
30 days prior to the date of such retirement, and (iii) no Termination of 
Employment has occurred prior to the date of such retirement. 
For purposes of determining the age and service requirement 
under Section 2(c)(i), the 
Participant’s age and years of service shall be determined by the Participant’s most recent birthday and employment 
anniversary, respectively. 
For purposes of 
this Section 2(c), vesting on a pro-rated basis shall be calculated 
as the difference between (x) the product of (A) the number 
of Restricted Stock Units set forth 
under Section 1 and (B) a fraction, the numerator of which 
is the number of days from the Grant Date to the 
date of the Participant’s Retirement and the 
denominator of which is the number of days from the Grant 
Date to the second anniversary of the Grant Date, minus 
(y) the number of Restricted Stock Units 
that have previously 
vested as of the date of the Participant’s Retirement (if any). 

(d)
 
The Restricted Stock Units shall become fully vested 
on the earliest of (i) a Termination of Employment by the Company (or 
a Subsidiary) without Cause occurring within the 2-year 
period following a Change of Control, (ii) the Participant’s Disability and (iii) the Participant’s death; 
provided that no Termination of Employment has occurred prior to any such event, unless otherwise 
provided expressly in a written agreement between the 
Participant and the Company (or a Subsidiary). 
For purposes of this Agreement, “Cause” shall have 
the meaning set forth in Section 7(b) of the Plan, but shall 
also include any breach by Participant of any agreement 
with the Company or any of its Subsidiaries. 
For purposes of this Agreement, a “Change of Control” 
shall mean a Change of Control as defined in the Plan. 
For purposes of this Agreement, “Disability” shall mean 
the approval of, and receiving benefits for, 
long term disability by the disability insurance carrier under 
the Company’s (or if applicable, Subsidiary’s) long term disability plan. 

(e)
 
The Participant shall be entitled to receive one share of Common 
Stock with respect to one vested Restricted Stock Unit. 
The 
Participant shall be paid one share of Common Stock with respect 
to each vested Restricted Stock Unit within thirty (30) 
days of the Scheduled Payment Date; 
except that, in the event of (i) Retirement, (ii) a Termination of Employment by the Company 
(or a Subsidiary) without Cause occurring within the 
2-year 
period following a Change of Control, (iii) death or (iv) 
Disability, the Participant shall be paid within thirty (30) days of such Retirement, Termination of 
Employment, death or Disability, subject to Section 18 set forth in Annex 1 to the extent 
applicable, including with respect to a Participant who 
qualifies for 
Retirement at any time following the Grant Date. 

3.
 
Forfeiture 
and 
Recoupment. 
(a)
 
Subject to Section 2 above, all unvested Restricted Stock Units will 
be forfeited on the Participant’s Termination of 
Employment. 
(b)
 
Notwithstanding anything herein or in the Plan to the 
contrary, the grant of Restricted Stock Units (including any dividends 
credited thereupon) provided for under this Agreement is conditioned 
on the Participant not engaging in any Competitive Activity 
(as defined below) from the 
date that is twelve (12) months prior to the applicable settlement 
date set forth in Section 2(a) or Section 2(e) above, as 
applicable (such applicable settlement 
date, the “Payment Date”) through the first anniversary 
of such Payment Date. If, on or after the date that is 
twelve (12) months prior to the Payment Date but 
prior to the Payment Date, the Participant engages in 
a Competitive Activity, the Committee shall have the right, in its sole discretion, to cause 
the immediate 

 

 

 

 

 

 

 
2 
Form 3 
3/21 
 
 
forfeiture of all of the Restricted Stock Units (including any 
dividends credited thereupon) (whether or not vested) shall 
be immediately forfeited in their 
entirety, in which case the Participant shall have no further rights or interests with respect 
to such Restricted Stock Units (including any such 
dividends). 
In the 
event that the Participant engages in a Competitive Activity 
on or after the Payment Date but on or prior to the first anniversary 
of such Payment Date, the 
Company shall have the right to recoup from the Participant, 
and the Participant shall repay to the Company, within thirty (30) days following demand 
by the 
Company, a payment equal to the Fair Market Value of the aggregate shares of Common Stock payable in respect of such Restricted 
Stock Units (including 
any dividends credited thereupon) on the Payment Date (including 
any dividends or other distributions thereafter paid thereon); 
provided, that, the Company 
may require the Participant to satisfy such payment obligations 
hereunder either by forfeiting and returning to the Company such 
shares of Common Stock, 
Restricted Stock Units, dividends or any other Shares, 
or making a cash payment or any combination of these methods, 
as determined by the Company in its 
sole discretion. 
The Company and its Subsidiaries, in their sole 
discretion, shall have the right to set off (or cause to be set off) any amounts 
otherwise due to 
the Participant from the Company (or the applicable Subsidiary) 
in satisfaction of such repayment obligation, provided 
that any such amounts are exempt from, 
or set off in a manner intended to comply with, the requirements 
of any applicable law (including, without limitation, Section 
409A of the Code). 
(c)
 
The Participant hereby acknowledges and agrees that the forfeiture 
and recoupment conditions set forth in this Section 
3, in 
view of the nature of the business in which the Company 
and its affiliates are engaged, are reasonable in scope and necessary 
in order to protect the legitimate 
business interests of the Company and its affiliates, and that any violation 
thereof would result in irreparable harm to the Company and 
its affiliates. The 
Participant also acknowledges and agrees that (i) it is a material 
inducement and condition to the Company’s issuance of the Restricted Stock Units 
(including 
any dividends credited thereupon) that such Participant agrees 
to be bound by such forfeiture and recoupment conditions and, further, that the amounts 
required 
to be forfeited or repaid to the Company pursuant to forfeiture 
and recoupment conditions set forth above are reasonable, 
and (ii) nothing in this Agreement or 
the Plan is intended to preclude the Company (or any 
affiliate thereof) from seeking any remedies available at law, in equity, under contract to the Company or 
otherwise, and the Company (or any affiliate thereof) shall have 
the right to seek any such remedy with respect 
to the Restricted Stock Units, any dividends 
credited thereupon, or otherwise. 
(d)
 
For purposes of this Agreement, the Participant will be deemed 
to engage in a “Competitive Activity” if, either directly 
or 
indirectly, without the express prior written consent of the Company, the Participant (i) takes other employment 
with, renders services to, or otherwise engages 
in any business activities with, companies or other entities 
that are competitors of the Company or any of its affiliates, (ii) solicits 
or induces, or in any manner 
attempts to solicit or induce, any person employed by or otherwise 
providing services to the Company or any of its 
affiliates, to terminate such person’s 
employment or service relationship, as the case may be, with 
the Company or any of its affiliates, (iii) diverts, or 
attempts to divert, any person or entity from 
doing business with the Company or any of its affiliates or induces, 
or attempts to induce, any such person or entity from 
ceasing to be a customer or other 
business partner of the Company or any of its affiliates, (iv) violates 
any agreement between the Participant and the Company or any 
of its affiliates relating to 
the non-disclosure of proprietary or confidential information 
of the Company or any of its affiliates, and/or (v) conducts himself 
or herself in a manner 
adversely affecting the Company or any of its affiliates, including, without limitation, 
making false, misleading or negative statements, either 
orally or in 
writing, about the Company or any of its affiliates. The determination 
as to whether the Participant has engaged in a Competitive Activity 
shall be made by the 
Committee in its sole discretion. 
(e)
 
This Section 3(e) applies solely with respect to Participants 
who are members of the Company’s Executive Management 
Committee. 
Notwithstanding anything herein to the contrary, Participant agrees and acknowledges 
that the Restricted Stock Units awarded under this 
Agreement and the underlying shares shall be subject to the terms 
and conditions of the Company’s Incentive Compensation Recoupment Policy 
approved by 
the Board. 
Notwithstanding the foregoing, Participant agrees that 
incentive compensation, as defined under of the Dodd-Frank Wall Street Reform and 
Consumer Protection Act of 2010 and such regulations as 
are promulgated thereunder from time to time (“Dodd-Frank”), 
payable to Participant under this 
Agreement shall be subject to any clawback policy adopted 
or implemented by the Company in respect of Dodd-Frank, 
or in respect of any other applicable 
law or regulation. 
4.
 
Dividend 
Equivalents.
 
Cash dividends on Shares shall be credited to a 
dividend book entry account on behalf of the Participant with respect 
to 
each Restricted Stock Unit granted to a Participant, provided 
that such cash dividends shall not be deemed to be reinvested 
in Shares and will be held 
uninvested and without interest and paid in cash if and when the 
Restricted Stock Unit vests. 
Stock dividends on Shares shall be credited to a dividend 
book 
entry account on behalf of the Participant with respect to each 
Restricted Stock Unit granted to a Participant, provided 
that the Participant shall not be entitled 
to such dividend unless and until the Restricted Stock Unit vests. 
5.
 
Rights 
as 
a 
Stockholder
. 
The Participant shall have no rights as a stockholder with 
respect to any shares covered by any Restricted Stock 
Unit 
unless and until the Participant has become the holder 
of record of the shares, and no adjustments shall be made 
for dividends in cash or other property, 
distributions or other rights in respect of any such shares, 
except as otherwise specifically provided for in 
this Agreement or the Plan. 
6.
 
Withholding
. 
Participant shall pay, or make arrangements to pay, in a manner satisfactory to the Company, an amount equal to the amount of all 
applicable foreign, federal, state, provincial and local taxes that 
the Company is required to withhold at any time. 
In the absence of such arrangements, the 
Company or one of its Subsidiaries shall have the right to withhold 
such taxes from the Participant’s normal pay or other amounts payable to the Participant. 

In addition, any statutorily required withholding obligation may 
be satisfied, in whole or in part, at the Participant’s election, in the form 
and manner 
prescribed by the Committee, by delivery of shares of Common 
Stock (including shares issuable under this Agreement). 
7.
 
Provisions 
of 
Plan 
Control
. 
This Agreement is subject to all the terms, conditions 
and provisions of the Plan, including, without limitation, 
the 
amendment provisions thereof, and to such rules, regulations 
and interpretations relating to the Plan as may be 
adopted by the Committee and as may be in 
effect from time to time. 
The Plan is incorporated herein by reference. 
Capitalized terms in this Agreement that are not otherwise 
defined shall have the same 
meaning as set forth in the Plan. 
Subject to Section 3, if and to the extent that this Agreement 
conflicts or is inconsistent with the terms, conditions 
and 
provisions of the Plan, the Plan shall control, and this Agreement 
shall be deemed to be modified accordingly. 
This Agreement contains the entire 
understanding of the parties with respect to the subject matter 
hereof and supersedes any prior agreements between the 
Company and the Participant with 
respect to the subject matter hereof. 

8.
 
Amendment.
 
To the extent applicable, the Board or the Committee may at any time and from time 
to time amend, in whole or in part, any or all of 
the provisions of this Agreement to comply with any applicable 
laws and stock exchange rules and regulations (including, 
without limitation, Section 409A of 
the Code and the regulations thereunder) and may also amend, 
suspend or terminate this Agreement subject to the 
terms of the Plan. 
Except as otherwise 
provided in the Plan, no modification or waiver of any of 
the provisions of this Agreement shall be effective unless in writing 
and signed by the party against 
whom it is sought to be enforced. 

9.
 
Notices.
 
Any notice or communication given hereunder shall be in writing 
and shall be deemed to have been duly given when delivered in 
person, 
or by regular United States mail or similar foreign mail 
or post, first class and prepaid, to the appropriate party 
at the address set forth below (or such other 
address as the party shall from time to time specify): 

If to the Company, to: 

 

 

 

 

 

 

 

 
3 
Form 3 
3/21 
 
 
Henry Schein, Inc. 
135 Duryea Road 
Melville, New York 
11747 
Attention: 
General Counsel 
If to the Participant, to the address on file with the Company. 
10.
 
 
No 
Obligation 
to 
Continue 
Employment 
or 
Services
. 
This Agreement is not an agreement of employment, 
consultancy or directorship. 
This 
Agreement does not guarantee that the Company or its Subsidiaries 
will employ or retain, or continue to employ or retain, 
the Participant during the entire, or 
any portion of the, term of this Agreement, including 
but not limited to any period during which any Restricted Stock 
Unit is outstanding, nor does it modify in 
any respect the Company or its Subsidiaries’ right to terminate 
or modify the Participant’s employment, service relationship or compensation. 

11.
 
 
Legend
. 
The Company may at any time place legends referencing any 
applicable federal, state or foreign securities law restrictions on all 
certificates representing Shares issued pursuant to this Agreement. 
The Participant shall, at the request of the Company, promptly present to the Company any 
and all certificates representing Shares acquired pursuant 
to this Agreement in the possession of the Participant 
in order to carry out the provisions of this 
Section. 
12.
 
 
Securities 
Representations
. 
The grant of the Restricted Stock Units and issuance of Shares 
upon vesting of the Restricted Stock Units shall be 
subject to, and in compliance with, all applicable requirements 
of federal, state or foreign securities law. 
No Shares may be 
issued hereunder if the issuance of 
such Shares would constitute a violation of any applicable federal, 
state or foreign securities laws or other law or regulations 
or the requirements of any stock 
exchange or market system upon which the Shares may 
then be listed. 
As a condition to the settlement of the Restricted Stock 
Units, the Company may 
require the Participant to satisfy any qualifications that may 
be necessary or appropriate, to evidence compliance with any 
applicable law or regulation. 
 
The Shares are being issued to the Participant and this Agreement 
is being made by the Company in reliance upon the following 
express 
representations and warranties of the Participant. 
The Participant acknowledges, represents and warrants 
that: 
(a)
 
He or she has been advised that he or she may be an “affiliate” within 
the meaning of Rule 144 under the Securities Act 
of 
1933, as amended (the “Act”) and in this connection the Company 
is relying in part on his or her representations set forth in 
this section. 
(b)
 
If he or she is deemed an affiliate within the meaning of Rule 
144 of the Act, the Shares must be held indefinitely 
unless an 
exemption from any applicable resale restrictions is available 
or the Company files an additional registration statement 
(or a “re-offer prospectus”) with regard 
to such Shares and the Company is under no obligation to register 
the Shares (or to file a “re-offer prospectus”). 
(c)
 
If he or she is deemed an affiliate within the meaning of Rule 
144 of the Act, he or she understands that the exemption from 
registration under Rule 144 will not be available unless (i) 
a public trading market then exists for the Common Stock 
of the Company, (ii) adequate information 
concerning the Company is then available to the public, and 
(iii) other terms and conditions of Rule 144 or any exemption 
therefrom are complied with; and 
that any sale of the Shares may be made only in limited 
amounts in accordance with such terms and conditions. 
13.
 
 
Transfer 
of 
Personal 
Data.
 
The Participant authorizes, agrees and unambiguously 
consents to the transmission and processing by the Company 
(or any Subsidiary) of any personal data information related 
to Restricted Stock Units awarded under this Agreement, 
for legitimate business purposes 
(including, without limitation, the administration of the Plan) 
out of the Participant’s home country and including to countries with less data protection 
laws 
than the data protection laws provided by the Participant’s home country. 
This authorization/consent is freely given by the Participant. 
14.
 
 
Delivery 
Delay.
 
The delivery of any certificate representing the Common 
Stock may be postponed by the Company for such period as 
may be 
required for it to comply with any applicable foreign, 
federal, state or provincial securities law, or any national securities 
exchange listing requirements and the 
Company is not obligated to issue or deliver any securities 
if, in the opinion of counsel for the Company, the issuance of such Shares shall constitute 
a 
violation by the Participant or the Company of any provisions 
of any applicable foreign, federal, state or provincial law 
or of any regulations of any 
governmental authority or any national securities exchange. 
The Participant acknowledges and understands that 
the Company intends to meet its delivery 
obligations in Common Stock with respect to Restricted Stock 
Units, except as may be prohibited by law or described 
in this Agreement, the Plan or 
supplementary materials.
 
15.
 
 
Miscellaneous.
 
This Agreement shall inure to the benefit of and be binding 
upon the parties hereto and their respective heirs, legal representatives, 
successors and 
assigns. 
(a)
 
This Agreement shall be governed and construed in accordance 
with the laws of New York (regardless of the law that might 
otherwise govern under applicable New York principles of conflict of laws). 
(b)
 
This Agreement may be executed in one or more counterparts, 
all of which taken together shall constitute one contract. 
(c)
 
The failure of any party hereto at any time to require performance 
by another party of any provision of this Agreement shall 
not affect the right of such party to require performance of that 
provision, and any waiver by any party of any breach of 
any provision of this Agreement shall 
not be construed as a waiver of any continuing or succeeding 
breach of such provision, a waiver of the provision itself, 
or a waiver of any right under this 
Agreement. 
(d)
 
This Agreement and the Plan do not create a joint venture 
or partnership between the Company and any Subsidiary. 

(e)
 
Notwithstanding any provisions in this Agreement, this 
grant of Restricted Stock Units shall be subject to any additional 
country-specific terms and conditions set forth in Annex 1 to 
the Agreement for the Participant’s country to the extent applicable. Moreover, if Participant 
relocates to one of the countries included in Annex 1, the additional 
country-specific terms and conditions for such country, if any, will apply to Participant to 
the extent that the Company determines that the application 
of such terms and conditions is necessary or advisable for legal 
or administrative reasons. 
16.
 
 
ACQUIRED 
RIGHTS
. 
THE PARTICIPANT 
ACKNOWLEDGES AND AGREES THAT: (A) THE COMPANY MAY 
TERMINATE OR 
AMEND THE PLAN AT ANY TIME; (B) THE AWARD 
OF RESTRICTED STOCK UNITS MADE UNDER THIS 
AGREEMENT IS COMPLETELY 
INDEPENDENT OF ANY OTHER AWARD OR GRANT AND IS MADE AT THE SOLE DISCRETION OF THE COMPANY; 
AND (C) NO PAST 
GRANTS OR AWARDS 
(INCLUDING, WITHOUT LIMITATION, THE RESTRICTED STOCK UNITS AWARDED 
HEREUNDER) GIVE THE 
PARTICIPANT 
ANY RIGHT TO ANY GRANTS OR AWARDS IN THE FUTURE WHATSOEVER. 

 

 

 

 

 

 

 
4 
Form 3 
3/21 
 
 
IN 
WITNESS 
WHEREOF
, the parties hereto have executed this Agreement as of 
the day and year first set forth above. 
HENRY 
SCHEIN, 
INC. 
 
___________________________ 
Michael S. Ettinger 
Senior Vice President, Corporate & Legal Affairs and Chief of Staff
 
 
 
PARTICIPANT 
 
[Electronic Signature]
 
 
 
 
 
 
 
[Participant Name]
 
 
 
 
[Acceptance Date] 
ANNEX 
1 
Additional 
Country 
Specific 
Terms 
and 
Conditions 

for 
the 
Restricted 
Stock 
Unit 
Agreement 
 

This Annex 1 includes additional terms and conditions that govern 
the Restricted Stock Units granted to the Participant 
under the Plan if the 
Participant works or resides in, or is otherwise subject to 
the taxes imposed by, one of the countries listed below. This Annex 1 also includes other information 
that may impact the Participant’s participation in the Plan. Certain capitalized terms 
used but not defined in this Annex 1 have the meanings set forth 
in the 
Plan and/or the Agreement. This Annex 1 forms part 
of the Agreement and should be read in conjunction with 
the Agreement and the Plan. 
 
The Participant agrees to sign any additional agreements 
or undertakings that may be necessary or advisable in order 
to comply with applicable law 
or facilitate the administration of the Plan. Furthermore, 
the Participant acknowledges that the applicable law of the 
country in which the Participant is subject 
to taxes or is residing or working at the time of grant or 
vesting of the Restricted Stock Units or the sale 
of shares of Common Stock received pursuant to the 
Restricted Stock Units (including any rules or regulations 
governing securities, foreign exchange, tax, labor, employment, or other matters) 
may restrict or 
prevent the issuance of shares of Common Stock or subject the Participant 
to additional terms and conditions or procedural or regulatory 
requirements that the 
Participant is or will be solely responsible for and must 
fulfill. Such requirements may be outlined in but are 
not limited to items listed below in this Annex 1. 

 
If the Participant is a citizen or resident of a country other 
than the country in which he or she is subject to 
taxes or is residing and/or working, or if 
the Participant transfers employment or residency after the Restricted 
Stock Units are granted to him or her, the information contained in this Annex 
1 may not 
be applicable to the Participant. Tax laws are often complex and outcomes can vary 
depending on individual circumstances. Accordingly, the Participant is 
advised to seek appropriate professional advice as to 
how tax and other relevant laws in the applicable country may 
apply to his or her situation. 
 
 
UNITED STATES 
 
The second to last sentence of Section 2(d) of Agreement 
is hereby deleted in its entirety and replaced with the following: 
“For the purposes of this Agreement, a “Change of Control” 
shall mean the occurrence of a Section 409A Change 
of Control (as defined in Section 
17).” 
 
As of the Grant Date, if the Participant either (i) qualifies 
for Retirement (as defined in Section 2(c) of the Agreement) 
or (ii) may become eligible to qualify 
for Retirement prior to the Scheduled Payment Date, Section 
4 of the Agreement is hereby deleted in its entirety and replaced 
with the following: 
 
 
“Dividend Equivalents. 
Cash dividends on Shares shall be credited to a 
dividend book entry account on behalf of the Participant with 
respect to 
each Restricted Stock Unit granted to the Participant, provided 
that such cash dividends shall not be deemed to be reinvested 
in Shares and will be held 
uninvested and without interest. 
The Participant’s right to receive any such cash dividends shall vest if 
and when the related Restricted Stock Unit vests, and 
such cash dividends shall be paid in cash to the Participant if and 
when the related Restricted Stock Unit is paid to the 
Participant. 
Stock dividends on Shares 
shall be credited to a dividend book entry account on behalf 
of the Participant with respect to each Restricted Stock Unit 
granted to the Participant. 
The 
Participant’s right to receive any such stock dividends shall vest if and when the 
related Restricted Stock Unit vests, and such stock dividends 
shall be paid in 
stock to the Participant if and when the related Restricted Stock 
Unit is paid to the Participant.” 
 
The following shall be added to the Agreement as a new Section 
17: 
 
“Change of Control Defined.
 

For purposes of this Agreement, a “Section 409A 
Change of Control” shall be deemed to have occurred upon: 

 
(i) an acquisition by any Person of beneficial ownership (within 
the meaning of Rule 13d-3 promulgated under the Act) of (A) 
50% or more of the 
then outstanding Shares or (B) 33% or more of the total combined 
voting power of the then outstanding voting securities of HSI 
entitled to vote 
generally in the election of directors (the “Outstanding HSI 
Voting 
Securities”); excluding, however, the following: (w) any acquisition directly 
from the Company, other than an acquisition by virtue of the exercise of a conversion privilege 
unless the security being so converted was itself 
acquired directly from the Company, (x) any acquisition by the Company, (y) any acquisition by an employee benefit 
plan (or related trust) 
sponsored or maintained by the Company or (z) any acquisition 
by any corporation pursuant to a reorganization, merger, consolidation or similar 
corporate transaction (in each case, a “Corporate Transaction”), if, pursuant 
to such Corporate Transaction, the conditions described in clauses (A), 
(B) and (C) of paragraph (iii) below are satisfied; or 
 

(ii) within any 12-month period beginning on or after the date 
of the Agreement, the individuals who constitute the Board immediately 
before the 
beginning of such period (the Board as of the date hereof shall 
be hereinafter referred to as the “Incumbent Board”) 
cease for any reason to 

 

 
5 
Form 3 
3/21 
 
 
constitute at least a majority of the Board; provided that for 
purposes of this Subsection any individual who becomes a 
member of the Board 
subsequent to the date hereof whose election, or nomination 
for election by HSI’s stockholders, was approved by a vote of at least a majority of 
those individuals who are members of the Board and who are 
also members of the Incumbent Board (or deemed to 
be such pursuant to this proviso) 
shall be considered as though such individual were a member 
of the Incumbent Board; but, provided further, that any such individual whose 
initial 
assumption of office occurs as a result of either an actual or threatened 
election contest (as such terms are used in Rule 14a-11 of Regulation 14A 
promulgated under the Act) or other actual or threatened solicitation 
of proxies or consents by or on behalf of a Person other than 
the Board shall 
not be so considered as a member of the Incumbent Board; 
or 
 
(iii) the consummation of a Corporate Transaction or, if consummation of such Corporate Transaction is subject 
to the consent of any government 
or governmental agency, the obtaining of such consent (either explicitly or implicitly by consummation); 
excluding, however, such a Corporate 
Transaction pursuant to which (A) all or substantially all of the individuals 
and entities who are the beneficial owners, respectively, of the 
outstanding Shares and Outstanding HSI Voting Securities immediately prior to such Corporate Transaction will beneficially 
own, directly or 
indirectly, more than 60% of, respectively, the outstanding shares of common stock of the corporation resulting from 
such Corporate Transaction 
and the combined voting power of the outstanding voting securities 
of such corporation entitled to vote generally in the election of directors, 
in 
substantially the same proportions as their ownership, immediately 
prior to such Corporate Transaction, of the outstanding Shares and Outstanding 
HSI Voting Securities, as the case may be, (B) no Person (other than the Company, any employee benefit plan (or related trust) of the Company or 
the corporation resulting from such Corporate Transaction and any Person 
beneficially owning, immediately prior to such Corporate Transaction, 
directly or indirectly, 33% or more of the outstanding Shares or Outstanding HSI 
Voting 
Securities, as the case may be, will beneficially own, 
directly or indirectly, 33% or more of, respectively, the outstanding shares of common stock of the corporation resulting 
from such Corporate 
Transaction or the combined voting power of the then outstanding securities 
of such corporation entitled to vote generally in the election 
of 
directors and (C) individuals who were members of the Incumbent 
Board will constitute at least a majority of the members 
of the board of directors 
of the corporation resulting from such Corporate Transaction; or 
 
(iv) the sale or other disposition of all or substantially all 
of the assets of the Company; excluding, however, such sale or other 
disposition to a 
corporation with respect to which, following such sale or 
other disposition, (x) more than 60% of, respectively, the then outstanding shares of 
common stock of such corporation and the combined 
voting power of the then outstanding voting securities 
of such corporation entitled to vote 
generally in the election of directors will be then beneficially 
owned, directly or indirectly, by all or substantially all of the individuals and entities 
who were the beneficial owners, respectively, of the outstanding 
Common Stock and Outstanding HSI Voting Securities immediately prior to such 
sale or other disposition in substantially the same proportion 
as their ownership, immediately prior to such sale or 
other disposition, of the 
outstanding Common Stock and Outstanding HSI Voting Securities, as the case may be, (y) no Person (other than 
the Company and any employee 
benefit plan (or related trust) of the Company or such corporation 
and any Person beneficially owning, immediately prior to such 
sale or other 
disposition, directly or indirectly, 33% or more of the outstanding Common Stock or Outstanding 
HSI Voting Securities, as the case may be) will 
beneficially own, directly or indirectly, 33% or more of, respectively, the then outstanding shares of common stock 
of such corporation and the 
combined voting power of the then outstanding voting securities 
of such corporation entitled to vote generally in the election 
of directors and (z) 
individuals who were members of the Incumbent Board will 
constitute at least a majority of the members of the board 
of directors of such 
corporation. 
 
(v) No event set forth herein shall constitute a “Section 
409A Change of Control” unless such event also qualifies 
as a “change in control event” for 
purposes of Treasury Regulation § 1.409A-3(i)(5). 
Accordingly, the definition of “Section 409A Change of Control” set forth herein shall 
be 
limited, construed and interpreted in accordance with Section 
409A and the regulations issued thereunder.” 
 
The following shall be added to the Agreement as a new Section 
18: 
 
 
“Section 409A.
 

This Agreement is subject to Section 16(i) of the 
Plan, and any provisions in this Agreement providing 
for the payment of 
“nonqualified deferred compensation” (as defined in Section 
409A of the Code and the Treasury regulations thereunder) to the Participant 
are intended to 
comply with, or be exempt from, the requirements of Section 
409A of the Code, and this Agreement shall be interpreted in 
accordance therewith. 
Neither 
party individually or in combination may accelerate or defer the 
timing of the payment of any such nonqualified deferred 
compensation, except in compliance 
with Section 409A of the Code and this Agreement, and no amount 
shall be paid prior to the earliest date on which 
it is permitted to be paid under Section 
409A of the Code and this Agreement. 
In no event whatsoever shall the Company be liable 
for any additional tax, interest or penalty that may be imposed 
on 
the Participant as a result of Section 409A of the Code or 
any damages for failing to comply with Section 409A 
of the Code. 
A Termination of Employment or 
Retirement shall not be deemed to have occurred for 
purposes of any provision of this Agreement providing for 
the payment of any amounts or benefits subject 
to Section 409A of the Code upon or following a Termination of Employment or Retirement, 
as applicable, unless such Termination of Employment or 
Retirement, as applicable, is also a “separation from service” 
within the meaning of Section 409A of the Code and, for 
purposes of any such provision of this 
Agreement, references to a “termination,” “termination of employment” 
or like terms shall mean “separation from service.” If 
the Participant is a “specified 
employee,” upon his or her “separation from service” (as defined 
under Section 409A of the Code under such definitions 
and procedures as established by the 
Company in accordance with Section 409A of the Code), any 
portion of a payment, settlement, or other distribution made 
upon such a “separation from 
service” that would cause the acceleration of, or an addition 
to, any taxes pursuant to Section 409A of the Code will 
not commence or be paid until a date that 
is six (6) months and one (1) day following the applicable 
“separation from service.” Any payments, settlements, 
or other distributions that are delayed 
pursuant to this Section 18 following the applicable “separation 
from service” shall be accumulated and paid to the Participant 
in a lump sum without interest 
on the first business day immediately following the required 
delay period. 
Any amounts payable hereunder that satisfy the short-term deferral 
exception in 
Treas. Reg. §1.409A-1(b)(4) shall not be subject to Section 409A of the Code. 
Whenever a payment under this Agreement may be 
paid within a specified 
period, the actual date of payment within the specified period shall 
be within the Company’s sole discretion.”

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