Document:

Change of Control Plan - marked  (M0711229.PDF;1)

 Exhibit 10.1
 

 IMPLANT SCIENCES CORPORATION 
 AMENDED AND RESTATED CHANGE OF CONTROL PAYMENT PLAN
 

 ARTICLE 1
 Purpose
 

 1.1
 The purposes of the Plan are 
 (a)
 to keep certain key employees and directors focused on the interests of the Company's shareholders and to secure their continued services in addition to their undivided dedication and objectivity in the event of any threat or occurrence of, or negotiation or other action that could lead to the possibility of, a Change of Control; and
 (b)
 to ensure that Participants who are employed by the Company and or its Affiliates do not (i) solicit or assist in the solicitation of employees of the Company or any affiliate for a specified period, or (ii) disclose any confidential or proprietary information of the Company or any affiliate prior to or after a Change of Control.
 1.2
 This Plan amends and restates in its entirety the Implant Sciences Corporation Change of Control Payment Plan adopted by the Board on September 7, 2012.
 

 ARTICLE 2
 Definitions
 

 The following capitalized terms used in the Plan have the respective meanings set forth in this Article:
 

 2.1
 Affiliate: shall have the meaning given to such term in Rule 12b-2 of the General Rules and Regulations of the Securities Exchange Act of 1934, as amended.
 2.2
 At-Risk Options: The options to purchase shares of capital stock of the Company identified on Appendix A hereto (but no other options).
 2.3
 Beneficiary:  The beneficiary or beneficiaries (including any contingent beneficiary or beneficiaries) of a Participant determined in accordance with the provisions of Article 6 hereof. 
 2.4
 Board: The Board of Directors of Implant Sciences Corporation or any successor entity thereto.
 

 
 
 2.5
 Change of Control: The occurrence of any one of the following events:
 (a)
 a merger or consolidation in which: 
 (i)
 the Company is a constituent party or 
 (ii)
 more than fifty percent (50%) owned subsidiary of the Company, measured by the total fair market value and the total voting power of the outstanding shares of the capital stock of such subsidiary (a “Controlled Subsidiary”) is a constituent party,
 where any one Person, or more than one Person Acting as a Group, other than Excluded Person(s), acquires ownership of the stock of the Company or Controlled Subsidiary that, together with the stock then held by such Person or Group, constitutes more than fifty percent (50%) of the total fair market value or total voting power of the stock of the Company or Controlled Subsidiary (determined on a fully diluted basis assuming the exercise, conversion or exchange of all exercisable, convertible or exchangeable securities, respectively).  However, if any one Person or more than one Person Acting as a Group is considered to own more than fifty percent (50%) of the total fair market value or total voting power of the stock of the Company, the acquisition of additional stock by the same Person or Persons is not considered to cause a Change of Control.
 (b)
 the sale, lease, transfer, exclusive license or other disposition by the Company or any subsidiary of the Company of all or substantially all the assets of the Company and its subsidiaries taken as a whole to any one Person, or more than one Person Acting as a Group, other than Excluded Person(s), in a single transaction or in a series of related transactions during the twelve (12) month period ending on the date of the most recent disposition to such Person or Persons, except where such sale, lease, transfer, exclusive license or other disposition is to a wholly owned subsidiary of the Company; or 
 

 (c)
 the sale, exchange or transfer to any one Person, or more than one Person Acting as a Group, other than Excluded Person(s), in a single transaction or in a series of related transactions during the twelve (12) month period ending on the date of the most recent transfer to such Person or Persons, of at least a majority, by voting power (determined on a fully diluted basis, assuming the exercise, conversion or exchange of all exercisable, convertible or exchangeable securities, respectively), of the outstanding shares of capital stock of the Company.
 For purposes of this Section 2.5:
 The term Excluded Person(s) means (A) the Company or any Affiliate; (B) a trustee or other fiduciary holding securities under an employee benefit plan of the Company or any Affiliate; (C) an underwriter temporarily holding securities pursuant to an offering of such securities; or (D) an entity owned, directly or indirectly, by the shareholders of the Company in substantially the same proportions as their ownership of stock in the Company. 
 The term Person shall mean an individual, a partnership, a joint venture, a corporation, a limited liability company, a trust, an unincorporated organization or other entity.  
 

 2
 

 
 Persons will be considered as Acting as a Group if they are owners of an entity that enters into a merger, consolidation, purchase or acquisition of assets, purchase or acquisition of stock, or similar business transaction with the Company or a Controlled Subsidiary.  If a Person, including an entity shareholder, owns an interest in both the Company and the other entity that enters into a merger, consolidation, purchase or acquisition of assets, purchase or acquisition of stock, or similar transaction, such Person is considered to be Acting as a Group with other shareholders in the Company only with respect to the ownership in the Company prior to the transaction giving rise to the change and not with respect to the ownership interest in the other entity.
 The term Change of Control as defined above is intended to comply with Code Section 409A and the regulations promulgated thereunder.
 2.6
 Change of Control Payment: The dollar amount payable pursuant to the provisions of this Plan to each Participant hereunder, which shall equal, in the case of each eligible Participant, (a) the product of  (i) the Net Proceeds of a Change of Control, multiplied by (ii) the applicable percentage as set forth on  Appendix B hereto, reduced, but not below zero, by (b) any portion of the Net Proceeds or any other consideration which are payable to such Participant with respect to the At-Risk Options or with respect to shares of capital stock of the Company acquired upon the exercise of the At-Risk Options. For purposes of the foregoing, and except as set forth in Section 4.3, the percentage applicable to each Participant shall be as set forth in Column A of Appendix B.
 2.7
 Code:  The Internal Revenue Code of 1986, as amended from time to time.
 2.8
 Committee: The Compensation Committee of the Board or such other committee or persons designated by the Board.
 2.9
 Company: Implant Sciences Corporation or any successor entity thereto, including without limitation, the transferee of all or substantially all of the stock or assets of the Company.
 2.10
 Effective Date:  The date on which the Plan becomes effective as set forth in Section 3.1 hereof.
 

 3
 

 
 
 2.11
 Net Proceeds: The aggregate consideration paid in connection with a Change of Control, after payment (i) all secured indebtedness of the Company, and any controlled subsidiary, together with all accrued but unpaid interest thereon and all other obligations related thereto, including without limitation all indebtedness owed to DMRJ Group, LLC and to the holders of promissory notes issued pursuant to that certain Note Purchase Agreement dated as of March 19, 2014 between the Company and certain other parties thereto, and (ii) of all other obligations and liabilities of the Company and any Controlled Subsidiary. Net Proceeds shall be deemed to include (i) any consideration to be paid to the Company, any Controlled Subsidiary, or the Company’s stockholders (as the case may be) that is to be held in escrow and (ii) any consideration to be paid to the Company, any Controlled Subsidiary, or the Company’s stockholders (as the case may be) that is based on the future outcome or performance of the Company or any Controlled Subsidiary in the form of an earn-out according to the terms of the Change of Control. Upon any release from escrow and/or any payment of an earn-out, the Company shall make the Change of Control Payments attributable to such amounts upon the same payment schedule and under the same terms and conditions as apply to the corresponding payments to the Company, any Controlled Subsidiary, or the Company’s stockholders (as the case may be) and in compliance with Section 409A of the Code. 
 2.12
 Participant: Any individual specified on Appendix B attached hereto in accordance with Article 4 hereof, and who, if he or she is an employee of the Company or any of its Affiliates, has entered into a non-solicitation agreement in the form and substance set forth on Appendix C hereto.
 2.13
 Plan: This Implant Sciences Amended and Restated Change of Control Payment Plan, as from time to time amended.
 2.14
 Termination of Board Membership:  With respect to a Participant, the date on which a Participant ceases to be a member of the Board.
 2.15
 Termination for Cause: The termination by the Company or any Affiliate of any Participant’s employment with the Company or any Affiliate for any of the following reasons:
 (a)
 the Participant’s conviction or entry of nolo contendere to any felony or a crime involving moral turpitude, fraud or embezzlement of the property of the Company or any Affiliate; or
 (b)
 the Participant’s dishonesty, gross negligence or gross misconduct that is materially injurious to the Company or any Affiliate or material breach of his duties to the Company or any Affiliate, which has not been cured by the Participant within 10 days (or longer period as is reasonably required to cure such breach, negligence or misconduct) after he shall have received written notice from the Company or such Affiliate stating with reasonable specificity the nature of such breach; or
 (c)
 the Participant’s illegal use or abuse of drugs, alcohol, or other related substances that is materially injurious to the Company or any Affiliate.
 2.16
 Termination without Cause: Any termination by the Company or any Affiliate of any Participant’s employment by the Company or any Affiliate other than a Termination for Cause.
 

 4
 

 
 
 2.17
 Resignation for Good Reason: The voluntary resignation of any Participant’s employment with the Company or any Affiliate for any of the following reasons:
 (a) 
 a “material diminution” (as such term is used in Section 409A of the Code) of the duties assigned to Participant; or
 (b) 
 a material reduction in the Participant’s base salary or other benefits (other than a reduction or change in benefits generally applicable to all executive employees of the Company and its Affiliates); or 
 (c) 
 relocation by the Company or any Affiliate of any Participant who is an employee of the Company to an office more than 50 miles outside the Participant’s current workplace. 
 Notwithstanding the occurrence of any of the events enumerated in this Section 2.17, resignation by any Participant shall be not deemed to be a Resignation for Good Reason unless (i) the Participant reports the event or condition to the Board, in writing, within 45 days of such event or condition occurring and (ii) within 30 days after the Participant provides such written notice, the Company or the appropriate Affiliate has failed to fully correct such matter and to make the Participant whole for any such losses.
 2.18
 Resignation without Good Reason: Any voluntary resignation of any Participant’s employment with the Company or an Affiliate other than a Resignation for Good Reason.
 ARTICLE 3
 Plan Term and Amendment
 

 3.1
 Effective Date:  The Plan shall be effective as of February 26, 2015.  
 3.2
 Termination and Amendment
 (a)
 Termination:  Subject to the provisions of Section 3.2(c) hereof, the Board or Committee may terminate the Plan effective on the date on which the notice requirement of Section 3.3 hereof has been satisfied.
 (b)
 Amendments:  Subject to Section 3.2(c) hereof, the Board or Committee may at any time, and from time to time, amend the Plan in any respect it deems appropriate or desirable effective on written notice to the Participants.
 (c)
 Termination and or Amendments Impacting Rights/Obligations of Participants: Notwithstanding Sections 3.2(a) and (b), any termination or amendment to the Plan that imposes additional obligations on, or impairs the rights of, a Participant hereunder shall not be effective without the Participant’s written consent. Additionally, any termination or amendment of the Plan shall not be effective until the date on which the notice requirement set forth in Section 3.3 hereof has been satisfied. 
 

 5
 

 
 3.3        Notice: The notice requirement of this Section shall be satisfied upon the expiration of a thirty-                  day written notice to all Participants from the Committee of its desire to terminate or amend the                  Plan.
 

 ARTICLE 4
 Eligibility and Termination
 

 4.1
 General:  The Board shall designate each individual who shall be a Participant in this Plan and the Change of Control Payment to be paid to the Participant in accordance with the provisions of this Plan. Each Participant and such Participant’s respective percentages of the Net Proceeds of any Change of Payment shall be listed on Appendix B.
 4.2
 Termination for Cause; Resignation without Good Reason: Except as otherwise determined by the Board in its sole discretion, all of the rights of a Participant under this Plan, including the eligibility of a Participant or his or her Beneficiary to receive a Change of Control Payment in accordance with the provisions of this Plan, shall immediately terminate upon such Participant’s Termination for Cause or Resignation without Good Reason.
 4.3
 Termination without Cause; Resignation for Good Reason: A Participant’s Termination without Cause or Resignation for Good Reason prior to or after a Change of Control shall not affect the eligibility of such Participant or his or her Beneficiary to receive a Change of Control Payment in accordance with the provisions of this Plan; provided, however, that, (x) in the event of a Participant’s Termination without Cause or Resignation for Good Reason after the Effective Date but on or before June 30, 2015, then, for purposes of the definition of Change of Control Payment, the percentage applicable to such Participant shall be as set forth in Column B of Appendix B; and (y) in the event of a Participant’s Termination without Cause or Resignation for Good Reason after June 30, 2015 but on or before December 31, 2015, the percentage applicable to such Participant shall be as set forth in Column C of Appendix B.
 4.4
 Termination of Board Membership:  A Participant’s Termination of Board Membership prior to or after a Change of Control shall not affect the eligibility of a Participant or his or her Beneficiary to receive a Change of Control Payment in accordance with the provisions of this Plan.
 4.5
 Death: A Participant’s death prior to or after a Change of Control shall not affect the eligibility of the Participant’s Beneficiary to receive a Change of Control Payment in accordance with the provisions of this Plan.
 

 6
 

 
 ARTICLE 5
 Payments
 

 5.1
 General:  In the event of a Change of Control, the Company shall distribute the Change of Control Payments to the Participants and their Beneficiaries subject to the provisions of this Article 5.
 5.2
 Lump-Sum Benefits:  Except as otherwise provided in Section 2.11, the Company shall pay each Participant (or the Participant’s Beneficiary), a lump-sum cash amount equal to the Participant’s Change of Control Payment not later than thirty (30) days after the receipt of the Net Proceeds.
 5.3
 Death Benefit: If a Participant shall die prior to receiving the Change of Control Payment provided for in Sections 5.1. Except as otherwise provided in Section 2.11, the Company shall pay the Participant’s Beneficiary, a lump-sum cash amount equal to the Participant’s Change of Control Payment not later than thirty (30) days after the receipt of the Net Proceeds.
 5.4
 Facility of Payment: If any person entitled to a distribution under the Plan is deemed by the Committee to be incapable of personally receiving such payment, then, unless and until claim therefor shall have been made by a duly appointed guardian or other legal representative of such person, the Committee may provide for such payment or any part thereof to be made to any other person or institution then contributing toward or providing for the care and maintenance of such person. Any such payment shall be a payment for the account of such person and a complete discharge of any liability of the Company and the Plan therefor.
 ARTICLE 6
 Beneficiary(ies)
 

 6.1
 Beneficiary Designation: Each Participant may, at any time, designate one or more Beneficiaries to receive the Participant’s Change of Control Payment in the event of the Participant’s death. A Participant may make an initial Beneficiary designation, or change an existing Beneficiary designation without the consent of the previously designated Beneficiary, by completing, signing and dating a form approved by the Committee as a beneficiary designation form and submitting the completed, signed and dated form to the Committee before the Participant’s death. Upon acceptance by the Committee of a Participant’s Beneficiary designation form, all Beneficiary designations previously filed by that Participant shall automatically be canceled. 
 6.2
 No Designated Beneficiary or no Surviving Designated Beneficiary:  If the Participant has not designated a Beneficiary or the Participant’s designated Beneficiary(ies) do not survive the Participant, the Participant’s Change of Control Payment shall be paid to the Participant’s spouse, or if there is no spouse, to the Participant’s estate.
 

 7
 

 
 ARTICLE 7
 Taxation of Payments 
 

 7.1
 Withholding Taxes:  The Company may withhold from the Participant's benefit payment hereunder the amount which it determines is necessary to satisfy its obligation to withhold federal, state and local income taxes or other taxes or amounts required to be withheld.
 7.2
 Section 4999 Gross-Up Payments.  If the total of all “payments in the nature of compensation” (as that term is defined in the regulations issued under Section 280G of the Code) to or for the benefit of the Participant (whether pursuant to the Plan or otherwise), determined on a pre-tax basis and before the application of the adjustment or gross-up provisions of this Section 7.2 (the “Participant's Parachute Payments”) would subject the Participant to the excise tax levied on certain “excess parachute payments” under Section 4999 of the Code, the Company shall pay to the Participant an additional payment (the “Section 4999 Gross-Up Payment”) in an amount such that after reduction for all taxes, including the excise tax described in Section 4999 of the Code with respect to the Section 4999 Gross-Up Payment, the remaining amount equals the excise tax described in Section 4999 of the Code and all related interest and penalties due with respect to the Participant's Parachute Payments. 
 Any Section 4999 Gross-Up Payment shall be paid in connection with or as soon as practicable after the remittance to the applicable taxing authorities of the underlying taxes and in all events not later than the close of the calendar year following the calendar year in which such remittance takes place. Payments under the Plan (including any payments pursuant to Section 8.2 hereof) shall be made without regard to whether the deductibility of such payments (or any other payments to or for the benefit of the Participant) would be limited or precluded by Section 280G of the Code and without regard to whether such payments (or any other payments) would subject the Participant to the excise tax levied on certain “excess parachute payments” under Section 4999 of the Code.
 

 7.3
 409A Gross-Up Payment:  If any payment or benefit (or any acceleration of any payment or benefit) made or provided to a Participant or the Participant’s Beneficiary or for the Participant’s or the Participant Beneficiary’s benefit in connection with this Plan (the “Payments”) are determined to be subject to the interest charges and taxes imposed by Section 409A(a)(1)(B) of the Code, or any state, local, employment or foreign taxes of a similar nature, or any interest charges or penalties with respect to such taxes (such taxes, together with any such interest charges and penalties, are collectively referred to as the “Section 409A Tax”), then the Company shall pay the Participant or the Participant’s Beneficiary, within 30 days after the date on which the Participant or the Participant’s Beneficiary provides the Company with a written request for reimbursement thereof (accompanied by proof of taxes paid), but in no event later than the end of the calendar year following the year in which the Participant or the Participant’s Beneficiary remits the Section 409A tax to the Internal Revenue Service or other applicable taxing authority, an additional amount (the “Section 409A Gross-Up Payment”). The Section 409A Gross-Up Payment shall be such that the net amount retained by the Participant or the Participant’s Beneficiary after deduction of the Section 409A Tax (but not any federal, state, or local income tax or employment tax) and any federal, state, or local income tax, or employment tax upon the payment provided for by this Section 7.3 shall be equal to the Payments. 
 

 8
 

 
 
 7.4
 Assumed Tax Bracket:  For purposes of determining the amount of the Section 4999 Gross-Up Payment and the Section 409A Gross-Up Payment, the Participant or the Participant’s Beneficiary shall be deemed to pay federal income tax and employment taxes at the highest marginal rate of federal income and employment taxation in the calendar year in which the Section 4999 Gross-Up Payment and the Section 409A Gross-Up Payment is to be made and state and local income taxes at the highest marginal rate of taxation in the state and locality of the Participant or the Participant’s Beneficiary’s domicile for income tax purposes on the date the Section 4999 Gross-Up Payment and the Section 409A Gross-Up Payment is made, net of the maximum reduction in federal income taxes that may be obtained from the deduction of such state and local taxes.
 7.5
 Determination of Excise Tax:  All determinations of Section 4999 Gross-Up Payments and Section 409A Gross-Up Payments that are required to be made under this Article 7 shall be made by such public accounting firm as may be retained by the Company. The determination by such accounting firm shall be final and conclusive, absent manifest error.  
 7.6
 Claim by Internal Revenue Service:  As soon as practicable, a Participant shall notify the Company in writing of any claim by the Internal Revenue Service that, if successful, would result in the imposition of the excise tax under Section 4999 of the Code or a Section 409A Tax. If the Company notifies the Participant in writing that it desires to contest such claim, the Participant shall cooperate in all reasonable ways with the Company in such contest and the Company shall be entitled to participate in all proceedings relating to such claim; provided, however, that the Company shall bear and pay directly all costs and expenses (including additional interest and penalties) incurred in connection with such contest and shall indemnify and hold the Participant harmless, on an after-tax basis, for any excise, employment or income tax (including interest and penalties with respect thereto) imposed as a result of such representation and payment of costs and expenses.
 ARTICLE 8
 Miscellaneous
 

 8.1
 No Mitigation and Burden of Proof:  Except as otherwise expressly provided for in this Plan, no payment payable hereunder shall be subject to offset including, but not limited to, amounts in respect of any claims which the Company may have against the Participant, provided, however, the amount payable hereunder to any Participant shall be reduced by any amounts payable to such Participant from the Company or any Affiliate pursuant to any other severance plan or policy (including any employment agreement). 
 8.2
 Legal Fees:  The Company shall reimburse all costs and expenses, including attorneys' fees, of the Participant in connection with any legal proceedings relating to the Plan; provided, however, the Company shall not reimburse such costs and expenses for the Participant if (a) prior to the initiation of any proceedings by the Participant, such Participant fails to specify in writing all claims relating to the Plan and to provide the Committee with thirty (30) days to address such claims, or (b) the judge or other individual presiding over the proceedings affirmatively finds that (i) the Participant did not initiate such proceedings in good faith, or (ii) if applicable, the Participant violated in any material respect the terms of the agreement set forth on Appendix C.
 

 9
 

 
 
 8.3
 Successors:  If the Company shall be merged into or consolidated with another entity, the provisions of this Plan shall be binding upon and inure to the benefit of the entity surviving such merger or resulting from such consolidation. The Company shall require any successor (whether direct or indirect, by purchase, merger, consolidation or otherwise) to all or substantially all of the business or assets of the Company to expressly assume and agree to perform the duties set forth hereunder in the same manner and to the same extent that the Company would be required to perform if no such succession had taken place (including but not limited to Section 8.6 hereof). 
 8.4
 Indemnification.  In addition to such other rights of indemnification as they may have as members of the Board or the Committee, the members of the Board and the Committee shall be indemnified by the Company against all costs and expenses reasonably incurred by them in connection with any action, suit or proceeding to which they or any of them may be party by reason of any action taken or failure to act under or in connection with the Plan and against all amounts paid by them in settlement thereof (provided such settlement is approved by independent legal counsel selected by the Company) or paid by them in satisfaction of a judgment in any such action, suit or proceeding, except a judgment based upon a finding that such member was not acting in good faith on the reasonable belief that he or she was acting in the best interests of the Company; provided that upon the institution of any such action, suit or proceeding, a Committee or Board member shall, in writing, give the Company notice thereof and an opportunity, at its own expense, to handle and defend the same before such Committee or Board member undertakes to handle and defend it on such member's own behalf.
 8.5
 Plan Expenses:  Any expenses of administering the Plan shall be borne by the Company.
 8.6
 Survival:  Notwithstanding any provision in the Plan to the contrary, the obligations hereunder to the Participants which arise due to a Change of Control shall survive any termination of the Plan and shall be binding upon the Company.
 8.7
 Notice:  All notices and other communications required or permitted hereunder shall be in writing and shall be deemed to have been duly given upon receipt, or five (5) days after deposit in the United States mail, registered or certified and return receipt requested, for delivery to the Participant at the last known address specified in the Company's records, by electronic mail or facsimile, upon electronic confirmation of receipt.
 Any notice required to come from the Committee shall be deemed to be satisfied by a notice from an authorized officer of the Company following approval by the Committee of the action described in such notice.
 

 8.8
 Governing Law:  The validity, construction and effect to the Plan and any actions taken under or relating to the Plan shall be determined in accordance with the laws of the Commonwealth of Massachusetts.
 

 10
 

 
 
 8.9
 Section 409A:  Notwithstanding any other provision hereunder:
 (a)
 The Plan and all benefit payments hereunder shall be construed and applied consistent with the applicable requirements for exemption from, or for complying with, Section 409A of the Code.  
 (b)
 Except as otherwise expressly provided for under the Plan, any reimbursement under the Plan to a Participant shall be paid or provided consistent with the Treasury Regulations under Section 409A of the Code.
 8.10
 No Effect on Employment.  Nothing contained in this Plan shall be construed to limit or restrict the right of the Company to terminate the Participant’s employment at any time, with or without cause or notice, or to increase or decrease the Participant’s compensation from the rate of compensation in existence at the time such person became a Participant hereunder. 
 8.11
 Case and Gender:  Wherever required by the context of this Plan, the singular or plural case and the masculine, feminine and neuter genders shall be interchangeable. 
 8.12
 Captions:  The captions used in this Plan are intended for descriptive and reference purposes only and are not intended to affect the meaning of any Section hereunder. 
 8.13
 Arbitration.  If any dispute shall arise between a Participant and the Company with reference to the interpretation of this Plan or the rights of any party with respect to the Plan, the dispute shall be referred to arbitration under the National Rules for the Resolution of Employment Disputes of the American Arbitration Association. The arbitration shall take place in the Commonwealth of Massachusetts and the arbitration proceedings will be governed by the rules of the American Arbitration Association, as applicable. The decision of the arbitrator shall be final and binding upon the Participant and the Company, and judgment upon the award rendered by the arbitrator may be entered by any court having jurisdiction thereof. Notwithstanding the foregoing, the Company does not waive its rights to specifically enforce in court, the obligations set forth in agreements set forth on Appendix C and specifically, the Company may file and sustain a claim in court to enforce such rights.
 The Company hereby delivers and the Participant hereby acknowledges receipt of a copy of the Implant Sciences Corporation Amended and Restated Change of Control Payment Plan. 
 

 11
 

 
 The Participant further acknowledges that he or she consents and agrees to all of the terms of the Plan and to the amendment and restatement hereby of the original Change of Control Plan. By the Participant’s signature below, such Participant, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, expressly waives any and all rights under the original Change of Control Plan, including rights under Section 3.3 thereof, to receive 30 days prior written notice of such amendment and restatement of or of the adoption or effectiveness of this Plan. 
 

 	 	
	  
	 IMPLANT SCIENCES CORPORATION

	  
	  

	  
	  

	  
	 By:_____________________________________

	  
	 Name & Title

	  
	  

	  
	  

	  
	 By:______________________________________

	  
	 Participant

 

 

 12
 

 
 APPENDIX A
 

 AT-RISK OPTIONS
 

 	 	 	 	
	 Participant
	 Grant Date
	 Option Price
	 Options

	 Glenn D. Bolduc
	 09/7/12
	  $1.40 
	  115,333 

	  
	 09/7/12
	  $1.40 
	  5,327,157 

	  
	 03/06/14
	  $0.79 
	  75,000 

	  
	 07/02/14
	  $1.10 
	  18,863 

	  
	 07/02/14
	  $1.10 
	  81,137 

	  
	  
	  
	  5,617,490 

 

 	 	 	 	
	  
	  
	  
	  

	 William McGann
	 09/7/12
	 $1.40 
	 214,284 

	  
	 09/7/12
	 $1.40 
	 1,284,688 

	  
	 03/06/14
	 $0.79 
	 75,000 

	  
	 07/02/14
	 $1.10 
	 181,818 

	  
	 07/02/14
	 $1.10 
	 118,182 

	  
	  
	  
	 1,873,972 

	  
	  
	  
	  

	 Darryl Jones
	 09/7/12
	 $1.40 
	 214,284 

	  
	 09/7/12
	 $1.40 
	 1,044,214 

	  
	 03/06/14
	 $0.79 
	 50,000 

	  
	 07/02/14
	 $1.10 
	 181,818 

	  
	 07/02/14
	 $1.10 
	 118,182 

	  
	  
	  
	 1,608,498 

	  
	  
	  
	  

	 Roger P. Deschenes
	 09/7/12
	 $1.40 
	 137,440 

	  
	 09/7/12
	 $1.40 
	 921,058 

	  
	 03/06/14
	 $0.79 
	 50,000 

	  
	 07/02/14
	 $1.10 
	 236,818 

	  
	 07/02/14
	 $1.10 
	 63,182 

	  
	  
	  
	 1,408,498 

	  
	  
	  
	  

	 Todd Silvestri
	 09/7/12
	 $1.40 
	 138,630 

	  
	 09/7/12
	 $1.40 
	 592,319 

	  
	 03/06/14
	 $0.79 
	 50,000 

	  
	 07/02/14
	 $1.10 
	 236,818 

	  
	 07/02/14
	 $1.10 
	 63,182 

	  
	  
	  
	 1,080,949 

	  
	  
	  
	  

	 Brenda Baron
	 09/7/12
	 $1.40 
	 138,528 

	  
	 09/7/12
	 $1.40 
	 592,421 

	  
	 03/06/14
	 $0.79 
	 50,000 

	  
	 07/02/14
	 $1.10 
	 236,818 

	  
	 07/02/14
	 $1.10 
	 63,182 

	  
	  
	  
	 1,080,949 

	  
	  
	  
	  

 

 13
 

 
 

 	 	 	 	
	 APPENDIX A (Cont’d)
 

 AT-RISK OPTIONS
 

	 Robert Liscouski
	 09/7/12
	 $1.40 
	 806,798 

	  
	 03/06/14
	 $0.79 
	 25,000 

	  
	 07/02/14
	 $1.10 
	 300,000 

	  
	  
	  
	 1,131,798 

	  
	  
	  
	  

	 Howard Safir
	 09/7/12
	 $1.40 
	 303,399 

	  
	 03/06/14
	 $0.79 
	 25,000 

	  
	 07/02/14
	 $1.10 
	 300,000 

	  
	  
	  
	 628,399 

	  
	  
	  
	  

	 John Keating
	 09/7/12
	 $1.40 
	 303,399 

	  
	 03/06/14
	 $0.79 
	 25,000 

	  
	 07/02/14
	 $1.10 
	 300,000 

	  
	  
	  
	 628,399 

	  
	  
	  
	  

	 Michael Turmelle
	 12/12/07
	 $1.15 
	 10,000 

	  
	 9/7/2012
	 $1.40 
	 640,949 

	  
	 03/06/14
	 $0.79 
	 25,000 

	  
	 07/02/14
	  $1.10 
	 300,000

	  
	  
	  
	 975,949 

	  
	  
	  
	  

	 Estate of Joseph Levangie
	 9/7/12
	 $1.40 
	 525,099 

	  
	  
	  
	  

 

 14
 

 
 APPENDIX B
 

 PARTICIPANTS AND CHANGE IN CONTROL PERCENTAGES
 

 

 	 	 	 	
	  
	 Applicable Percentage

	 

 Participant
	 

 A
	 

 B
	 

 C

	 Glenn D. Bolduc
	 4.00%
	 4.00%
	 4.00%

	 William McGann
	 1.47%
	 1.47%
	 1.47%

	 Darryl Jones
	 1.10%
	 .60%
	 .80%

	 Roger P. Deschenes
	 .97%
	 .60%
	 .80%

	 Todd Silvestri
	 1.00%
	 .60%
	 .80%

	 Brenda Baron
	 1.00%
	 .60%
	 .80%

	 Robert Liscouski
	 .65%2
	 .65%
	 .65%

	 Howard Safir
	 .32%
	 .32%
	 .32%

	 John Keating
	 .32%
	 .32%
	 .32%

	 Michael Turmelle
	 .55%
	 .55%
	 .55%

	 Estate of Joseph Levangie
	 .25%
	 .25%
	 .25%

	 Totals
	 11.63%
	 9.36%
	 9.96%

	  
	  
	  
	  

 

 

 The Company has reserved .87% for future issuance by the Board of Directors.
 The percentages set forth for above are agreed to by the Company and the Participant this __th day of _________, 2015.
 

 	 	
	  
	 IMPLANT SCIENCES CORPORATION

	  
	  

	  
	  

	  
	 By:____________________________________

	  
	 Name & Title

	  
	  

	  
	  

	  
	 By:____________________________________

	  
	 Participant

 

 

 15
 

 
  APPENDIX C
 

 AGREEMENT RELATED TO NONDISCLOSURE, NONCOMPETITION AND OTHER MATTERS
 

 This Agreement is made this __ day of ________, 2015 between Implant Sciences Corporation, a Massachusetts corporation and _________________ (the “Executive”).
 WHEREAS, Executive acknowledges that the Company could be significantly harmed if the Executive solicits the Company’s employees, clients, or customers, or discloses any proprietary or confidential business information of the Company.
 NOW, THEREFORE, in consideration of the continued employment of the Executive by the Company and/or the protection afforded Executive by being designated a “Participant” under Implant Sciences Corporation Amended and Restated Change of Control Payment Plan (the “Plan”) (whether or not benefit payments are ever triggered thereunder), the Executive and the Company agree as follows:
 1.
 Proprietary Information.
 (a)
 Executive agrees that all information and know-how, whether or not in writing, of a private, secret or confidential nature concerning the Company’s business or financial affairs (collectively, “Proprietary Information”) is and shall be the exclusive property of the Company.  By way of illustration, but not limitation, Proprietary Information may include inventions, products, processes, methods, techniques, formulas, designs, drawings, slogans, tests, logos, ideas, practices, projects, developments, plans, research data, financial data, personnel data, computer programs and codes, and customer and supplier lists.  Executive will not disclose any Proprietary Information to others outside the Company except in the performance of his duties or use the same for any unauthorized purposes without written approval by an officer of the Company, either during or after his employment, unless and until such Proprietary Information has become public knowledge or generally known within the industry without fault by Executive, or unless otherwise required by law.
 (b)
 Executive agrees that all files, letters, memoranda, reports, records, data, sketches, drawings, laboratory notebooks, program listings, or other written, photographic, electronic or other material containing Proprietary Information, whether created by Executive or others, which shall come into his custody or possession, shall be and are the exclusive property of the Company to be used by Executive only in the performance of his duties for the Company.
 (c)
 Executive agrees that his obligation not to disclose or use information, know-how and records of the types set forth in paragraphs (a) and (b) above, also extends to such types of information, know-how, records and tangible property of subsidiaries and joint ventures of the Company, customers of the Company or suppliers to the Company or other third parties who may have disclosed or entrusted the same to the Company or to Executive in the course of the Company’s business.
 

 16
 

 
 
 2.
 Inventions.
 (a)
 Executive shall disclose promptly to an officer or to attorneys of the Company in writing any idea, invention, work of authorship, whether patentable or unpatentable, copyrightable or uncopyrightable, including, but not limited to, any computer program, software, command structure, code, documentation, compound, genetic or biological material, formula, manual, device, improvement, method, process, discovery, concept, algorithm, development, secret process, machine or contribution (any of the foregoing items hereinafter referred to as an "Invention") Executive may conceive, make, develop or work on, in whole or in part, solely or jointly with others. The disclosure required by this Section applies (a) during the period of Executive’s employment with the Company and for one year thereafter; (b) with respect to all Inventions whether or not they are conceived, made, developed or worked on by Executive during Executive’s regular hours of employment with the Company; (c) whether or not the Invention was made at the suggestion of the Company; (d) whether or not the Invention was reduced to drawings, written description, documentation, models or other tangible form; and (e) whether or not the Invention is related to the general line of business engaged in by the Company. 
 (b)
 Executive hereby assigns to the Company without royalty or any other further consideration Executive’s entire right, title and interest in and to all Inventions which Executive conceives, makes, develops or works on during employment and for one year thereafter, except those Inventions that Executive develops entirely on Executive’s own time after the date of this Agreement without using the Company's equipment, supplies, facilities or trade secret information unless those Inventions either (a) relate at the time of conception or reduction to practice of the Invention to the Company's business, or actual or demonstrably anticipated research or development of the Company; or (b) result from any work performed by Executive for the Company. 
 (c)
 Executive will make and maintain adequate and current written records of all Inventions. These records shall be and remain the property of the Company.
 (d)
 Subject to Section 4, Executive will assist the Company in obtaining, maintaining and enforcing patents and other proprietary rights in connection with any Invention covered by Section 1.  Executive further agrees that his obligations under this Section shall continue beyond the termination of his employment with the Company, but if he is called upon to render such assistance after the termination of such employment, he shall be entitled to a fair and reasonable rate of compensation for such assistance. Executive shall, in addition, be entitled to reimbursement of any expenses incurred at the request of the Company relating to such assistance.
 

 17
 

 
 
 3.
 Prior Contracts and Inventions; Information Belonging to Third Parties.  
 (a)
 Executive represents that there are no contracts to assign Inventions between any other person or entity and Executive.  
 (b)
 Executive further represents that (a) Executive is not obligated under any consulting, employment or other agreement which would affect the Company's rights or my duties under this Agreement, (b) there is no action, investigation, or proceeding pending or threatened, or any basis therefor known to me involving Executive’s prior employment or any consultancy or the use of any information or techniques alleged to be proprietary to any former employer, and (c) the performance of Executive’s duties as an employee of the Company will not breach, or constitute a default under any agreement to which Executive is bound, including, without limitation, any agreement limiting the use or disclosure of proprietary information acquired in confidence prior to engagement by the Company.
 (c)
  Executive will not, in connection with Executive’s employment by the Company, use or disclose to the Company any confidential, trade secret or other proprietary information of any previous employer or other person to which Executive is not lawfully entitled. 
 4.
 Noncompetition and Nonsolicitation.
 (a)
 During the Employment Period and for a period of twelve (12) months after the termination of Executive’s employment with the Company for any reason, Executive will not directly or indirectly, absent the Company’s prior written approval, render services of a business, professional or commercial nature to any other person or entity in the area of trace explosives detection surface modification services to the medical device and semiconductor industries or such other services or products provided by the Company at the time employment terminates in the (same geographical area where the Company does business at the time this covenant is in effect) (or where the Company has made, as of the effective date of termination, active plans to do business), whether such services are for compensation or otherwise, whether alone or in conjunction with others, as an employee, as a partner, or as a shareholder (other than as the holder of not more than 1% of the combined voting power of the outstanding stock of a public company), officer or director of any corporation or other business entity, or as a trustee, fiduciary or in any other similar representative capacity.
 (b)
 During the Employment Period and for a period of twelve (12) months after the termination of Executive’s employment for any reason, Executive will not, directly or indirectly, recruit, solicit or induce, or attempt to recruit, solicit or induce any employee or employees of the Company to terminate their employment with, or otherwise cease their relationship with, the Company.
 (c)
 During the Employment Period and for a period of twelve (12) months after termination of Executive’s employment for any reason, Executive will not, directly or indirectly, contact, solicit, divert or take away, or attempt to solicit, contact, divert or take away, the business or patronage of any of the clients, customers or accounts, or prospective clients, customers or accounts, of the Company.
 

 18
 

 
 
 5.
 If any restriction set forth in this Section is found by any court of competent jurisdiction to be unenforceable because it extends for too long a period of time or over too great a range of activities or in too broad a geographic area, it shall be interpreted to extend only over the maximum period of time, range of activities or geographic area as to which it may be enforceable.
 6.
 The restrictions contained in this Section are necessary for the protection of the business and goodwill of the Company and are considered by Executive to be reasonable for such purpose.  Executive agrees that any breach of this Section will cause the Company substantial and irrevocable damage and therefore, in the event of any such breach, in addition to such other remedies which may be available, the Company shall have the right to seek specific performance and injunctive relief.  The Company shall be entitled to recover its reasonable attorneys’ fees in the event it prevails in such an action.  
 7.
 Notices.
 All notices required or permitted under this Agreement shall be in writing and shall be deemed effective upon receipt or five (5) days after deposit in the United States Post Office, by registered or certified mail, postage prepaid, return receipt requested, addressed to the other party at the address shown below, by electronic mail or facsimile, upon electronic confirmation of receipt, or at such other address or addresses as either party shall designate to the other in accordance with this Section:
 The Company:
 Implant Sciences Corporation 
 500 Research Drive, Unit 3
 Wilmington, MA 01887
 Attention: Chief Financial Officer
 

 The Executive: 
 Home Address as reflected on Company records or electronic email or facsimile provided from time to time by Executive.
 

 8.
 Pronouns.
 Whenever the context may require, any pronouns used in this Agreement shall include the corresponding masculine, feminine or neuter forms, and the singular forms of nouns and pronouns shall include the plural, and vice versa.
 9.
 Entire Agreement.
 This Agreement constitutes the entire agreement between the parties and supersedes all prior agreements and understandings, whether written or oral, relating to the subject this of this Agreement.
 10.
 Amendment.
 This Agreement may be amended or modified only by a written instrument executed by both the Company and the Executive.
 11.
 Law.
 This Agreement shall be construed, interpreted and enforced in accordance with the laws of the Commonwealth of Massachusetts.
 

 19
 

 
 
 12.
 Successors and Assigns.
 This Agreement shall be binding upon and inure to the benefit of both parties and their respective successors and assigns, including any corporation with which or into which the Company may be merged or which may succeed to its assets or business, provided, however, that the obligations of the Executive are personal and shall not be assigned by him or her.
 13.
 Miscellaneous.
 13.1
 No delay or omission by the Company in exercising any right under this Agreement shall operate as a waiver of that or any other right. A waiver or consent given by the Company on any one occasion shall be effective only in that instance and shall not be construed as a bar or waiver of any right on any other occasion.
 13.2
 The captions of the sections of this Agreement are for convenience of reference only and in no way define, limit or affect the scope or substance of any section of this Agreement.
 13.3
 In case any provision of this Agreement shall be invalid, illegal or otherwise unenforceable, the validity, legality and enforceability of the remaining provisions shall in no way be affected or impaired thereby.
 13.4
 Nothing contained in this Agreement shall be construed to limit or restrict the right of Company to terminate an Executive’s employment at any time, with or without cause or notice, or to increase or decrease an Executive’s compensation from the rate of compensation in existence on the date hereof.
 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date and year set forth above.
 

 IMPLANT SCIENCES CORPORATION 
 

 By: 
 

 

 

 EXECUTIVE
 

 

 Name: 
 

 

 20Form of Medium-Term Notes, Series K, 0.125% Optionally Exchangeable Notes

 Exhibit 4.1 

[Face of Note] 

Unless this certificate is presented by an authorized representative of The Depository Trust Company, a New York corporation
(“DTC”), 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 requested by an authorized representative
of DTC (and any payment is made to Cede & Co. or such other entity as is requested by an authorized representative of DTC), 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. 
  

	 CUSIP NO. 94986RVY4 
	
PRINCIPAL AMOUNT: $                   
  

 REGISTERED NO.      

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

0.125% Optionally Exchangeable Notes due February 21, 2020 

Exchangeable for a Basket of Shares or the Cash Value 

of Such Basket of Shares 

WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware (hereinafter
called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay to CEDE & Co., or its registered assigns, the number of shares of
the Basket Stocks (as defined below) or the amount of cash, as applicable, determined in accordance with the provisions set forth below under “Payment at Stated Maturity” due with respect to the principal amount of
                                         
                                        DOLLARS
($                        ) on February 21, 2020 (the “Stated Maturity Date”), subject to
postponement due to the occurrence of a Market Disruption Event (as defined below) as set forth below under “Payment at Stated Maturity” unless and to the extent the Company has exercised the Redemption Right (as defined and described
below) or the Holder hereof has exercised the Exchange Right (as defined and described below), and to pay interest on the principal amount of this Security from February 23, 2015 or from the most recent Interest Payment Date (as defined below)
to which interest has been paid or duly provided for, as the case may be, at the rate of 0.125% per annum, payable on each Interest Payment Date. Interest shall be calculated on the basis of a year of 360 days with twelve 30-day months. 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 Security (or one or more
Predecessor Securities) is registered at the close of business on the Regular Record Date for such Interest 

 
Payment Date; provided that the interest payable on the Stated Maturity Date shall be paid to the Person to whom the Stated Maturity Payment Amount (as defined below) is paid. The
“Regular Record Date” for an Interest Payment Date shall be the date one Business Day (as defined below) prior to such Interest Payment Date. The “Interest Payment Dates” shall be each February 21 and
August 21, commencing August 21, 2015, and ending on the Stated Maturity Date. 
 The amount payable on this
Security at Maturity will be based upon the value of a basket of stocks (the “Basket”) consisting of shares of common stock of the following two companies (with the initial weightings noted parenthetically): Schlumberger N.V.
(Schlumberger Limited) (59.46%) and Halliburton Company (40.54%) (each, a “Basket Stock” and collectively, the “Basket Stocks”). The issuers of the Basket Stocks are sometimes referred to herein
individually as a “Basket Stock Issuer” and collectively as the “Basket Stock Issuers.” 

Any interest not punctually paid or duly provided for will forthwith cease to be payable to the Holder on such Regular Record
Date and may either be paid to the Person in whose name this Security (or one or more Predecessor Securities) is registered at the close of business on a Special Record Date for the payment of such Defaulted Interest to be fixed by the Trustee,
notice whereof shall be given to the Holder of this Security not less than 10 days prior to such Special Record Date, or be paid at any time in any other lawful manner not inconsistent with the requirements of any securities exchange on which this
Security may be listed, and upon such notice as may be required by such exchange, all as more fully provided in the Indenture. 

All cash payable on this Security shall be payable in such coin or currency of the United States of America as at the time of
payment is legal tender for payment of public and private debts. Payments of interest on this Security shall be payable at the office or agency of the Company maintained for such purpose in the City of Minneapolis, Minnesota and at any other office
or agency maintained by the Company for such purpose; provided, however, that at the option of the Company payment of interest may be made by check mailed to the address of the Person entitled thereto as such address shall appear in the Security
Register or by wire transfer to such account as may have been appropriately designated by such Person. Any cash payable on this Security at Maturity shall be paid against presentation of this Security at the office or agency of the Company
maintained for that purpose in the City of Minneapolis, Minnesota and any shares of the Basket Stocks deliverable at Maturity shall be delivered against such presentation. Notwithstanding the foregoing, for so long as this Security is in the form of
a Global Security registered in the name of the Depositary, all payments on this Security in the form of cash will be made to the Depositary by wire transfer of immediately available funds, and any shares of the Basket Stocks deliverable under the
terms of this Security at Maturity will be delivered to the Depositary through the book-entry facilities of the Depositary if such shares are then in book-entry form and, if such shares are then in definitive form, certificates representing such
shares will be delivered pursuant to the Depositary’s instructions. 
 Payment at Stated Maturity 

On the Stated Maturity Date, for each $1,000 principal amount of this Security that has not been previously exchanged by the
Holder hereof or redeemed by the Company, the Holder of this Security shall receive an amount in cash equal to the greater of $1,000 and Parity (such amount, the 

  
 2 

 
“Stated Maturity Payment Amount”), as determined on the fifth Trading Day (as defined below) prior to the Stated Maturity Date (the “Final Exchange Date”), plus
any accrued and unpaid interest. “Parity” on any Trading Day equals the sum of the products of the Closing Price (as defined below) of each Basket Stock and its Exchange Ratio (as defined below) on such Trading Day.
“Principal amount” shall mean, when used with respect to this Security, the amount set forth on the face of this Security as its “Principal Amount.” 

If a Market Disruption Event occurs or is continuing with respect to a Basket Stock on the Final Exchange Date and the Holder
of this Security does not exercise the Exchange Right with respect to the principal amount for which payment must be made by the Company on the Stated Maturity Date as described in the immediately preceding paragraph, such Final Exchange Date for
such Basket Stock, solely for purposes of determining Parity as described in the immediately preceding paragraph, will be postponed to the first succeeding Trading Day on which a Market Disruption Event for such Basket Stock has not occurred and is
not continuing. If such first succeeding Trading Day has not occurred as of the eighth scheduled Trading Day after the scheduled Final Exchange Date, that eighth scheduled Trading Day shall be deemed the Final Exchange Date for such Basket Stock. If
the Final Exchange Date has been postponed eight scheduled Trading Days after the scheduled Final Exchange Date and such eighth scheduled Trading Day is not a Trading Day, or if a Market Disruption Event occurs or is continuing with respect to a
Basket Stock on such eighth scheduled Trading Day, the Calculation Agent (as defined below) will determine the Closing Price of such Basket Stock on such eighth scheduled Trading Day using its good faith estimate of the Closing Price that would have
prevailed for such Basket Stock on such date. For the avoidance of doubt, in no circumstances will the Holder hereof have the right to exercise the Exchange Right on any date following the originally scheduled Final Exchange Date. Notwithstanding a
postponement of the Final Exchange Date for a particular Basket Stock due to a Market Disruption Event with respect to that Basket Stock, the originally scheduled Final Exchange Date will remain the Final Exchange Date for a Basket Stock not
affected by a Market Disruption Event. 
 If a Market Disruption Event has occurred or is continuing on the Final Exchange
Date and the Holder of this Security does not exercise the Exchange Right with respect to the principal amount for which payment must be made by the Company on the Stated Maturity Date as described in the second preceding paragraph, and such Final
Exchange Date, for purposes of determining Parity, is postponed so that it falls less than three Business Days (as defined below) prior to the Stated Maturity Date, the Stated Maturity Date will be postponed to the third Business Day following the
Final Exchange Date as postponed. 
 Exchange Right 

Beginning March 4, 2015 to and including the earlier of (i) the Trading Day prior to the Redemption Notice Date (as
defined below), if applicable, and (ii) the Final Exchange Date, the Holder of this Security may exchange each $1,000 principal amount of this Security for a number of shares of each Basket Stock equal to its Exchange Ratio as it may have been
adjusted through the Exchange Settlement Date (as defined below) (or, at the Company’s option, the cash value of a number of shares of each Basket Stock equal to its Exchange Ratio as it may have been adjusted through the Exchange Notice Date
(as defined below), based on the Closing Prices of the Basket Stocks on the Exchange Notice Date), subject to the Company’s right to redeem this Security on 

  
 3 

 
any day from and including February 21, 2018. This right of the Holder of this Security to exchange this Security is referred to herein as the “Exchange Right.” 

The “Exchange Ratio” is equal to: with respect to Schlumberger N.V. (Schlumberger Limited), 6.33412; and with
respect to Halliburton Company, 8.50396. The Exchange Ratio for each Basket Stock will remain constant for the term of this Security unless adjusted for certain corporate events relating to the issuer of that Basket Stock. See
“ — Adjustment Events” below. 
 When the Holder of this Security exchanges this Security or any
portion hereof, the Calculation Agent will determine the exact number of shares of the Basket Stocks to be received by the Holder based on the principal amount of this Security exchanged and each Exchange Ratio as it may have been adjusted through
the Exchange Settlement Date. Since this Security will be held only in book-entry form, a beneficial owner of this Security may exercise the Exchange Right only by acting through its participant at DTC, whose nominee is the registered Holder of this
Security. Accordingly, if a beneficial owner of this Security desires to exchange all or any portion of this Security, such beneficial owner must instruct the participant through which it owns its interest to exercise the Exchange Right on its
behalf. 
 To exchange this Security or any portion hereof on any day, a beneficial owner of this Security or any portion
hereof must instruct its broker or other person with whom it holds its beneficial interest to take the appropriate steps through normal clearing system channels. A beneficial owner’s book-entry interest in this Security must be transferred to
Wells Fargo Bank, N.A., the Paying Agent, on the day the Company delivers shares or pays cash to the Holder hereof, as described below. In addition, a beneficial owner of this Security must give the Company notice of exchange as follows: 

 

	 	•	 	 fill out an Official Notice of Exchange, which is attached as Annex A hereto; and 

 

	 	•	 	 deliver such Official Notice of Exchange to the Company before 11:00 A.M., New York City time, on the day such beneficial owner notifies the
Company of its exercise of the Exchange Right (the “Exchange Notice Date”). 

 In order
to ensure that the instructions are received by the Company on a particular day, a beneficial owner of this Security must instruct the participant through which it owns its interest before that participant’s deadline for accepting instructions
from their customers. Different firms may have different deadlines for accepting instructions from their customers. Accordingly, a beneficial owner of this Security should consult the participant through which it owns its interest for the relevant
deadline. If the Company receives an Official Notice of Exchange after 11:00 A.M., New York City time, on any Trading Day or at any time on a day that is not a Trading Day, such notice will not become effective until the next Trading Day, and such
next Trading Day will be the Exchange Notice Date. All instructions given to the Company by participants on behalf of a beneficial owner relating to the right to exchange this Security will be irrevocable. In addition, at the time instructions are
given, a beneficial owner of this Security must direct the participant through which it owns its interest to transfer its book-entry interest in this Security, on DTC’s records, to the Paying Agent on the Company’s behalf. 

This Security must be exchanged in $1,000 principal amount minimum increments at a time. 

  
 4 

 The Holder of this Security will no longer have the Exchange Right if the Company
redeems this Security. 
 Upon any exercise of the Exchange Right, the Holder of this Security will not be entitled to
receive any cash payment representing any accrued but unpaid interest. Consequently, if the Holder of this Security exchanges this Security or any portion hereof so that the Exchange Settlement Date occurs during the period from the close of
business on a Regular Record Date and prior to the next succeeding Interest Payment Date, this Security or portion hereof exchanged must, as a condition to the delivery of the shares of the Basket Stocks or cash to the Holder of this Security, be
accompanied by funds equal to the interest payable on the succeeding Interest Payment Date on the principal amount of this Security or portion hereof exchanged. 

Upon any such exchange, the Company may, at its sole option, either deliver such shares of the Basket Stocks or pay an amount
in cash equal to Parity on the Exchange Notice Date, as determined by the Calculation Agent, in lieu of the Basket Stocks. 

The Company will, or will cause the Calculation Agent to, deliver such shares of the Basket Stocks or cash to the Paying Agent
for delivery to the Holder of this Security on the third Business Day after the Exchange Notice Date, upon delivery of this Security to the Paying Agent. The “Exchange Settlement Date” will be the third Business Day after the
Exchange Notice Date, or, if later, the day on which this Security is delivered to the Paying Agent. 
 If upon exchange of
this Security or any portion hereof the Company delivers shares of the Basket Stocks, the Company will pay cash in lieu of delivering any fractional share of a Basket Stock in an amount equal to the value of such fractional share based on the
Closing Price of the Basket Stock as determined by the Calculation Agent on the Trading Day before the Exchange Settlement Date. 
 Redemption Right

 The Company may redeem this Security, in whole but not in part, for settlement on any day from and including
February 21, 2018, to and including the Stated Maturity Date, for an amount in cash for each $1,000 principal amount of this Security equal to the greater of (i) $1,000 and (ii) Parity determined by the Calculation Agent on the
Trading Day prior to the Redemption Notice Date (the “Redemption Determination Date”). This right of the Company to redeem this Security is referred to herein as the “Redemption Right.” 

If the Company redeems this Security, the Company will specify the Redemption Date in its notice of redemption. The
“Redemption Date” will be 10 days following the day on which the Company gives its notice of redemption (the “Redemption Notice Date”), unless the 10th day
following the Redemption Notice Date is not a Business Day, in which case the Redemption Date will be the immediately following day that is a Business Day. If the Company redeems this Security, the Holder of this Security will not receive any
accrued but unpaid interest on the Redemption Date. 
 If the Company redeems this Security, the Holder of this Security
will no longer be able to exercise the Exchange Right. 

  
 5 

 Business Day Adjustments 

If the Stated Maturity Date, any Interest Payment Date, the Redemption Date or any Exchange Settlement Date is not a Business
Day, any payments due on this Security on such day will be made on the next succeeding Business Day with the same force and effect as if made on such day and no interest on such payment will accrue from and after the Stated Maturity Date or such
Interest Payment Date, as applicable. 
 Certain Definitions 

“Business Day” shall mean a day, other than a Saturday or Sunday, that is neither a legal holiday nor a day
on which banking institutions are authorized or required by law or regulation to close in New York, New York. 

“Calculation Agent” shall mean the Person that has entered into the Calculation Agent Agreement with the
Company, which term shall, unless the context otherwise requires, include its successors under such Calculation Agent Agreement. The initial Calculation Agent shall be Wells Fargo Securities, LLC. Pursuant to the Calculation Agent Agreement, the
Company may appoint a different Calculation Agent from time to time after the initial issuance of this Security without the consent of the Holder of this Security and without notifying the Holder of this Security. 

“Calculation Agent Agreement” shall mean the Calculation Agent Agreement dated as of May 29, 2012
between the Company and the Calculation Agent, as amended from time to time. 
 The “Closing Price” for one
share of a Basket Stock (or one unit of any other security for which a Closing Price must be determined) on any Trading Day means: 
  

	 	•	 	 if the Basket Stock (or any such other security) is listed or admitted to trading on a national securities exchange (other than The NASDAQ Stock
Market LLC (the “NASDAQ”)), the last reported sale price, regular way, of the principal trading session on such day on the principal United States securities exchange registered under the Securities Exchange Act of 1934, as amended
(the “Exchange Act”), on which the Basket Stock (or any such other security) is listed or admitted to trading; 

  

	 	•	 	 if the Basket Stock (or any such other security) is a security of the NASDAQ, the official closing price published by the NASDAQ on such day; or

  

	 	•	 	 if the Basket Stock (or any such other security) is not listed or admitted to trading on any national securities exchange but is included in the
OTC Bulletin Board Service (the “OTC Bulletin Board”) operated by the Financial Industry Regulatory Authority, Inc. (the “FINRA”), the last reported sale price of the principal trading session on the OTC Bulletin
Board on such day. 

 If the Basket Stock (or any such other security) is listed or admitted to trading on
any national securities exchange but the last reported sale price or the official closing price published by the NASDAQ, as applicable, is not available pursuant to the preceding sentence, then the Closing Price for one share of the Basket Stock (or
one unit of any such other security) on any Trading Day 

  
 6 

 
will mean the last reported sale price of the principal trading session on the over-the-counter market as reported on the NASDAQ or the OTC Bulletin Board on such day. 

If the last reported sale price or the official closing price published by the NASDAQ, as applicable, for the Basket Stock (or
any such other security) is not available pursuant to either of the two preceding sentences, then the Closing Price per share for any Trading Day will be the mean, as determined by the Calculation Agent, of the bid price for the Basket Stock (or any
such other security) obtained from as many recognized dealers in such security, but not exceeding three, as will make such bid prices available to the Calculation Agent. Bids of Wells Fargo Securities, LLC or any of its affiliates may be included in
the calculation of such mean, but only to the extent that any such bid is the highest of the bids obtained. The term “OTC Bulletin Board Service” will include any successor service thereto. 

A “Market Disruption Event” means, with respect to a Basket Stock, the occurrence or existence of any of the
following events: 
  

	 	•	 	 a suspension, absence or material limitation of trading in such Basket Stock on its primary market for more than two hours of trading or during the
one-half hour before the close of trading in that market, as determined by the Calculation Agent in its sole discretion; 

  

	 	•	 	 a suspension, absence or material limitation of trading in option or futures contracts relating to such Basket Stock, if available, in the primary
market for those contracts for more than two hours of trading or during the one-half hour before the close of trading in that market, as determined by the Calculation Agent in its sole discretion; 

 

	 	•	 	 such Basket Stock does not trade on the New York Stock Exchange, the NASDAQ Global Select Market, the NASDAQ Global Market or what was the primary
market for such Basket Stock, as determined by the Calculation Agent in its sole discretion; or 

  

	 	•	 	 any other event, if the Calculation Agent determines in its sole discretion that the event materially interferes with the Company’s ability or
the ability of any of its affiliates to unwind all or a material portion of a hedge with respect to this Security that the Company or its affiliates have effected or may effect. 

The following events will not be Market Disruption Events: 

 

	 	•	 	 a limitation on the hours or number of days of trading in such Basket Stock in its primary market, but only if the limitation results from an
announced change in the regular business hours of the relevant market; and 

  

	 	•	 	 a decision to permanently discontinue trading in the option or futures contracts relating to such Basket Stock. 

For this purpose, a “suspension, absence or material limitation of trading” in the applicable market will not
include any time when that market is itself closed for trading under ordinary circumstances. In contrast, a “suspension, absence or material limitation of trading” in 

  
 7 

 
the applicable market for a Basket Stock or option or futures contracts relating to a Basket Stock, as applicable, by reason of any of: 

 

	 	•	 	 a price change exceeding limits set by that market; 

  

	 	•	 	 an imbalance of orders relating to that Basket Stock or those contracts; or 

 

	 	•	 	 a disparity in bid and asked quotes relating to that Basket Stock or those contracts 

will constitute a “suspension, absence or material limitation of trading” in that Basket Stock or those contracts, as the case may
be, in the applicable market. 
 A “Trading Day” means a day, as determined by the Calculation Agent, on
which trading is generally conducted on the principal trading market for each of the Basket Stocks (as determined by the Calculation Agent, in its sole discretion), the Chicago Mercantile Exchange and the Chicago Board Options Exchange and in the
over-the-counter market for equity securities in the United States. 
 Calculation Agent 

All determinations made by the Calculation Agent with respect to this Security will be at the sole discretion of the
Calculation Agent and, in the absence of manifest error, will be conclusive for all purposes and binding on the Company and the Holder of this Security. All percentages and other amounts resulting from any calculation with respect to this Security
will be rounded at the Calculation Agent’s discretion. 
 Events of Default and Acceleration 

In case an Event of Default, as defined in the Indenture, with respect to this Security has occurred and is continuing, the
amount payable to the Holder of this Security upon any acceleration permitted by this Security, with respect to each $1,000 principal amount of this Security, will be equal to the greater of (i) $1,000 and (ii) Parity determined by the
Calculation Agent on the date of acceleration. 
 Adjustment Events 

The Exchange Ratios of the Basket Stocks are subject to adjustment by the Calculation Agent as a result of the dilution and
reorganization events described in this section. 
 How adjustments will be made 

If one of the events described below occurs with respect to any Basket Stock and the Calculation Agent determines that the
event has a dilutive or concentrative effect on the market price of such Basket Stock, the Calculation Agent will calculate a corresponding adjustment to the Exchange Ratio for such Basket Stock as the Calculation Agent deems appropriate to account
for that dilutive or concentrative effect. For example, if an adjustment is required because of a two-for-one stock split, then the Exchange Ratio for such Basket Stock will be adjusted by the Calculation Agent by multiplying the existing Exchange
Ratio by a fraction whose numerator is the number of 

  
 8 

 
shares of such Basket Stock outstanding immediately after the stock split and whose denominator is the number of shares of such Basket Stock outstanding immediately prior to the stock split.
Consequently, the Exchange Ratio will be adjusted to double the prior Exchange Ratio, due to the corresponding decrease in the market price of such Basket Stock. Adjustments will be made for events with an effective date or Ex-Dividend Date (as
defined below), as applicable, from but excluding February 13, 2015 to and including (i) if the Holder hereof exercises the Exchange Right and the Company delivers shares of Basket Stocks to the Holder hereof on an Exchange Settlement
Date, such Exchange Settlement Date or (ii) in all other circumstances, the Exchange Notice Date, the Redemption Determination Date or the Final Exchange Date, as applicable (the “Adjustment Period”). 

The Calculation Agent will also determine the effective date of that adjustment, and the replacement of the Basket Stock, if
applicable, in the event of a consolidation or merger or certain other events in respect of the Basket Stock Issuer. Upon making any such adjustment, the Calculation Agent will give notice as soon as practicable to the Trustee and the Paying Agent,
stating the adjustment to the Exchange Ratio with respect to such Basket Stock. In no event, however, will an antidilution adjustment to the Exchange Ratio during the term of this Security be deemed to change the principal amount of this Security.

 If more than one event requiring adjustment occurs with respect to a Basket Stock, the Calculation Agent will make an
adjustment for each event in the order in which the events occur, and on a cumulative basis. Thus, having made an adjustment for the first event, the Calculation Agent will adjust the Exchange Ratio for the second event, applying the required
adjustment to the Exchange Ratio of any such Basket Stock as already adjusted for the first event, and so on for any subsequent events. 

For any dilution event described below, other than a consolidation or merger, the Calculation Agent will not have to adjust
the Exchange Ratio unless the adjustment would result in a change to the Exchange Ratio of any such Basket Stock then in effect of at least 0.10%. The Exchange Ratio with respect to such Basket Stock resulting from any adjustment will be rounded up
or down, as appropriate, to the nearest one-hundred thousandth. 
 If an event requiring an antidilution adjustment occurs,
the Calculation Agent will make the adjustment with a view to offsetting, to the extent practical, any change in the economic position of the Holder of this Security relative to this Security that results solely from that event. The Calculation
Agent may, in its sole discretion, modify the antidilution adjustments as necessary to ensure an equitable result. 
 The
Calculation Agent will make all determinations with respect to antidilution adjustments, including any determination as to whether an event requiring adjustment has occurred, as to the nature of the adjustment required and how it will be made or as
to the value of any property distributed in a Reorganization Event (as defined below), and will do so in its sole discretion. In the absence of manifest error, those determinations will be conclusive for all purposes and will be binding on the
Holder of this Security and the Company, without any liability on the part of the Calculation Agent. The Holder of this Security will not be entitled to any compensation from the Company for any loss suffered as a result of any of these
determinations by the Calculation Agent. 

  
 9 

 
The Calculation Agent will provide information about the adjustments that it makes upon the written request of the Holder of this Security. 

If any of the adjustments specified below is required to be made with respect to an amount or value of any cash or other
property that is distributed by any Basket Stock Issuer organized outside the United States, such amount or value will be converted to U.S. dollars, as applicable, and will be reduced by any applicable foreign withholding taxes that would apply to
such distribution if such distribution were paid to a U.S. person that is eligible for the benefits of an applicable income tax treaty, if any, between the United States and the jurisdiction of organization of such Basket Stock Issuer, as determined
by the Calculation Agent, in its sole discretion. 
 No adjustments will be made for certain other events, such as offerings
of common stock by any Basket Stock Issuer for cash or in connection with the occurrence of a partial tender or exchange offer for any Basket Stock by the issuer of such Basket Stock or any other person. 

Ordinary Dividend Adjustments 

In addition to any adjustments to the Exchange Ratio described herein, the Exchange Ratio for each Basket Stock will be
adjusted for changes (whether positive or negative) in the regular quarterly cash dividend payable to holders of such Basket Stock relative to its Base Quarterly Dividend (as defined below). If the issuer of a Basket Stock pays a regular quarterly
cash dividend for which the Ex-Dividend Date is within the Adjustment Period and the amount of such regular quarterly cash dividend (the “Current Quarterly Dividend”) differs from the Base Quarterly Dividend payable to the holders
of such Basket Stock, the Exchange Ratio with respect to such Basket Stock will be adjusted (an “Ordinary Dividend Adjustment”) on such Ex-Dividend Date so that the new Exchange Ratio will equal the prior Exchange Ratio multiplied
by the Ordinary Dividend Adjustment Factor. If a Basket Stock Issuer declares that it will pay no dividend in any quarter, other than in connection with a Payment Period Adjustment as defined and discussed below, an adjustment will be made in
accordance with this paragraph on the date determined by the Calculation Agent that, but for the discontinuation of the regular quarterly cash dividend in such quarter, would have been the Ex-Dividend Date in such quarter, corresponding to the
Ex-Dividend Date in the immediately prior dividend payment period during which a regular quarterly cash dividend was paid (or, if such date is not a Trading Day, the next day that is a Trading Day). If a Reorganization Event occurs, no Ordinary
Dividend Adjustment will be made in respect of any New Stock (other than Spin-Off Stock), Successor Stock or Replacement Stock (each as defined below). 

The “Ordinary Dividend Adjustment Factor” will equal a fraction, the numerator of which is the Closing Price
of such Basket Stock on the Trading Day preceding the Ex-Dividend Date for the payment of the Current Quarterly Dividend (such Closing Price, the “Ordinary Dividend Base Closing Price”), and the denominator of which equals the
Ordinary Dividend Base Closing Price of such Basket Stock on the Trading Day preceding the Ex-Dividend Date minus the Dividend Differential. If the Dividend Differential is negative (because the Current Quarterly Dividend is less than the Base
Quarterly Dividend), then the Ordinary Dividend Adjustment Factor will be less than 1, and the corresponding adjustment to the Exchange Ratio will result in a reduction of the Exchange Ratio. 

  
 10 

 The “Dividend Differential” equals the amount of the Current
Quarterly Dividend minus the Base Quarterly Dividend. 
 The “Base Quarterly Dividend” means (i) with
respect to the common stock of Schlumberger N.V. (Schlumberger Limited), a quarterly dividend of $0.50 per share; and (ii) with respect to the common stock of Halliburton Company, a quarterly dividend of $0.18 per share; provided that
(x) if there occurs any corporate event with respect to a Basket Stock that requires an adjustment to such Basket Stock’s Exchange Ratio as described in this section “Adjustment Events” or (y) if a Basket Stock effects a
change in the periodicity of its dividend payments (e.g., from quarterly payments to semi-annual payments) (a “Payment Period Adjustment”), then in each case the Calculation Agent will make an appropriate adjustment to the Base
Quarterly Dividend with respect to the applicable Basket Stock with a view to offsetting, to the extent practical, any change in the Holder’s economic position relative to this Security that results solely from that event, and references in
this section to a quarter or a quarterly dividend shall be deemed to refer instead to such other period or periodic dividend, as appropriate. In the event of a spin-off with respect to any Basket Stock, the Base Quarterly Dividend for such Basket
Stock will remain unchanged and the Base Quarterly Dividend with respect to the spin-off stock will be $0.00 per share. 
 Stock Splits and Reverse
Stock Splits 
 A stock split is an increase in the number of a corporation’s outstanding shares of stock
without any change in its stockholders’ equity. Each outstanding share will be worth less as a result of a stock split. 

A reverse stock split is a decrease in the number of a corporation’s outstanding shares of stock without any change in
its stockholders’ equity. Each outstanding share will be worth more as a result of a reverse stock split. 
 If any
Basket Stock is subject to a stock split or a reverse stock split, then once the split has become effective the Calculation Agent will adjust the Exchange Ratio with respect to such Basket Stock to equal the product of the prior Exchange Ratio of
such Basket Stock and the number of shares issued in such stock split or reverse stock split with respect to one share of such Basket Stock. 
 Stock
Dividends 
 In a stock dividend, a corporation issues additional shares of its stock to all holders of its
outstanding stock in proportion to the shares they own. Each outstanding share will be worth less as a result of a stock dividend. 

If any Basket Stock is subject to a stock dividend payable in shares of such Basket Stock that is given ratably to all holders
of shares of such Basket Stock, then once the dividend has become effective the Calculation Agent will adjust the Exchange Ratio for such Basket Stock on the Ex-Dividend Date to equal the sum of the prior Exchange Ratio for such Basket Stock and the
product of: 
  

	 	•	 	 the number of shares issued with respect to one share of such Basket Stock, and 

  
 11 

	 	•	 	 the prior Exchange Ratio for such Basket Stock. 

The “Ex-Dividend Date” for any dividend or other distribution is the first day on and after which such Basket
Stock trades without the right to receive that dividend or distribution. 
 No Adjustments for Other Dividends and Distributions 

The Exchange Ratio will not be adjusted to reflect dividends, including cash dividends, or other distributions paid with
respect to any Basket Stock, other than: 
  

	 	•	 	 Ordinary Dividend Adjustments described above, 

  

	 	•	 	 stock dividends described above, 

  

	 	•	 	 issuances of transferable rights and warrants as described in “ — Transferable Rights and Warrants” below, 

 

	 	•	 	 distributions that are spin-off events described in “ — Reorganization Events” below, and 

 

	 	•	 	 Extraordinary Dividends described below. 

An “Extraordinary Dividend” means each of (a) the full amount per share of a Basket Stock of any cash
dividend or special dividend or distribution that is identified by the issuer of a Basket Stock as an extraordinary or special dividend or distribution, (b) the excess of any cash dividend or other cash distribution (that is not otherwise
identified by the issuer of such Basket Stock as an extraordinary or special dividend or distribution) distributed per share of such Basket Stock over the immediately preceding cash dividend or other cash distribution, if any, per share of such
Basket Stock that did not include an Extraordinary Dividend (as adjusted for any subsequent corporate event requiring an adjustment as described herein, such as a stock split or reverse stock split) if such excess portion of the dividend or
distribution is more than 5.00% of the Closing Price of such Basket Stock on the Trading Day preceding the Ex-Dividend Date for the payment of such cash dividend or other cash distribution (such Closing Price, the “Extraordinary Dividend
Base Closing Price”) and (c) the full cash value of any non-cash dividend or distribution per share of a Basket Stock (excluding Marketable Securities, as defined below). 

If any Basket Stock is subject to an Extraordinary Dividend, then once the Extraordinary Dividend has become effective the
Calculation Agent will adjust the Exchange Ratio for such Basket Stock on the Ex-Dividend Date to equal the product of: 
  

	 	•	 	 the prior Exchange Ratio for such Basket Stock, and 

  

	 	•	 	 a fraction, the numerator of which is the Extraordinary Dividend Base Closing Price of such Basket Stock on the Trading Day preceding the
Ex-Dividend Date and the denominator of which is the amount by which the Extraordinary Dividend Base Closing Price of such Basket Stock on the Trading Day preceding the Ex-Dividend Date exceeds the Extraordinary Dividend. 

  
 12 

 Notwithstanding anything herein, the initiation by the issuer of a Basket Stock
of an ordinary dividend on such Basket Stock or any announced increase in the ordinary dividend on the such Basket Stock will not constitute an Extraordinary Dividend requiring an adjustment. 

To the extent an Extraordinary Dividend is not paid in cash or is paid in a currency other than U.S. dollars, the value of the
non-cash component or non-U.S. currency will be determined by the Calculation Agent, in its sole discretion. A distribution on a Basket Stock that is a dividend payable in shares of such Basket Stock, an issuance of rights or warrants or a spin-off
event and also an Extraordinary Dividend will result in an adjustment to the number of shares of a Basket Stock only as described in “—Stock Dividends” above, “—Transferable Rights and Warrants” below or
“—Reorganization Events” below, as the case may be, and not as described here. 
 Transferable Rights and Warrants 

If the issuer of a Basket Stock issues transferable rights or warrants to all holders of such Basket Stock to subscribe for or
purchase such Basket Stock at an exercise price per share that is less than the Closing Price of such Basket Stock on the Trading Day before the Ex-Dividend Date for the issuance, then the Exchange Ratio for such Basket Stock will be adjusted to
equal the product of: 
  

	 	•	 	 the prior Exchange Ratio for such Basket Stock, and 

  

	 	•	 	 a fraction, (1) the numerator of which will be the number of shares of such Basket Stock outstanding at the close of trading on the Trading
Day before the Ex-Dividend Date (as adjusted for any subsequent event requiring an adjustment hereunder) plus the number of additional shares of such Basket Stock offered for subscription or purchase pursuant to the rights or warrants and
(2) the denominator of which will be the number of shares of such Basket Stock outstanding at the close of trading on the Trading Day before the Ex-Dividend Date (as adjusted for any subsequent event requiring an adjustment hereunder) plus the
number of additional shares of such Basket Stock (referred to herein as the “Additional Shares”) that the aggregate offering price of the total number of shares of such Basket Stock so offered for subscription or purchase pursuant
to the rights or warrants would purchase at the Closing Price on the Trading Day before the Ex-Dividend Date for the issuance. 

The number of Additional Shares will be equal to: 
  

	 	•	 	 the product of (1) the total number of additional shares of such Basket Stock offered for subscription or purchase pursuant to the rights or
warrants and (2) the exercise price of the rights or warrants, divided by 

  

	 	•	 	 the Closing Price of such Basket Stock on the Trading Day before the Ex-Dividend Date for the issuance. 

If the number of shares of the Basket Stock actually delivered in respect of the rights or warrants differs from the number of
shares of the Basket Stock offered in respect of the rights or warrants, then the Exchange Ratio for such Basket Stock will promptly be readjusted to the 

  
 13 

 
Exchange Ratio for such Basket Stock that would have been in effect had the adjustment been made on the basis of the number of shares of the Basket Stock actually delivered in respect of the
rights or warrants. 
 Reorganization Events 

Each of the following is a “Reorganization Event”: 

 

	 	•	 	 a Basket Stock is reclassified or changed (other than in a stock split or reverse stock split), 

 

	 	•	 	 the issuer of a Basket Stock has been subject to a merger, consolidation or other combination and either is not the surviving entity or is the
surviving entity but all outstanding shares of such Basket Stock are exchanged for or converted into other property, 

  

	 	•	 	 a statutory share exchange involving outstanding shares of a Basket Stock and the securities of another entity occurs, other than as part of an
event described above, 

  

	 	•	 	 a Basket Stock Issuer sells or otherwise transfers its property and assets as an entirety or substantially as an entirety to another entity,

  

	 	•	 	 a Basket Stock Issuer effects a spin-off, other than as part of an event described above (in a spin-off, a corporation issues to all holders of its
common stock equity securities of another issuer), or 

  

	 	•	 	 the issuer of a Basket Stock is liquidated, dissolved or wound up or is subject to a proceeding under any applicable bankruptcy, insolvency or
other similar law, or another entity completes a tender or exchange offer for all the outstanding shares of such Basket Stock. 

Adjustments for Reorganization Events 

If a Reorganization Event occurs with respect to a Basket Stock Issuer, then the Calculation Agent will adjust the applicable
Exchange Ratio to reflect the amount and type of property or properties—whether cash, securities, other property or a combination thereof—that a holder of one share of the applicable Basket Stock would have been entitled to receive in
relation to the Reorganization Event. This new property is referred to as the “Reorganization Property.” 

Reorganization Property can be classified into two categories: 

 

	 	•	 	 an equity security listed on a national securities exchange, which is generally referred to as a “Marketable Security” and, in
connection with a particular Reorganization Event, “New Stock,” which may include any tracking stock, any stock received in a spin-off (“Spin-Off Stock”) or any Marketable Security received in exchange for the
Basket Stock; and 

  
 14 

	 	•	 	 cash and any other property, assets or securities other than Marketable Securities (including equity securities that are not listed, that are
traded over the counter or that are listed on a non-U.S. securities exchange), which is referred to as “Non-Stock Reorganization Property.” 

For the purpose of making an adjustment required by a Reorganization Event, the Calculation Agent, in its sole discretion,
will determine the value of each type of the Reorganization Property. For purposes of valuing any New Stock, the Calculation Agent will use the Closing Price of the security on the relevant Trading Day. The Calculation Agent will value Non-Stock
Reorganization Property in any manner it determines, in its sole discretion, to be appropriate. In connection with a Reorganization Event in which Reorganization Property includes New Stock, for the purpose of determining the Exchange Ratio for any
New Stock as described below, the term “New Stock Reorganization Ratio” means the product of (i) the number of shares of the New Stock received with respect to one share of the applicable Basket Stock and (ii) the Exchange
Ratio for such Basket Stock on the Trading Day immediately prior to the effective date of the Reorganization Event. 
 If a
holder of shares of the applicable Basket Stock may elect to receive different types or combinations of types of Reorganization Property in the Reorganization Event, the Reorganization Property will consist of the types and amounts of each type
distributed to a holder of shares of such Basket Stock that makes no election, as determined by the Calculation Agent in its sole discretion. 

If any Reorganization Event occurs with respect to a Basket Stock Issuer, then on and after the effective date for such
Reorganization Event (or, if applicable, in the case of spinoff stock, the Ex-Dividend Date for the distribution of such spinoff stock) the term “Basket Stock” herein will be deemed to mean the following in respect of the applicable
original Basket Stock, and for each share of Basket Stock, New Stock and/or Replacement Stock so deemed to constitute Basket Stock, the applicable Exchange Ratio will be equal to the applicable number indicated: 

 

	 	(a)	 if the Basket Stock continues to be outstanding: 

  

	 	(1)	 that Basket Stock (if applicable, as reclassified upon the issuance of any tracking stock) at the Exchange Ratio in effect for that Basket Stock on
the Trading Day immediately prior to the effective date of the Reorganization Event; and 

  

	 	(2)	 if the Reorganization Property includes New Stock, a number of shares of New Stock equal to the New Stock Reorganization Ratio;

  

	 	    	 provided that, if any Non-Stock Reorganization Property is received in the Reorganization Event, the results of (a)(1) and (a)(2) above will
each be multiplied by the “Gross-Up Multiplier,” which will be equal to a fraction, the numerator of which is the Closing Price of the Basket Stock on the Trading Day immediately prior to the effective date of the Reorganization
Event and the denominator of which is the amount by which such Closing Price of the Basket Stock exceeds the value of the Non-Stock Reorganization Property received per share of Basket Stock as determined by the Calculation Agent as of the close of
trading on such Trading Day; or 

  
 15 

	 	(b)	 if the Basket Stock is surrendered for Reorganization Property: 

 

	 	(1)	 that includes New Stock, a number of shares of New Stock equal to the New Stock Reorganization Ratio; provided that, if any Non-Stock
Reorganization Property is received in the Reorganization Event, such number will be multiplied by the Gross-Up Multiplier; or 

  

	 	(2)	 that consists exclusively of Non-Stock Reorganization Property: 

 

	 	(i)	 if the surviving entity has Marketable Securities outstanding following the Reorganization Event and either (A) such Marketable Securities
were in existence prior to such Reorganization Event or (B) such Marketable Securities were exchanged for previously outstanding Marketable Securities of the surviving entity or its predecessor (“Predecessor Stock”) in
connection with such Reorganization Event (in either case of (A) or (B), the “Successor Stock”), a number of shares of the Successor Stock determined by the Calculation Agent on the Trading Day immediately prior to the
effective date of such Reorganization Event equal to the Exchange Ratio in effect for the Basket Stock on the Trading Day immediately prior to the effective date of such Reorganization Event multiplied by a fraction, the numerator of which is the
value of the Non-Stock Reorganization Property per share of the Basket Stock on such Trading Day and the denominator of which is the Closing Price of the Successor Stock on such Trading Day (or, in the case of Predecessor Stock, the Closing Price of
the Predecessor Stock multiplied by the number of shares of the Successor Stock received with respect to one share of the Predecessor Stock); or 

  

	 	(ii)	 if the surviving entity does not have Marketable Securities outstanding, or if there is no surviving entity (in each case, a “Replacement
Stock Event”), a number of shares of Replacement Stock (selected as defined below) with an aggregate value on the effective date of such Reorganization Event equal to the value of the Non-Stock Reorganization Property multiplied by the
Exchange Ratio in effect for the Basket Stock on the Trading Day immediately prior to the effective date of such Reorganization Event. 

If a Reorganization Event occurs with respect to the shares of a Basket Stock and the Calculation Agent adjusts the Exchange
Ratio of such Basket Stock to reflect the Reorganization Property in the event as described above, the Calculation Agent will make further antidilution adjustments for any later events that affect the Reorganization Property, or any component of the
Reorganization Property, comprising the new Exchange Ratio. The Calculation Agent will do so to the same extent that it would make adjustments if the shares of such Basket Stock were outstanding and were affected by the same kinds of events. If a
subsequent Reorganization Event affects only a particular component of the number of shares of such Basket Stock, the required 

  
 16 

 
adjustment will be made with respect to that component as if it alone were the number of shares of such Basket Stock. 

For purposes of adjustments for Reorganization Events, in the case of a consummated tender or exchange offer or going-private
transaction involving Reorganization Property of a particular type, Reorganization Property will be deemed to include the amount of cash or other property paid by the offeror in the tender or exchange offer with respect to such Reorganization
Property (in an amount determined on the basis of the rate of exchange in such tender or exchange offer or going-private transaction). In the event of a tender or exchange offer or a going-private transaction with respect to Reorganization Property
in which an offeree may elect to receive cash or other property, Reorganization Property will be deemed to include the kind and amount of cash and other property received by offerees who elect to receive cash. 

Replacement Stock Events 

Following the occurrence of a Replacement Stock Event described in paragraph (b)(2)(ii) above or in “—Delisting of
American Depositary Shares or Termination of American Depositary Receipt Facility” below, the amount of shares of a Basket Stock or cash, as applicable, payable on this Security upon exchange or redemption or at Maturity will be determined by
reference to a Replacement Stock and an Exchange Ratio (subject to any further antidilution adjustments) for such Replacement Stock as determined in accordance with the following paragraphs. 

The “Replacement Stock” will be the stock having the closest “Option Period Volatility” to the
Basket Stock among the stocks that then comprise the Replacement Stock Selection Index (or, if publication of such index is discontinued, any successor or substitute index selected by the Calculation Agent in its sole discretion) with the same GICS
Code (as defined below) as the issuer of such Basket Stock; provided, however, that a Replacement Stock will not include (i) any stock that is subject to a trading restriction under the trading restriction policies of the Company, the hedging
counterparties of the Company or any of their affiliates that would materially limit the ability of the Company, the hedging counterparties of the Company or any of their affiliates to hedge this Security with respect to such stock or (ii) any
stock for which the aggregate number of shares to be referenced (equal to the product of (a) the Exchange Ratio that would be in effect immediately after selection of such stock as the Replacement Stock and (b) the principal amount of this
Security outstanding divided by $1,000) exceeds 25% of the ADTV (as defined in Rule 100(b) of Regulation M under the Exchange Act) for such stock as of the effective date of the Replacement Stock Event (an “Excess ADTV Stock”).

 If a Replacement Stock is selected in connection with a Reorganization Event, the Exchange Ratio with respect to such
Replacement Stock will be equal to the number of shares of such Replacement Stock with an aggregate value, based on the Closing Price on the effective date of such Reorganization Event, equal to the product of (a) the value of the Non-Stock
Reorganization Property received per share of the Basket Stock and (b) the Exchange Ratio in effect for such Basket Stock on the Trading Day immediately prior to the effective date of such Reorganization Event. If Replacement Stock is selected
in connection with an ADS Termination Event (as defined below), the Exchange Ratio with respect to such Replacement Stock will be equal to the number of shares of such Replacement Stock with an aggregate value, based on the Closing Price on the
Change Date (as defined below), equal to the product of (x) the Closing Price of the Basket Stock on the Change 

  
 17 

 
Date and (y) the Exchange Ratio in effect for such Basket Stock on the Trading Day immediately prior to the Change Date. 

The “Option Period Volatility” means, in respect of any Trading Day, the volatility (calculated by referring
to the Closing Price of the Basket Stock on its primary exchange) for a period equal to the 125 Trading Days immediately preceding the announcement date of the Reorganization Event, as determined by the Calculation Agent. 

“GICS Code” means the Global Industry Classification Standard (“GICS”) sub-industry code
assigned to the Basket Stock Issuer; provided, however, if (i) there is no other stock in the Replacement Stock Selection Index in the same GICS sub-industry or (ii) a Replacement Stock (a) for which there is no trading restriction
and (b) that is not an Excess ADTV Stock cannot be identified from the Replacement Stock Selection Index in the same GICS sub-industry, the GICS Code will mean the GICS industry code assigned to such Basket Stock Issuer. If no GICS Code has
been assigned to such Basket Stock Issuer, the applicable GICS Code will be determined by the Calculation Agent to be the GICS sub-industry code assigned to companies in the same sub-industry (or, subject to the proviso in the preceding sentence,
industry, as applicable) as such Basket Stock Issuer at the time of the relevant Replacement Stock Event. 
 The
“Replacement Stock Selection Index” means the S&P 500® Index. 

Delisting of American Depositary Shares or Termination of American Depositary Receipt Facility. If a Basket Stock is an
ADS and such Basket Stock is no longer listed or admitted to trading on a U.S. securities exchange registered under the Exchange Act or included in the OTC Bulletin Board Service operated by the FINRA, or if the American depositary receipt facility
between the issuer of such Basket Stock and the depositary is terminated for any reason (each, an “ADS Termination Event”), then, on the last Trading Day on which such Basket Stock is listed or admitted to trading or the last
Trading Day immediately prior to the date of such termination, as applicable (the “Change Date”), a Replacement Stock Event shall be deemed to occur. 
  

 

Reference is hereby made to the further provisions of this Security 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 referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall not be entitled to any benefit
under the Indenture or be valid or obligatory for any purpose. 
 [The remainder of this page has been left intentionally blank] 

  
 18 

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

					
	WELLS FARGO & COMPANY
		
	By:		 
			 
			Its:		 

 [SEAL] 
  

					
	Attest:		 
			 
			Its:		 

  

			
	 TRUSTEE’S CERTIFICATE OF

AUTHENTICATION
 This is one of the Securities of the

series designated therein described
 in the within-mentioned Indenture.

	
	 CITIBANK, N.A.,

      as Trustee

		
	By:		 
			Authorized Signature
	
	OR
	
	 WELLS FARGO BANK, N.A.,

  as Authenticating Agent for the Trustee

		
	By:		 
			Authorized Signature

  
 19 

 [Reverse of Note] 

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

0.125% Optionally Exchangeable Notes due February 21, 2020 

Exchangeable for a Basket of Shares or the Cash Value of Such Basket of Shares 

This Security is one of a duly authorized issue of securities of the Company (herein called the
“Securities”), issued and to be issued in one or more series under an indenture dated as of July 21, 1999, as amended or supplemented from time to time (herein called the “Indenture”), between the Company and
Citibank, N.A., as Trustee (herein called 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 Securities, and of the terms upon which the Securities are, and are to be, authenticated and delivered. This Security is
one of the series of the Securities designated as Medium-Term Notes, Series K, of the Company, which series is limited to an aggregate principal amount or face amount, as applicable, of $25,000,000,000 or the equivalent thereof in one or more
foreign or composite currencies. The amount payable on the Securities of this series may be determined by reference to the performance of one or more equity-, commodity- or currency-based indices, exchange traded funds, securities, commodities,
currencies, statistical measures of economic or financial performance, or a basket comprised of two or more of the foregoing, or any other market measure or may bear interest at a fixed rate or a floating rate. The Securities of this series may
mature at different times, be redeemable at different times or not at all, be repayable at the option of the Holder at different times or not at all and be denominated in different currencies. 

Article Sixteen of the Indenture shall not apply to this Security. 

The Securities are issuable only in registered form without coupons and will be either
(a) book-entry securities represented by one or more Global Securities recorded in the book-entry system maintained by the Depositary or (b) certificated
securities issued to and registered in the names of, the beneficial owners or their nominees. 
 The Company agrees, to the
extent permitted by law, not to voluntarily claim the benefits of any laws concerning usurious rates of interest against a Holder of this Security. 

  
 20 

 Modification and Waivers 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights
and obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the time Outstanding of all series to be affected, acting together as a class. The Indenture also contains provisions permitting the Holders of a majority in principal amount of the Securities of all series at the time Outstanding
affected by certain provisions of the Indenture, acting together as a class, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain past defaults under the
Indenture and their consequences may be waived under the Indenture by the Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such series. Solely for the
purpose of determining whether any consent, waiver, notice or other action or Act to be taken or given by the Holders of Securities pursuant to the Indenture has been given or taken by the Holders of Outstanding Securities in the requisite aggregate
principal amount, the principal amount of this Security will be deemed to be equal to the amount set forth on the face hereof as the “Principal Amount” hereof. Any such consent or waiver by the Holder of this Security shall be conclusive
and binding upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not notation of such consent or waiver is made upon
this Security. 
 Defeasance 

Section 403 and Article Fifteen of the Indenture and the provisions of clause (ii) of Section 401(1)(B) of the
Indenture, relating to defeasance at any time of (a) the entire indebtedness on this Security and (b) certain restrictive covenants and certain Events of Default, upon compliance by the Company with certain conditions set forth therein,
shall not apply to this Security. The remaining provisions of Section 401 of the Indenture shall apply to this Security. 
 Authorized
Denominations 
 This Security is issuable only in registered form without coupons in denominations of $1,000 or any
amount in excess thereof which is an integral multiple of $1,000. 
 Registration of Transfer 

Upon due presentment for registration of transfer of this Security at the office or agency of the Company in the City of
Minneapolis, Minnesota, a new Security or Securities of this series, with the same terms as this Security, in authorized denominations for an equal aggregate principal amount will be issued to the transferee in exchange herefor, as provided in the
Indenture and subject to the limitations provided therein and to the limitations described below, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is exchangeable for definitive Securities in registered form only if (x) the Depositary notifies the
Company that it is unwilling or unable to continue as Depositary for this Security or if at any time the Depositary ceases to be a clearing agency registered under the Securities Exchange Act of 1934, as amended, and a successor depositary is not
appointed within 

  
 21 

 
90 days after the Company receives such notice or becomes aware of such ineligibility, (y) the Company in its sole discretion determines that this Security shall be exchangeable for
definitive Securities in registered form and notifies the Trustee thereof or (z) an Event of Default with respect to the Securities represented hereby has occurred and is continuing. If this Security is exchangeable pursuant to the preceding
sentence, it shall be exchangeable for definitive Securities in registered form, having the same date of issuance, Stated Maturity Date and other terms and of authorized denominations aggregating a like amount. 

This Security may not be transferred except as a whole by the Depositary to a nominee of the Depositary or by a nominee of the
Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor. Except as provided above, owners of beneficial interests in this Global
Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture. 

Prior to due presentment of this Security 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 Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 Obligation of the Company Absolute 

No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation
of the Company, which is absolute and unconditional, to make the payments on this Security at the times, place and rate, and in the coin or currency or shares of the Basket Stocks, as the case may be, herein prescribed, except as otherwise provided
in this Security. 
 No Personal Recourse 

No recourse shall be had for the payment of amounts payable on this Security, or for any claim based hereon, or otherwise in
respect hereof, or based on or in respect of the Indenture or any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or any successor corporation, whether by
virtue of any constitution, statute or rule of law, or by the enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance hereof and as part of the consideration for the issuance hereof, expressly waived and
released. 
 Defined Terms 

All terms used in this Security which are defined in the Indenture shall have the meanings assigned to them in the Indenture
unless otherwise defined in this Security. 
 Governing Law 

This Security shall be governed by and construed in accordance with the law of the State of New York, without regard to
principles of conflicts of laws. 

  
 22 

 ABBREVIATIONS 

The following abbreviations, when used in the inscription on the face of this instrument, shall be construed as though they
were written out in full according to applicable laws or regulations: 
  

					
	 TEN COM
		  -- 
		 as tenants in common

			
	 TEN ENT
		  -- 
		 as tenants by the entireties

			
	 JT TEN
		  -- 
		 as joint tenants with right

of survivorship and not
 as
tenants in common

  

									
	 UNIF GIFT MIN ACT
		  -- 
		 		 Custodian
		 
					(Cust)				(Minor)

  

	
	Under Uniform Gifts to Minors Act
	
	   

	(State)

 Additional abbreviations may also be used though not in the above list. 

FOR VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 

 

	
	 Please Insert Social Security or
 Other
Identifying Number of Assignee

	
	   

  
  

 
  
  

 
 (PLEASE
PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL ZIP CODE OF ASSIGNEE)

  
 23 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute and
appoint                                  attorney to transfer the said Security on
the books of the Company, with full power of substitution in the premises. 
 Dated:
                         
  

	
	   

  

	
	   

 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the
within instrument in every particular, without alteration or enlargement or any change whatever. 

  
 24 

 Annex A 

OFFICIAL NOTICE OF EXCHANGE 

Dated: On or after March 4, 2015 
  

			
	 Wells Fargo & Company

375 Park Avenue, 4th Floor

MAC J0127-045
 New York, NY
10152
 Facsimile No: (212) 214-5913

Telephone No: (212) 214-6101

Attention: Derivatives Structuring Group
		 Wells Fargo Securities, LLC
 c/o Investment
Solutions
 375 Park Avenue, 4th Floor

MAC J0127-033
 New York, NY 10152

Facsimile No: (212) 214-5912
 Telephone No:
(212) 214-6299
 Attention: Geoffrey Keith

 Dear Sirs or Madams: 

The undersigned beneficial owner of the Medium-Term Notes, Series K, 0.125% Optionally Exchangeable Notes due February 21, 2020 of
Wells Fargo & Company (CUSIP No. 94986RVY4) (the “notes”) hereby irrevocably elects to exercise its exchange right with respect to the principal amount of the notes indicated below, as of the date hereof (or if this
notice is received after 11:00 A.M., New York City time, on any trading day or at any time on a day that is not a trading day, as of the next trading day), provided that such a day is on or after March 4, 2015, and is on or before the earlier
of (i) the trading day prior to the redemption notice date, if applicable, and (ii) the fifth trading day before the stated maturity date. The exchange right is to be exercised as described under “Specific Terms of the Notes —
Exchange Right” in the pricing supplement dated March 2, 2015 (the “pricing supplement”) relating to Registration Statement No. 333-180728. Terms not defined in this notice
shall have their respective meanings as described in the pricing supplement. 
 Please (i) date and acknowledge receipt of this
Official Notice of Exchange in the place provided below, and (ii) fax a copy to the fax number indicated. The amount of any such cash payment will be determined by the calculation agent and indicated in its acknowledgment of this Official
Notice of Exchange. Wells Fargo will then deliver, in its sole discretion, the shares of the basket stocks, or an equivalent amount in cash based on the values thereof, on the third business day after the exchange notice date, in accordance with the
terms of the notes as described in the pricing supplement. 
 The undersigned certifies to you that (i) it is, or is duly authorized to
act for, the beneficial owner of the notes to be exchanged (and attaches evidence of such ownership as provided by the undersigned’s position services department or the position services department of the entity through which the undersigned
holds its notes) and (ii) it will cause the principal amount of notes to be exchanged to be transferred to the paying agent on the exchange settlement date. 

 
			
	Very truly yours,
	
	   

	Name of Beneficial Owner
	
	By:
	
	   

	Name
	
	   

	Title and/or Organization
	
	   

	Fax No./Direct No.
	$		 
	Principal amount of notes to be surrendered for exchange
		
	$		 
	Accrued interest, if any, due upon surrender of notes for exchange
	
	   

	Please specify: Exchange Notice Date

 Receipt of the above 

Official Notice of Exchange is hereby acknowledged. 
 WELLS
FARGO & COMPANY, as issuer 
  

					
	By:		
			Title:		

 Date and time of acknowledgment
                         

  
 Annex A-2 

 WELLS FARGO SECURITIES, LLC, as Calculation Agent 

 

					
	By:		
			Title:		

 Date and time of acknowledgment
                         

$                         
                        
 Accrued
interest, if any, due upon 
 surrender of notes for exchange 

  
 Annex A-3

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