Common use of Election Form Clause in Contracts

Election Form. TO: Internal Revenue Service Center [Address where the employee files his or her personal income tax return] The undersigned taxpayer hereby elects, pursuant to § 83(b) of the Internal Revenue Code of 1986, as amended, to include in gross income as compensation for services the excess (if any) of the fair market value of the shares described below over the amount paid for those shares. 1. The name, taxpayer identification number, address of the undersigned, and the taxable year for which this election is being made are: TAXPAYER’S NAME: _____________________________________________ TAXPAYER’S SOCIAL SECURITY NUMBER: __________________________ ADDRESS: ______________________________________________________ TAXABLE YEAR: Calendar Year 20__ 2. The property which is the subject of this election is __________ shares of common stock of __________________________. 3. The property was transferred to the undersigned on [DATE]. 4. The property is subject to the following restrictions: [Describe applicable restrictions here.] 5. The fair market value of the property at the time of transfer (determined without regard to any restriction other than a nonlapse restriction as defined in § 1.83-3(h) of the Income Tax Regulations) is: $_______ per share x ________ shares = $___________. 6. For the property transferred, the undersigned paid $______ per share x _________ shares = $______________. 7. The amount to include in gross income is $______________. [The result of the amount reported in Item 5 minus the amount reported in Item 6.]

Election Form. TO: Internal Revenue Service Center [Address where the employee files his or her personal income tax return] The undersigned taxpayer hereby elects, pursuant to § 83(b) of the Internal Revenue Code of 1986, as amended, to include in gross income as compensation for services the excess (if any) of the fair market value of the shares described below over the amount paid for those shares. 1. The name, taxpayer identification number, address of the undersigned, and the taxable year for which this election is being made are: TAXPAYER’S NAME: _____________________________________________ TAXPAYER’S SOCIAL SECURITY NUMBER: __________________________ ADDRESS: ______________________________________________________ TAXABLE YEAR: Calendar Year 20__ 2. The property which is the subject of this election is __________ shares of common stock of __________________________. 3. The property was transferred to the undersigned on [DATE]. 4. The property is subject to the following restrictions: [Describe applicable restrictions here.]: 5. The fair market value of the property at the time of transfer (determined without regard to any restriction other than a nonlapse restriction as defined in § 1.83-3(h) of the Income Tax Regulations) is: $_______ per share x ________ shares = $___________. 6. For the property transferred, the undersigned paid $______ per share x _________ shares = $______________. 7. The amount to include in gross income is $______________. [The result of the amount reported in Item 5 minus the amount reported in Item 6.]

Election Form. TO: Internal Revenue Service Center [Address where the employee files his or her personal income tax return] The undersigned taxpayer hereby elects, pursuant to § 83(b) of the Internal Revenue Code of 1986, as amended, to include in gross income as compensation for services the excess (if any) of the fair market value of the shares described below over the amount paid for those shares. 1. The name, taxpayer identification number, address of the undersigned, and the taxable year for which this election is being made are: TAXPAYER’S NAME: _________________________________________________________________________________________ TAXPAYER’S SOCIAL SECURITY NUMBER: ________________________________________________________________________ TAXPAYER’S ADDRESS: _______________________________________________________________________________________ TAXABLE YEAR: Calendar Year 20201___ 2. The property which is the subject of this election is __________ shares of common stock of Med One Oak, Inc. 3. The property was transferred to the undersigned on ____________________, 201______. 3. The property was transferred to the undersigned on [DATE]. 4. The property is subject to the following restrictions: [Describe applicable restrictions hereThe shares will be forfeited if certain vesting conditions are not satisfied and are not transferrable until vested.] 5. The fair market value of the property at the time of transfer (determined without regard to any restriction other than a nonlapse restriction as defined in § 1.83-3(h) of the Income Tax Regulations) is: $_______ per share x ________ shares = $___________. 6. For the property transferred, the undersigned paid $______ per share x × _____________ shares = $________________________________. 6. For the property transferred, the undersigned paid $ 0 per share x _____ shares = $ 0. 7. The amount to include in gross income is $_________________________. [The result of the amount reported in Item 5 minus the amount reported in Item 6.]

Election Form. TO: Internal Revenue Service Center [Address where the employee files his or her personal income tax return] The undersigned taxpayer hereby elects, pursuant to § 83(b) of the Internal Revenue Code of 1986, as amended, to include in gross income as compensation for services the excess (if any) of the fair market value of the shares described below over the amount paid for those shares. 1. The name, taxpayer identification number, address of the undersigned, and the taxable year for which this election is being made are: TAXPAYER’S NAME: ____________________________________________________________________________ TAXPAYER’S SOCIAL SECURITY NUMBER: ___________________________________________________________ TAXPAYER’S ADDRESS: __________________________________________________________________________ TAXABLE YEAR: Calendar Year 20201___ 2. The property which is the subject of this election is __________ shares of common stock of Med One Oak, Inc. 3. The property was transferred to the undersigned on ____________________, 201______. 3. The property was transferred to the undersigned on [DATE]. 4. The property is subject to the following restrictions: [Describe applicable restrictions hereThe shares will be forfeited if certain vesting conditions are not satisfied and are not transferrable until vested.] 5. The fair market value of the property at the time of transfer (determined without regard to any restriction other than a nonlapse restriction as defined in § 1.83-3(h) of the Income Tax Regulations) is: $_______ per share x ________ shares = $___________. 6. For the property transferred, the undersigned paid $______ per share x × _____________ shares = $________________________________. 6. For the property transferred, the undersigned paid $ 0 per share x _____ shares = $ 0. 7. The amount to include in gross income is $_________________________. [The result of the amount reported in Item 5 minus the amount reported in Item 6.]