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: ________________________________________________________________________ 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 Election Pursuant to § Section 83(b) of the Internal Revenue Code to Include Property in Gross Income in Year 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.Transfer 1. The name, address, and taxpayer identification number, address number of the undersigned, and the taxable year for which this election is being made undersigned are: TAXPAYER’S NAME: ______________________________ ______________________________ ______________________________ ___-__-____ 2. The property with respect to which the election is made is _____________________ shares of Common Stock, par value $____ per share, of CytoSorbents Corporation, a Delaware corporation (the “Company”). 3. The date on which the property was transferred was ________________, the date on which the taxpayer received the property pursuant to a grant of restricted stock. 4. The taxable year to which this election relates is calendar year 20__. 5. The property is subject to restrictions in that the property is not transferable and is subject to a substantial risk of forfeiture until the taxpayer vests in the property. The taxpayer will vest in ____ percent of the shares of Common Stock on __________, 20__, in an additional ___ percent of the shares on __________, 20__, and in the remaining ___ percent of the shares on __________, 20__, provided the taxpayer is in the employ of the Company on such dates. 6. The fair market value at the time of transfer (determined without regard to any restrictions other than restrictions which by their terms will never lapse) of the property with respect to which this election is being made is $________________ per share; with a cumulative fair market value of $______________. 7. The taxpayer did not pay any amount for the property transferred. [If award included a purchase price, insert the following in lieu of the preceding sentence: The amount paid by the taxpayer for the property with respect to which this election is being made was $________________ per share; with a cumulative fair market value of $______________.] 8. A copy of this statement was furnished to the Corporate Secretary or other designated officer of the Company. The taxpayer rendered the services to _________________________________ TAXPAYER’S SOCIAL SECURITY NUMBER: __________________________ ADDRESSin connection with the transfer of the property with respect to which this election is being made. 9. This election is made to the same effect, and with the same limitations, for purposes of any applicable state statute corresponding to Section 83(b) of the Internal Revenue Code. Signed: ______________________________________________________ TAXABLE YEARDate: 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.]